HESI LPN
HESI Fundamentals Test Bank
1. A client in an oncology clinic is being assessed by a nurse while undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
- A. I keep having nightmares about my upcoming surgery.
- B. I feel more energetic than I did before.
- C. I have been making plans for the future.
- D. I am looking forward to starting my new treatment.
Correct answer: A
Rationale: Choice A is the correct answer as nightmares about upcoming surgery indicate psychological distress commonly associated with fears, anxiety, and stress related to the treatment. Choices B, C, and D suggest positive emotions and proactive behaviors that are not typical signs of psychological distress in this context. Feeling more energetic, making future plans, and looking forward to treatment are generally positive indicators of coping and adjustment to the situation.
2. A client with Cushing's Syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
- A. Irregular apical pulse
- B. Purple marks on the skin of the abdomen
- C. Quarter-sized blood spot on the dressing
- D. Pitting ankle edema
Correct answer: A
Rationale: The correct answer is A: Irregular apical pulse. In a client recovering from a laparoscopic procedure with Cushing's Syndrome, an irregular apical pulse can be indicative of a life-threatening arrhythmia and requires immediate intervention. Choices B, C, and D are not as urgent as an irregular apical pulse. Purple marks on the skin of the abdomen may be related to Cushing's Syndrome, a quarter-sized blood spot on the dressing can be managed with appropriate wound care, and pitting ankle edema may be expected postoperatively but does not require immediate intervention.
3. A female client with schizophrenia is experiencing auditory hallucinations. What is the most therapeutic response by the nurse?
- A. I don't hear any voices. They must be in your head.
- B. What are the voices telling you to do?
- C. You need to ignore the voices and focus on reality.
- D. I know the voices are real to you, but I don't hear them.
Correct answer: D
Rationale: Acknowledging the client's experience while gently presenting reality can help build trust and provide reassurance without reinforcing the hallucination.
4. A pregnant client mentions in her history that she changes the cat's litter box daily. Which test should the nurse anticipate the healthcare provider to prescribe?
- A. Biophysical profile
- B. Fern test
- C. Amniocentesis
- D. TORCH screening
Correct answer: D
Rationale: The correct answer is D, TORCH screening. TORCH screening is done to detect infections such as toxoplasmosis, which can be contracted from handling cat litter and is harmful during pregnancy. Biophysical profile (choice A) is a prenatal ultrasound evaluation. Fern test (choice B) is used to assess for amniotic fluid leakage. Amniocentesis (choice C) involves taking a sample of amniotic fluid to test for genetic abnormalities and certain infections, not specifically related to toxoplasmosis from cat litter.
5. The nurse is caring for an infant with osteogenesis imperfecta and is providing instruction on how to reduce the risk of injury. Which response from the mother indicates a need for further teaching?
- A. I need to avoid pushing or pulling on an arm or leg.
- B. I must avoid lifting the baby from under the armpits.
- C. I should not bend an arm or leg into an awkward position.
- D. We must avoid lifting the legs by the ankles to change diapers.
Correct answer: B
Rationale: Lifting the baby from under the armpits can cause fractures in infants with osteogenesis imperfecta. The correct approach is to support the baby's body and head carefully, avoiding pressure on vulnerable areas prone to fractures. Choices A, C, and D demonstrate proper awareness of caring for an infant with osteogenesis imperfecta by emphasizing caution to prevent fractures.