HESI LPN
HESI Fundamentals 2023 Test Bank
1. During a skin assessment, a client expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy?
- A. A mole with an asymmetrical appearance.
- B. A mole with a regular border.
- C. A mole that is the same color throughout.
- D. A mole that is smaller than 6mm in diameter.
Correct answer: A
Rationale: The correct answer is A: A mole with an asymmetrical appearance. Asymmetry is a key characteristic of potential skin malignancy. An asymmetrical mole does not have a uniform shape when divided in half. This irregularity raises suspicion for skin cancer. Choices B, C, and D are incorrect. A mole with a regular border (B) is more likely to be benign. A mole that is the same color throughout (C) is also a feature commonly seen in benign moles. Additionally, a mole smaller than 6mm in diameter (D) is not necessarily indicative of malignancy, as some melanomas can be smaller or larger than this size.
2. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?
- A. Risk for injury related to suicidal ideation.
- B. Risk for injury related to alcohol detoxification.
- C. Knowledge deficit related to ineffective coping.
- D. Health-seeking behaviors related to personal crisis.
Correct answer: B
Rationale: The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Giving lorazepam (Ativan) to address the elevated vital signs due to alcohol withdrawal is a priority. Addressing the risk for injury related to suicidal ideation (A) should come after stabilizing the client's physiological state. Both (C) and (D) can be addressed once immediate safety needs are met, but the priority is managing the alcohol detoxification to prevent potential complications.
3. In order to establish priorities in planning and implementing the occupational health program, which of the following data will the nurse need?
- A. disease trends, birth and death rates, and social environmental conditions
- B. birth and death rates
- C. disease trends
- D. social environmental conditions
Correct answer: A
Rationale: To effectively plan and implement an occupational health program, the nurse needs comprehensive data, including disease trends, birth and death rates, and social environmental conditions. This holistic approach ensures that the program addresses a wide range of health aspects impacting the target population. Option A is the correct choice as it considers multiple factors influencing occupational health. Choices B, C, and D are each individually important but do not provide the breadth of information required to establish priorities in a comprehensive occupational health program.
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?
- A. “I believe in this case you should make an exception and accept the blood transfusion.”
- B. “I know your family would approve of your decision to have a blood transfusion.”
- C. “Why does your religion mandate that you cannot receive any blood transfusions?”
- D. “Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.”
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. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
- A. Why don’t we now have the client turn back to the left side.
- B. That was done correctly. Did you have any problems with the insertion?
- C. Let’s check to see if the suppository is in far enough.
- D. Did you feel any stool in the intestinal tract?
Correct answer: B
Rationale: The appropriate comment by the nurse is to affirm the correct technique while offering support and checking for any issues during the insertion.