HESI LPN
Adult Health Exam 1
1. A client with a severe headache is being assessed by a nurse. What should the nurse do first?
- A. Administer pain relief medication
- B. Check the client's blood pressure
- C. Assess for associated symptoms such as nausea or photophobia
- D. Offer a quiet environment
Correct answer: B
Rationale: When a client presents with a severe headache, the initial action should be to check their blood pressure. This step is crucial as it can help determine if the headache is related to hypertension or other cardiovascular issues. Administering pain relief medication should only be done after assessing the client's vital signs and confirming the cause of the headache. While assessing for associated symptoms like nausea or photophobia is important for a comprehensive evaluation, it should follow checking the blood pressure to address immediate concerns. Offering a quiet environment is indeed beneficial for the client's comfort, but it is not the priority when dealing with a severe headache.
2. A healthcare professional is assessing a child with suspected bacterial meningitis. What is a common clinical manifestation that the healthcare professional is likely to observe?
- A. Rash
- B. Photophobia
- C. Jaundice
- D. Kernig sign
Correct answer: D
Rationale: A common clinical manifestation of bacterial meningitis is a positive Kernig sign, indicating irritation of the meninges. Rash (Choice A) is not typically associated with bacterial meningitis. Photophobia (Choice B) can be present but is more commonly seen in viral meningitis. Jaundice (Choice C) is not a typical clinical manifestation of meningitis and is more indicative of liver dysfunction.
3. A nurse is caring for a client with depression who has been prescribed sertraline (Zoloft). The client reports experiencing nausea. What is the nurse's best response?
- A. "You should stop taking the medication immediately."
- B. "Nausea is a common side effect and usually decreases over time."
- C. "Try taking the medication with food to reduce nausea."
- D. "I will inform the healthcare provider to change your medication."
Correct answer: B
Rationale: The correct answer is B: "Nausea is a common side effect of sertraline, and clients should be reassured that it usually decreases as their body adjusts to the medication." Choice A is incorrect because abruptly stopping the medication without consulting a healthcare provider can be harmful. Choice C is a good suggestion to reduce nausea by taking the medication with food but does not address the temporary nature of the side effect. Choice D is unnecessary at this point since nausea is a common side effect that may improve with time.
4. A client has active genital herpes simplex virus type 2. Which of the following medications should the nurse plan to administer?
- A. Metronidazole
- B. Penicillin
- C. Acyclovir
- D. Gentamicin
Correct answer: C
Rationale: Acyclovir is the antiviral medication specifically used to treat herpes simplex virus infections, including genital herpes caused by herpes simplex virus type 2. Metronidazole (Choice A) is an antibiotic used for different types of infections, but not for viral infections like herpes. Penicillin (Choice B) is an antibiotic effective against bacterial infections, not viruses like herpes. Gentamicin (Choice D) is an antibiotic mainly used to treat bacterial infections, not viral infections like herpes.
5. Which intervention is most appropriate when caring for a patient experiencing a tonic-clonic seizure?
- A. Restrain the patient to prevent injury
- B. Place a tongue depressor in the patient's mouth
- C. Turn the patient to the side to maintain an open airway
- D. Attempt to stop the seizure by holding the patient’s arms
Correct answer: C
Rationale: During a tonic-clonic seizure, the priority is to ensure patient safety by maintaining an open airway to prevent aspiration. Turning the patient to the side helps achieve this goal by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration. Restraint can lead to injury, placing a tongue depressor can cause harm or obstruct the airway further, and attempting to stop the seizure by holding the patient's arms is ineffective and can also result in injury. Therefore, the most appropriate intervention is to turn the patient to the side.