HESI LPN
HESI Practice Test for Fundamentals
1. A nurse is assigned to a manipulative client for 5 days and becomes aware of feelings of reluctance to interact with the client. What should the nurse do next?
- A. Discuss the feelings of reluctance with an objective peer or supervisor
- B. Limit contacts with the client to avoid reinforcement of the manipulative behavior
- C. Confront the client about the negative effects of behaviors on other clients and staff
- D. Develop a behavior modification plan that will promote more functional behavior
Correct answer: A
Rationale: It is important for the nurse to address their feelings of reluctance when dealing with a manipulative client by discussing them with an objective peer or supervisor. This action can provide valuable insight and support for managing the nurse-client relationship. Choice B should be avoided as limiting contacts with the client may not address the underlying issues and could potentially harm the therapeutic relationship. Choice C is confrontational and may escalate the situation rather than resolve it. Choice D, while important, should come after addressing the nurse's feelings and seeking support.
2. The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions?
- A. The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred.
- B. The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem.
- C. The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation.
- D. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.
Correct answer: D
Rationale: (D) provides the most validation for suspecting child abuse. The parent's explanation (subjective data) that the child was burned in a house fire is incompatible with the objective data observed by the nurse (small, round burns on the legs and trunk). (A) relies on subjective data, and the child's explanation might not accurately reflect the situation due to various factors like age or fear. The apparent lack of concern from the parents (B) is inconclusive as the nurse's interpretation of their reaction could be subjective. While parental anxiety (C) could hint at potential child abuse, it's important to note that most parents would naturally be anxious about their child's hospitalization, making it a less definitive indicator compared to the inconsistency in the explanation provided by the parents in option (D).
3. How should a healthcare provider manage a child with newly diagnosed congenital hypothyroidism?
- A. Monitor for signs of hyperactivity
- B. Ensure regular thyroid hormone replacement therapy
- C. Encourage a high-calcium diet
- D. Increase physical exercise
Correct answer: B
Rationale: Correct Answer: Ensuring regular thyroid hormone replacement therapy is crucial for managing congenital hypothyroidism in children. This therapy supports normal growth and development by replacing the deficient thyroid hormones. Monitoring for signs of hyperactivity (Choice A) is not the primary management for congenital hypothyroidism; rather, the focus should be on addressing the hormone deficiency. Encouraging a high-calcium diet (Choice C) may not directly address the thyroid hormone deficiency characteristic of congenital hypothyroidism. Increasing physical exercise (Choice D) is not the mainstay treatment for this condition; hormone replacement therapy is the cornerstone of management.
4. What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?
- A. Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.
- B. Risk for altered gas exchange.
- C. Risk for deficient fluid volume, related to increased sodium retention secondary to the administration of magnesium sulfate.
- D. Risk for increased cardiac output, related to the use of antihypertensive drugs.
Correct answer: A
Rationale: The most appropriate nursing diagnosis for a woman experiencing severe preeclampsia is 'Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.' Severe preeclampsia poses a significant risk of injury to both the mother and the fetus due to complications such as seizures, stroke, and placental abruption. 'Risk for altered gas exchange' is not the priority diagnosis as pulmonary edema is more common in severe preeclampsia. 'Risk for deficient fluid volume' is incorrect as sodium retention in severe preeclampsia often leads to fluid overload. 'Risk for increased cardiac output' is also incorrect as antihypertensive drugs are used to reduce cardiac output in this condition.
5. A client is being treated for dehydration. Which clinical finding would indicate that treatment is effective?
- A. Dry mucous membranes
- B. Increased urine output
- C. Tachycardia
- D. Hypotension
Correct answer: B
Rationale: The correct answer is B: Increased urine output. When a client is being treated for dehydration, increased urine output is a positive indication that the treatment is effective. This signifies that the body is beginning to rehydrate and eliminate excess fluid. Choices A, C, and D are incorrect because dry mucous membranes, tachycardia, and hypotension are all associated with dehydration and would not be signs of effective treatment.