a nurse is assisting a client with a meal the client suddenly grabs at her neck with both hands and appears frightenethe appropriate nursing action is
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. While assisting a client with a meal, the client suddenly grabs at their neck with both hands and appears frightened. The appropriate nursing action is to:

Correct answer: A

Rationale: The correct action when a client suddenly grabs at their neck and appears frightened is to ask if they are choking. This allows the nurse to gather more information from the client directly. Performing abdominal thrusts (choice B) should only be done if the client is unable to speak, cough, or breathe. Calling for emergency help (choice C) should be done after assessing the situation and confirming choking. Checking the client's airway (choice D) is important but should come after confirming that the client is choking.

2. A client is evaluated by a nurse regarding the use of a sequential compression device. Which of the following client statements indicates understanding of the device's purpose?

Correct answer: B

Rationale: The correct answer is B because sequential compression devices are utilized to enhance circulation and prevent clot formation in the legs. Option A is incorrect because these devices are not primarily meant to prevent skin sores. Option C is incorrect because the devices do not directly address muscle weakness. Option D is incorrect as the main purpose of sequential compression devices is not related to joint health.

3. A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia?

Correct answer: D

Rationale: The correct answer is D: Report of continued pain following resolution of the rash. Postherpetic neuralgia is a complication of herpes zoster characterized by persistent pain that continues even after the rash has resolved. This pain can be severe and debilitating, affecting the quality of life of the individual. Choices A, B, and C are incorrect because linear clusters of vesicles on the right shoulder would suggest an active herpes zoster outbreak, purulent drainage from both eyes would indicate an eye infection unrelated to postherpetic neuralgia, and a decreased white blood cell count is not typically associated with postherpetic neuralgia.

4. A client expresses that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?

Correct answer: D

Rationale: The correct response is to involve the client's religious and spiritual leaders in the discussion to find a solution that respects both the client's values and medical needs. Option A is incorrect as it dismisses the client's beliefs. Option B assumes the family's opinion over the client's. Option C is inappropriate as it questions the client's religious beliefs rather than addressing the concern respectfully.

5. The healthcare provider is caring for a client who has just been diagnosed with myasthenia gravis. Which symptom should the healthcare provider expect to observe?

Correct answer: A

Rationale: Muscle weakness is a hallmark symptom of myasthenia gravis, a neuromuscular disorder characterized by impaired neuromuscular transmission. This results in muscle weakness, particularly in skeletal muscles that control eye movements, facial expressions, chewing, swallowing, and speaking. Joint pain (Choice B) is not a typical symptom of myasthenia gravis and is more commonly associated with conditions like arthritis. Vision changes (Choice C) may occur in conditions affecting the eyes, but they are not specific to myasthenia gravis. Skin rash (Choice D) is also not a typical manifestation of myasthenia gravis. Therefore, the correct answer is muscle weakness (Choice A).

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