HESI LPN
Fundamentals of Nursing HESI
1. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Invasion of privacy
Correct answer: A
Rationale: The correct answer is A: Assault. Assault involves making threats or using actions that cause the client to fear harm. In this scenario, the AP's threat to use diapers next time the urinal is used improperly constitutes as assault. Choice B, Battery, involves intentional harmful or offensive touching without consent, which is not evident in the scenario. Choice C, False imprisonment, refers to restraining or restricting a client's freedom of movement, which is not occurring in this situation. Choice D, Invasion of privacy, involves violating a client's right to privacy, which is also not applicable here.
2. In what position does the Pavlik harness hold a child's femurs for developmental hip dysplasia?
- A. Abduction
- B. Adduction
- C. Flexion
- D. Extension
Correct answer: A
Rationale: The Pavlik harness is designed to position a child's femurs in abduction for developmental hip dysplasia. Abduction helps align the hip joint correctly and promotes proper development in cases of hip dysplasia. Adduction (choice B) brings the legs closer to the midline, which is not the desired position in this condition. Flexion (choice C) refers to bending at a joint, while extension (choice D) is the opposite of flexion. However, in the case of developmental hip dysplasia, abduction is crucial for the Pavlik harness to work effectively.
3. A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement?
- A. Tell the client to have a complete blood count (CBC) drawn
- B. Instruct the client to seek medical attention immediately
- C. Encourage them to take the medication at night with a snack
- D. Explain that these are common side effects of the medication
Correct answer: B
Rationale: Increased agitation, irritability, and anxiety can be signs of serotonin syndrome or other serious side effects, not common side effects of fluoxetine. Instructing the client to seek medical attention immediately is crucial to address any potential serious adverse reactions. Option A is unnecessary as a CBC would not address the symptoms described. Option C is not the priority when serious side effects are suspected. Option D is incorrect as these symptoms should not be dismissed as common side effects.
4. While assessing an Rh-positive newborn whose mother is Rh-negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
- A. Jaundice evident at 26 hours
- B. Hematocrit of 55%
- C. Serum bilirubin of 12 mg/dL
- D. Positive Coombs test
Correct answer: C
Rationale: A serum bilirubin level of 12 mg/dL in a newborn is concerning and can indicate a significant risk of hyperbilirubinemia, which requires immediate medical intervention to prevent complications like kernicterus. Jaundice at 26 hours (Choice A) is a symptom, not a laboratory result, and needs monitoring but not an immediate report. Hematocrit of 55% (Choice B) may be elevated but is not indicative of hyperbilirubinemia. A positive Coombs test (Choice D) indicates the presence of antibodies on the newborn's red blood cells but does not directly correlate with the risk of hyperbilirubinemia.
5. Do dizygotic (DZ) twins run in families?
- A. Yes
- B. No
- C. Rarely
- D. Never
Correct answer: A
Rationale: Yes, dizygotic (DZ) twins can run in families. This is due to genetic factors that influence hyperovulation, where a woman releases multiple eggs during her menstrual cycle. This genetic predisposition can be passed down through generations, increasing the likelihood of having dizygotic twins. Choices B, C, and D are incorrect because the statement that dizygotic twins run in families is true, as supported by scientific evidence. It is important to note that while the genetic predisposition for dizygotic twins can run in families, it does not guarantee that every generation will have twins, as other factors also play a role in twin pregnancies.