HESI LPN
Fundamentals HESI
1. During a family assessment, a nurse is interviewing a family composed of a husband, a wife, and three children. One child is biological from this marriage, and the other two are from the wife’s previous marriage. How should the nurse identify this family form?
- A. Extended
- B. Blended
- C. Nuclear
- D. Alternative
Correct answer: B
Rationale: The correct answer is 'Blended.' This family is considered a blended family because it consists of children from previous marriages, along with the biological child of the current marriage. Choice A ('Extended') refers to a family that includes relatives beyond the nuclear family, such as grandparents or aunts/uncles. Choice C ('Nuclear') typically consists of a husband, wife, and their biological children only. Choice D ('Alternative') does not accurately describe the family structure presented in the scenario.
2. What could suddenly occur in a child with acute epiglottitis?
- A. Increased carbon dioxide levels
- B. Airway obstruction
- C. Inability to swallow
- D. Bronchial collapse
Correct answer: B
Rationale: In acute epiglottitis, the infected epiglottis becomes inflamed and can lead to sudden airway obstruction, which is a life-threatening emergency. This can cause difficulty breathing and necessitates immediate intervention to secure the airway. Increased carbon dioxide levels may occur due to inadequate ventilation resulting from airway obstruction, but the primary concern is the obstruction itself, not the carbon dioxide levels. Inability to swallow may be present due to pain and swelling in the throat but is not the immediate life-threatening complication associated with acute epiglottitis. Bronchial collapse is not a typical consequence of acute epiglottitis.
3. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Place the tablet under your tongue and let it dissolve completely.
- C. Swallow the tablet whole with a glass of water.
- D. Chew the tablet for faster relief.
Correct answer: B
Rationale: The correct instruction for a client prescribed nitroglycerin sublingual tablets is to place the tablet under the tongue and let it dissolve completely. This route of administration allows for rapid absorption of the medication through the oral mucosa, providing quick relief for angina symptoms. Option A, taking the medication with food, is incorrect as nitroglycerin should be taken sublingually, not with food. Option C, swallowing the tablet whole with water, is incorrect as sublingual tablets should not be swallowed whole. Option D, chewing the tablet for faster relief, is also incorrect as chewing the tablet can lead to rapid absorption and potential adverse effects rather than a controlled release for angina relief.
4. While caring for an older adult client who is violent and attempting to disconnect her IV lines, the provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
- A. Remove the restraints one at a time
- B. Secure the restraints tightly to prevent movement
- C. Check the restraints every hour
- D. Use leather restraints for additional security
Correct answer: A
Rationale: Removing restraints one at a time is the correct action to take when caring for a client in soft wrist restraints. This approach ensures safety and comfort while still maintaining the necessary restrictions. Choice B is incorrect as securing the restraints tightly can lead to circulatory issues and discomfort. Choice C of checking the restraints every hour is a reasonable action, but it is not the priority when compared to the correct choice of removing the restraints one at a time. Choice D of using leather restraints for additional security is unnecessary and may be more restrictive and uncomfortable for the client.
5. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?
- A. You are in the hospital, and I am the nurse caring for you
- B. It must be difficult for you to control your anxious feelings
- C. Go to occupational therapy and start a project
- D. You are not in a war area now; this is the United States
Correct answer: C
Rationale: Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.