HESI LPN
Fundamentals of Nursing HESI
1. During a skin assessment, a client expresses concern about skin cancer due to a lesion on the anterior thigh. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?
- A. An uneven shape
- B. A uniformly colored lesion
- C. A lesion that is small and flat
- D. A lesion that is less than 1 cm in diameter
Correct answer: A
Rationale: An uneven shape of a lesion is a common characteristic of malignant skin lesions. Asymmetric or irregularly shaped lesions are concerning for skin cancer and should be reported promptly for further evaluation and management. Choice B, a uniformly colored lesion, is more indicative of a benign lesion as malignant lesions often exhibit variations in color. Choice C, a lesion that is small and flat, does not necessarily indicate malignancy by itself. Choice D, a lesion that is less than 1 cm in diameter, is more suggestive of a benign lesion, as malignant lesions are typically larger in size.
2. When planning interventions for a group of clients who are obese, what can the nurse do to improve their commitment to a long-term goal of weight loss?
- A. Developing a strict diet plan
- B. Attempting to develop the clients’ self-motivation
- C. Providing frequent rewards
- D. Encouraging group exercise
Correct answer: B
Rationale: To improve clients' commitment to a long-term goal of weight loss, attempting to develop their self-motivation is crucial. Self-motivation is essential for sustaining behavior changes over time. Providing a strict diet plan (choice A) may not address the root motivation needed for long-term success. While rewards (choice C) can be motivating, relying solely on external rewards may not foster the intrinsic motivation required for sustained weight loss. Encouraging group exercise (choice D) is beneficial, but without addressing individual motivation, it may not lead to long-term commitment to weight loss goals.
3. A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?
- A. Firmly tell the client not to grab
- B. Redirect the client’s attention
- C. Use physical restraints
- D. Avoid contact with the client
Correct answer: B
Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.
4. A client has a new diagnosis of hypothyroidism. Which of the following interventions should the nurse include in the plan of care?
- A. Provide a high-calorie diet.
- B. Encourage frequent rest periods.
- C. Restrict fluid intake.
- D. Increase iodine intake.
Correct answer: B
Rationale: The correct intervention for a client with hypothyroidism is to encourage frequent rest periods. Hypothyroidism often leads to fatigue, making rest essential for recovery and symptom management. Providing a high-calorie diet is not necessary unless the client has gained weight due to hypothyroidism. Restricting fluid intake is not indicated unless there are specific medical reasons for it. Increasing iodine intake is not recommended for primary hypothyroidism, as it is typically caused by autoimmune thyroiditis or other factors rather than iodine deficiency.
5. When caring for a client with diarrhea due to shigellosis, what precautions should the nurse implement?
- A. Wear a gown when caring for the client.
- B. Wear gloves only.
- C. Use standard precautions only.
- D. Wear a mask and face shield.
Correct answer: A
Rationale: The correct answer is to wear a gown when caring for the client. Shigellosis is highly contagious, and contact precautions are essential to prevent the spread of infection. Wearing gloves alone may not provide adequate protection as the client's diarrhea can contain infectious pathogens that can easily spread. Standard precautions include hand hygiene, but specific precautions for shigellosis require wearing a gown to protect against contact with infectious material. Wearing a mask and face shield are not necessary for shigellosis, as the primary mode of transmission is through the fecal-oral route, and these precautions are not indicated for this type of transmission.
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