HESI LPN
Fundamentals HESI
1. During an admission history assessment, a client informs the nurse about consuming herbal tea every afternoon at work to alleviate stress. What ingredient is likely present in the tea?
- A. Chamomile
- B. Ginseng
- C. Ginger
- D. Echinacea
Correct answer: A
Rationale: The correct answer is A: Chamomile. Chamomile tea is commonly used for stress relief. Choice B, Ginseng, is not typically used in teas for stress relief but for energy and immune system support. Choice C, Ginger, is more commonly used for digestive health and nausea. Choice D, Echinacea, is often used to boost the immune system. Therefore, in the context of stress relief, Chamomile is the most appropriate ingredient.
2. What should be a priority for a 4-year-old child with nephrosis?
- A. Impaired body image
- B. Skin impairment
- C. Nutritional deficit
- D. Injury
Correct answer: B
Rationale: The correct answer is B: Skin impairment. Skin care is a priority in nephrosis due to edema and increased risk of skin breakdown, requiring careful monitoring and management. While impaired body image (Choice A) can be a concern, it is not typically a priority in a 4-year-old with nephrosis. Nutritional deficit (Choice C) is important but addressing skin impairment takes precedence due to the immediate risk of complications related to skin breakdown. Injury (Choice D) is a general concern for children but is not the priority in a child with nephrosis.
3. A client has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
- A. Abdominal cramping
- B. Increased thirst
- C. Elevated blood pressure
- D. Elevated heart rate
Correct answer: A
Rationale: Abdominal cramping is a common manifestation of hyponatremia (low sodium levels). When sodium levels drop, it can lead to changes in the body's water balance, affecting cell function and causing symptoms like abdominal cramping. Increased thirst (choice B) is more commonly associated with hypernatremia (high sodium levels) due to the body's attempt to dilute the excess sodium. Elevated blood pressure (choice C) and elevated heart rate (choice D) are not typically direct manifestations of low sodium levels and are more commonly seen in conditions like dehydration or shock.
4. A nurse is caring for an adolescent client who has full-thickness burns on his leg. The client expresses concern about his future. Which of the following is a therapeutic response by the nurse?
- A. “You’re concerned about what will happen when you leave the hospital?”
- B. “If you work hard on your physical therapy, you won’t need to worry.”
- C. “You shouldn’t worry about the future so you can concentrate on getting well.”
- D. “Why are you concerned even though everyone is here to help you?”
Correct answer: A
Rationale: The correct response is A, “You’re concerned about what will happen when you leave the hospital?” This response acknowledges the client's concerns about the future, validating their feelings and encouraging open communication. It shows empathy and allows the client to express their worries. Choice B minimizes the client's concerns by suggesting that they won't need to worry if they work hard on physical therapy, which may invalidate their emotions. Choice C dismisses the client's worry, implying that they should ignore their concerns to focus on getting well. Choice D uses a confrontational approach by questioning the client's concerns, which may discourage open communication and make the client feel defensive.
5. A 2-week-old infant is admitted with a tentative diagnosis of a ventricular septal defect. The parents report that their baby has had difficulty feeding since coming home after birth. What should the nurse consider before responding?
- A. Feeding problems are common in neonates.
- B. Inadequate sucking is not significant unless cyanosis is present.
- C. Ineffective sucking and swallowing may be early indications of a heart defect.
- D. Many neonates retain mucus, which can interfere with feeding for several weeks.
Correct answer: C
Rationale: Ineffective sucking and swallowing can be early signs of a heart defect like a ventricular septal defect. This is crucial information for the nurse to consider as it aligns with the infant's tentative diagnosis. Choice A is too general and does not provide specific relevance to the situation. Choice B is incorrect as inadequate sucking can indeed be significant, especially in the context of a potential heart defect. Choice D is not directly related to the potential heart defect and feeding difficulties mentioned in the scenario.