HESI LPN
Community Health HESI Test Bank 2023
1. A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?
- A. Pain related to periosteal injury
- B. Impaired mobility related to bleeding
- C. Parental anxiety related to knowledge deficit
- D. Injury related to intracranial hemorrhage
Correct answer: C
Rationale: The correct nursing diagnosis to guide the plan of care for a newborn with a pronounced cephalic hematoma following a birth in the posterior position is 'Parental anxiety related to knowledge deficit.' This is appropriate because the parents may be worried about the appearance and potential complications of the cephalic hematoma. They may require education and reassurance from the nurse. Choices A, B, and D are incorrect because they do not address the emotional needs of the parents and the knowledge deficit they may have regarding the condition.
2. A patient with stomatitis is receiving oral care education from a nurse. Which instructions will the nurse provide?
- A. Avoid commercial mouthwashes.
- B. Avoid normal saline rinses.
- C. Brush with a hard toothbrush.
- D. Brush with an alcohol-based toothpaste.
Correct answer: A
Rationale: The correct instruction for a patient with stomatitis is to avoid commercial mouthwashes. Commercial mouthwashes often contain alcohol and other ingredients that can irritate the already inflamed oral mucosa in patients with stomatitis. Avoiding commercial mouthwashes helps prevent further irritation and discomfort. Choice B is incorrect because normal saline rinses are gentle and can help soothe the oral mucosa in patients with stomatitis. Choice C is incorrect because a soft toothbrush should be used to prevent further irritation or injury to the gums. Choice D is incorrect because an alcohol-based toothpaste can be too harsh and drying for patients with stomatitis.
3. The client is being taught about a low-sodium diet. Which food should the client avoid?
- A. Fresh fruits
- B. Canned vegetables
- C. Fresh chicken
- D. Unsalted nuts
Correct answer: B
Rationale: The correct answer is B: Canned vegetables. Canned vegetables are often high in sodium due to the preservation process, so they should be avoided on a low-sodium diet. Fresh fruits (choice A), fresh chicken (choice C), and unsalted nuts (choice D) are all low-sodium options and can be included in a low-sodium diet. It is important to choose fresh or frozen vegetables over canned ones to reduce sodium intake. Fresh chicken and unsalted nuts are also good protein sources that are naturally low in sodium, making them suitable for a low-sodium diet. Therefore, clients following a low-sodium diet should prioritize fresh, whole foods over processed or canned options.
4. A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (select one that does not apply.)
- A. Compulsions relieve anxiety
- B. Anxiety is the key reason for OCD
- C. Obsessions cause compulsions
- D. Obsessive thoughts are linked to levels of neurochemicals
Correct answer: C
Rationale: The correct answer is C. Obsessions do not cause compulsions; rather, obsessions are intrusive, unwanted thoughts, images, or urges that trigger intensely distressing feelings, while compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession or according to rules that must be applied rigidly. Choices A, B, and D are incorrect. Choice A is incorrect because compulsions are behaviors or mental acts aimed at reducing distress or preventing a dreaded event or situation. Choice B is incorrect because while anxiety is often a significant component of OCD, it is not the only reason for the disorder. Choice D is incorrect because obsessive thoughts are not solely linked to levels of neurochemicals but are more complex and multifactorial.
5. 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.