HESI LPN
HESI Fundamentals 2023 Quizlet
1. 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.
2. In planning care for a premature infant with respiratory distress syndrome, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to
- A. Stabilize alveolar surface tension
- B. Maintain alveolar surface tension
- C. Promote normal pulmonary blood flow
- D. Regulate intra-cardiac pressure
Correct answer: B
Rationale: The correct answer is B: Maintain alveolar surface tension. Respiratory distress syndrome in premature infants is often caused by a deficiency in surfactant, a substance that helps maintain alveolar surface tension. Without adequate surfactant, the alveoli collapse, making it difficult for the infant to oxygenate effectively. Choices A, C, and D are incorrect because stabilizing alveolar surface tension is not the issue, promoting normal pulmonary blood flow and regulating intra-cardiac pressure are not directly related to the pathophysiology of respiratory distress syndrome in premature infants.
3. When assisting an older adult client with dysphagia following a CVA during mealtime, what should the nurse prioritize?
- A. Offer the client tart or sour foods.
- B. Ensure the client is sitting upright while eating.
- C. Provide soft and easily swallowable foods.
- D. Give the client thickened liquids to help with swallowing.
Correct answer: B
Rationale: The correct answer is to ensure the client is sitting upright while eating. This position helps prevent aspiration and facilitates swallowing. Offering tart or sour foods (Choice A) may not be suitable for someone with dysphagia as they can be difficult to swallow and may increase the risk of aspiration. Providing soft and easily swallowable foods (Choice C) is crucial for individuals with swallowing difficulties. While giving thickened liquids (Choice D) is a common intervention for dysphagia, the priority during mealtime should be ensuring the client's proper positioning to support safe swallowing and prevent aspiration.
4. 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?
- A. “Really, you look just fine to me. There’s no need to feel undesirable.”
- B. “I’m interested in finding out more about how your body feels to you.”
- C. “Consider an afternoon at a spa; a facial will make you feel more attractive.”
- D. “It’s still too soon to expect to feel normal. Give it a little more time.”
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.
5. What will ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed?
- A. Place the pillow under the patient's head and shoulders.
- B. Attempt to do it alone if the bed is in a flat position.
- C. Place the side rails in the up position.
- D. Use a friction-reducing device.
Correct answer: D
Rationale: To ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed, it is essential to use a friction-reducing device. This device helps reduce the risk of injury to both the patient and the healthcare provider by minimizing the effort required to reposition the patient. Placing a pillow under the patient's head and shoulders (Choice A) may provide comfort but does not address the safety concerns associated with moving the patient. Attempting to move the patient alone (Choice B) is not recommended as it can lead to injuries for both the patient and the healthcare provider. Placing the side rails in the up position (Choice C) may not directly contribute to the safe movement of the patient in this scenario.
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