HESI LPN
HESI CAT
1. A male client with schizophrenia is jerking his neck and smacking his lips. Which finding indicates to the nurse that he is experiencing an irreversible side effect of antipsychotic agents?
- A. Cramping muscular pain
- B. Worming movements of the tongue
- C. Decreased tendon reflexes
- D. Dry oral mucous membranes
Correct answer: B
Rationale: The correct answer is B: Worming movements of the tongue. Worming movements of the tongue, known as tardive dyskinesia, are an irreversible side effect of antipsychotic medications. Tardive dyskinesia is characterized by involuntary, repetitive movements of the tongue, lips, face, trunk, and extremities. Cramping muscular pain (Choice A) is more indicative of dystonia, an extrapyramidal side effect that can be treated effectively with antiparkinsonian medications. Decreased tendon reflexes (Choice C) are not typically associated with irreversible side effects of antipsychotic agents. Dry oral mucous membranes (Choice D) are not specific to irreversible side effects of antipsychotic medications.
2. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?
- A. Did you really believe you were Jesus Christ?
- B. I think you're getting well.
- C. Others have had similar thoughts when under stress.
- D. Why did you think you were Jesus Christ?
Correct answer: C
Rationale: Choice C is the best response because it validates the client's experience by acknowledging that others have had similar thoughts when under stress. This response helps normalize the client's past experiences without judgment, fostering a supportive and empathetic environment. Choices A and D may come off as judgmental or confrontational, potentially making the client feel misunderstood or defensive. Choice B, 'I think you're getting well,' does not address the client's past belief or provide the understanding and validation that Choice C offers.
3. What is one function of water in the human body?
- A. Water provides calories for energy.
- B. Water helps transport nutrients and waste products.
- C. Water acts as a solvent for many biological reactions.
- D. Water maintains body temperature.
Correct answer: B
Rationale: The correct answer is B: Water helps transport nutrients and waste products. Water plays a crucial role in the body by aiding in the transportation of essential nutrients to cells and removing waste products. While water is essential for various metabolic processes, it does not provide calories for energy (choice A). Although water can act as a solvent for biological reactions (choice C), its primary function is not as a solvent. Additionally, while water does help in regulating body temperature to some extent, its main role is not to maintain body temperature (choice D).
4. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?
- A. Excessive work activity.
- B. Decreased need for sleep.
- C. Medication management.
- D. Inflated self-esteem.
Correct answer: C
Rationale: The most important nursing problem is medication management (C) because compliance with the medication regimen will help prevent hospitalization. The client is also exhibiting signs of mania, such as excessive work activity (A), decreased need for sleep (B), and inflated self-esteem (D); however, these problems do not have the priority of medication management. Managing the medications is crucial to stabilize the client's condition and prevent potential harm associated with untreated bipolar disorder.
5. The increasing number of people who must learn to live with chronic illness in the community implies the need for the PHN to plan and implement a program on:
- A. communicable disease control
- B. health education
- C. child survival
- D. environmental education
Correct answer: B
Rationale: The correct answer is B: health education. Health education is crucial for individuals dealing with chronic illnesses as it helps them learn how to manage their conditions effectively. Communicable disease control (choice A) focuses on preventing the spread of infectious diseases, which is not directly related to managing chronic conditions. Child survival (choice C) pertains to initiatives aimed at reducing child mortality rates, which is not directly related to addressing chronic illnesses. Environmental education (choice D) involves raising awareness about environmental issues, which is also not directly related to helping individuals live with chronic illnesses.