a nurse is caring for a client who had a mastectomy 6 months ago the client tells the nurse that there has been a decreased desire for sexual relation
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Nursing Elites

HESI LPN

HESI Fundamentals Test Bank

1. A client had a mastectomy 6 months ago and expresses a decreased desire for sexual relations, stating “My body is so different now.” Which of the following responses should the nurse make?

Correct answer: B

Rationale: In this situation, the appropriate response is to reflect on the client’s feelings and explore their experience. Choice A may unintentionally dismiss the client's concerns by not addressing their emotional needs. Choice C suggests a spa treatment as a solution without addressing the underlying emotional issues. Choice D implies that the client's feelings will resolve with time, which may not be helpful in addressing the client's current emotional state.

2. A client is being admitted to a same-day surgery center for an exploratory laparotomy procedure. The surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that:

Correct answer: B

Rationale: The correct answer is B because as a witness, the nurse's primary responsibility is to confirm that the signature on the preoperative consent form belongs to the client. The nurse is not confirming the client's understanding of the procedure (Choice A), but rather the authenticity of the signature. Choice C is incorrect because the nurse is not responsible for verifying that the procedure has been explained, but rather confirming the client's signature. Similarly, Choice D is incorrect because the nurse's role as a witness is not to ensure the client is aware of potential complications, but to verify the signature.

3. A nurse is collecting a blood pressure reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mmHg. Which of the following actions should the nurse take?

Correct answer: C

Rationale: When a nurse obtains a blood pressure reading that is elevated, the appropriate action is to recheck the client's BP and measure the other arm for comparison. This step helps ensure accuracy by ruling out errors like improper cuff size, positioning, or equipment malfunction. Repositioning the client supine is not necessary unless the client shows signs of distress or symptoms. Ensuring the appropriate cuff width is important for accurate readings but does not address the immediate need to confirm the current BP. Requesting another nurse to check the BP in 30 minutes delays immediate action and does not address the need for verification and comparison of the current reading.

4. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate?

Correct answer: D

Rationale: The correct answer is D because there is no need to wait 72 hours before allowing the child to stand. The synthetic cast does not affect weight-bearing capacity, and standing can be done as tolerated. Choice A is incorrect because keeping the cast covered can lead to damage or accidents. Choice B is acceptable as applying an ice pack can help relieve itching. Choice C is also correct as elevating the cast on pillows can help reduce swelling and promote comfort during rest.

5. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?

Correct answer: A

Rationale: The correct answer is A. Nasogastric suctioning can lead to hypovolemia due to the loss of gastric fluids. Chronic constipation and syndrome of inappropriate antidiuretic hormone (SIADH) are not typically associated with hypovolemia. A toxic dose of sodium bicarbonate antacids may lead to metabolic alkalosis, not hypovolemia.

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