HESI LPN
HESI PN Exit Exam
1. A male client who has been diagnosed with schizophrenia is withdrawn, isolates himself in the day room, and answers questions with one or two-word responses. This morning, the practical nurse observes that he is diaphoretic and is pacing in the hall. Which intervention is most important for the PN to implement?
- A. Persuade the client to lie down
- B. Provide a drink high in electrolytes
- C. Observe the client during the shift
- D. Measure appropriate vital signs
Correct answer: D
Rationale: Measuring vital signs is crucial in this situation as it helps to determine if the client is experiencing a physical health issue or if the symptoms are related to a mental health crisis, such as anxiety or agitation. The presence of diaphoresis and pacing may indicate physiological changes requiring immediate attention. Providing a drink high in electrolytes or persuading the client to lie down may not address the underlying cause of the symptoms. Simply observing the client during the shift without taking necessary actions to assess his physiological status may delay appropriate intervention.
2. A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?
- A. Hypostatic pneumonia
- B. Renal stones
- C. Pressure ulcers
- D. Thrombus formation
Correct answer: B
Rationale: The correct answer is B: Renal stones. Renal calculi are calcium stones that can form in the renal pelvis or pass through the ureters. Immobilized patients, who have hypercalcemia, are at increased risk for developing renal stones. Monitoring for signs and symptoms of renal stones is crucial in this patient population. Choices A, C, and D are incorrect because although they are potential complications in immobilized patients, they are not directly associated with hypercalcemia and do not match the scenario described in the question.
3. After receiving a report on an inpatient acute care unit, which client should the nurse assess first?
- A. The client with bowel obstruction due to a volvulus who is experiencing abdominal rigidity
- B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
- C. The client with an obstruction of the large intestine who is experiencing abdominal distention
- D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid
Correct answer: A
Rationale: The correct answer is A. Abdominal rigidity in a client with bowel obstruction due to a volvulus indicates possible complications and requires immediate assessment. Choice B is incorrect because although a paralytic ileus with absent bowel sounds is concerning, abdominal rigidity in a client with a volvulus takes priority. Choice C is incorrect as abdominal distention, though indicative of an obstruction, is not as urgent as the sign of abdominal rigidity. Choice D is incorrect as the drainage of greenish fluid from a nasogastric tube in a client with a small bowel obstruction, while concerning, does not present as immediate a threat as the abdominal rigidity in a client with a volvulus.
4. A nurse is caring for an infant with phenylketonuria (PKU). What diet should the nurse anticipate will be ordered by the health care provider?
- A. Fat-free
- B. Protein-enriched
- C. Phenylalanine-free
- D. Low-phenylalanine
Correct answer: D
Rationale: A low-phenylalanine diet is required for infants with PKU to prevent the buildup of phenylalanine, which can lead to brain damage.
5. Select the stage of viral hepatitis that is accurately paired with its characteristic(s).
- A. The prodromal stage: Jaundice begins
- B. The icteric stage: Flu-like symptoms occur
- C. The pre-icteric stage: Elevated urine bilirubin levels
- D. The post-icteric stage: Jaundice and dark urine occur
Correct answer: D
Rationale: The post-icteric stage of viral hepatitis is accurately described as the stage where jaundice and dark urine occur due to the accumulation of bilirubin. The resolution of jaundice and normalization of urine color are seen in this stage. Choices A, B, and C are incorrect. In the prodromal stage, symptoms like fatigue and malaise appear before jaundice. The icteric stage is characterized by jaundice, not flu-like symptoms. The pre-icteric stage does not typically involve elevated urine bilirubin levels, as this occurs after the icteric stage.