HESI LPN
Fundamentals of Nursing HESI
1. When evaluating care of an immobilized patient, which action will the nurse take?
- A. Focus on whether the interdisciplinary team is satisfied with the care.
- B. Compare the patient's actual outcomes with the outcomes in the care plan.
- C. Involve primarily the patient's family and health care team to determine goal achievement.
- D. Use objective data solely in determining whether interventions have been successful.
Correct answer: B
Rationale: When evaluating the care of an immobilized patient, the nurse should focus on assessing outcomes and response to nursing care. By comparing the patient's actual outcomes with the outcomes identified during planning, the nurse can determine the effectiveness of the interventions implemented. This process allows for a comprehensive evaluation of the care provided. Choice A is incorrect because the satisfaction of the interdisciplinary team does not directly reflect the patient's outcomes and response to care. Choice C is incorrect as it mainly focuses on the involvement of the patient's family and healthcare team, which may not provide a holistic evaluation of the patient's care. Choice D is incorrect as relying solely on objective data may lead to overlooking important subjective aspects of the patient's response and outcomes, which are also crucial in evaluating care effectively.
2. To accommodate a patient who is an Orthodox Jew, you would assure that her diet does not include which of the following?
- A. Any combination of meat and milk at the same meal
- B. Fish with scales
- C. Salmon
- D. Grape juice
Correct answer: A
Rationale: The correct answer is A. Orthodox Jewish dietary laws prohibit mixing meat and dairy in the same meal, so to accommodate an Orthodox Jew, you should ensure that their diet does not include any combination of meat and milk at the same meal. Choices B, C, and D are not prohibited in a kosher diet. Fish with scales, including salmon, are typically kosher, and grape juice is also permissible under kosher guidelines if certified. Therefore, options B, C, and D are acceptable in an Orthodox Jewish diet, while option A contradicts their dietary laws.
3. A client with a history of bipolar disorder presents to the emergency department with symptoms of mania. What is the priority nursing intervention?
- A. Administer prescribed medication to manage symptoms.
- B. Provide a calm environment with minimal stimulation.
- C. Encourage the client to express feelings and emotions.
- D. Reinforce the need for consistent medication adherence.
Correct answer: A
Rationale: Administering prescribed medication to manage symptoms is the priority intervention for a client with symptoms of mania. During a manic episode, the client may be at risk of harm to self or others due to impulsivity and poor judgment. Medication helps stabilize the client, reduce manic symptoms, and prevent further escalation. Providing a calm environment (choice B) is important but not the priority when the client's safety is at risk. Encouraging expression of feelings (choice C) and reinforcing medication adherence (choice D) are valuable aspects of care but addressing the acute symptoms of mania takes precedence to ensure the client's immediate safety and well-being.
4. Inspiratory and expiratory stridor may be heard in a client who:
- A. Is experiencing an exacerbation of goiter
- B. Is experiencing an acute asthmatic attack
- C. Has aspirated a piece of meat
- D. Has severe laryngotracheitis
Correct answer: D
Rationale: Inspiratory and expiratory stridor are high-pitched, wheezing sounds caused by disrupted airflow due to airway obstruction. Severe laryngotracheitis, involving inflammation and swelling of the larynx and trachea, leads to airway obstruction and can produce both inspiratory and expiratory stridor. Exacerbation of goiter, an acute asthmatic attack, and aspiration of a piece of meat are not typically associated with both inspiratory and expiratory stridor. Therefore, choices A, B, and C are incorrect.
5. A client with severe depression is prescribed sertraline. Which statement by the client indicates the need for further teaching?
- A. I can stop taking this medication once I feel better.
- B. It may take 1 to 4 weeks to notice improvement in symptoms.
- C. I should avoid alcohol while taking this medication.
- D. I should take this medication in the morning with food.
Correct answer: A
Rationale: The correct answer is A. Clients should not stop taking sertraline abruptly once they feel better without consulting their healthcare provider. It is important to complete the full course of treatment as prescribed to prevent a relapse of symptoms. Stopping the medication suddenly can lead to withdrawal symptoms and may worsen the condition. Choice B is correct because sertraline may take 1 to 4 weeks to show noticeable improvement in symptoms. Choice C is correct as alcohol should be avoided while taking sertraline due to the increased risk of side effects. Choice D is also correct as taking sertraline in the morning with food can help reduce gastrointestinal side effects.