HESI LPN
HESI Fundamentals Study Guide
1. A nurse in a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which concept should the nurse and client discuss in the termination phase of the relationship?
- A. Loss
- B. Autonomy
- C. Confidentiality
- D. Accountability
Correct answer: A
Rationale: In the termination phase of a nurse-client relationship, discussing 'loss' is crucial to help the client understand and process the end of the therapeutic relationship and any emotional impact. This discussion can aid in closure and transitioning out of the professional relationship. 'Autonomy' refers to the client's right to make decisions about their care, which is important throughout the relationship but not specifically in the termination phase. 'Confidentiality' is essential for maintaining trust but is not the primary focus during termination. 'Accountability' involves being answerable for one's actions, which is important in nursing practice but not a central topic in the termination phase of the relationship.
2. For an older postoperative client with the nursing diagnosis 'impaired mobility related to fear of falling,' which desired outcome best directs the nurse's actions for the client?
- A. The client will ambulate with assistance every 4 hours
- B. The physical therapist will instruct the client in the use of a walker
- C. The client will use self-affirmation statements to decrease fear
- D. The nurse will place a gait belt on the client prior to ambulation
Correct answer: C
Rationale: Encouraging the client to use self-affirmation statements is the most appropriate desired outcome in this scenario. By utilizing self-affirmation statements, the client can address their fears directly and build confidence, which can ultimately lead to a reduction in fear of falling. While ambulating with assistance (choice A) is important, the focus here is on addressing the fear itself. Instructing the client in the use of a walker (choice B) and placing a gait belt on the client (choice D) are interventions that may be helpful but do not directly address the client's fear of falling.
3. During a blood transfusion, which observation indicates that the client is experiencing a transfusion reaction?
- A. The client reports feeling warm and flushed.
- B. The client develops a rash on the chest and back.
- C. The client experiences chills and a fever.
- D. The client complains of back pain and shortness of breath.
Correct answer: D
Rationale: Complaints of back pain and shortness of breath are classic signs of a transfusion reaction, specifically indicating a hemolytic reaction. This reaction can lead to the release of hemoglobin into the bloodstream, causing back pain and shortness of breath due to clot formation in the blood vessels, leading to decreased oxygen delivery. Warmth, flushing, rash, chills, and fever are more commonly associated with allergic reactions or febrile non-hemolytic reactions during transfusions. Therefore, options A, B, and C are incorrect in this context.
4. How should a healthcare professional manage a child with scabies?
- A. Use topical permethrin cream
- B. Administer oral antibiotics
- C. Apply topical antifungals
- D. Provide supportive care only
Correct answer: A
Rationale: Corrected Rationale: Topical permethrin cream is the appropriate treatment for scabies as it effectively kills the mites causing the infestation. Oral antibiotics are not indicated for scabies as it is not a bacterial infection. Topical antifungals are used to treat fungal infections, not scabies. Providing supportive care only would not address the underlying cause of scabies, which is the mite infestation.
5. A 16-year-old female client returns to the clinic because she is pregnant for the third time by a new boyfriend. Which vaccine should the nurse plan to administer?
- A. Measles-mumps-rubella.
- B. Hepatitis B.
- C. Human papillomavirus.
- D. Pneumococcal.
Correct answer: B
Rationale: The correct answer is B: Hepatitis B. The Hepatitis B vaccine is crucial for pregnant women as it helps prevent transmission of the virus to the baby during childbirth. Measles-mumps-rubella vaccine (choice A) is not directly related to the current situation of the client being pregnant. Human papillomavirus vaccine (choice C) is recommended for adolescents but is not specifically indicated in this case. Pneumococcal vaccine (choice D) is not a priority in this scenario compared to Hepatitis B, which is crucial for preventing vertical transmission.