HESI LPN
Medical Surgical Assignment Exam HESI
1. A teenage girl has been placed in a brace for the treatment of scoliosis, the most common skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion from the nurse is the most appropriate?
- A. Enrolling her in a health club
- B. Taking her to the mall in a wheelchair
- C. Purchasing clothes to disguise the brace
- D. Spending a majority of their time with her
Correct answer: C
Rationale: The most appropriate suggestion from the nurse is to recommend purchasing clothes to disguise the brace. Adolescents with scoliosis often have body image concerns and wish to fit in with their peers. By providing clothes that help conceal the brace, the family can support the teenage girl's emotional well-being. Choices A, B, and D do not directly address the adolescent's concerns about body image and fitting in, making them less appropriate in this situation.
2. A client with a spinal cord injury at the level of T1 is at risk for autonomic dysreflexia. Which symptom is indicative of this condition?
- A. Hypotension
- B. Tachycardia
- C. Severe headache
- D. Flushed skin below the level of injury
Correct answer: C
Rationale: Corrected Rationale: Autonomic dysreflexia is a condition commonly seen in clients with spinal cord injuries at T6 or above. It is characterized by a sudden onset of severe hypertension, pounding headache, profuse sweating, nasal congestion, and flushing of the skin above the level of injury. The severe headache is a key symptom resulting from uncontrolled hypertension. Choices A, B, and D are incorrect as autonomic dysreflexia typically presents with hypertension, not hypotension, tachycardia, or flushed skin below the level of injury.
3. A child has developed a diaper rash, and the parents are using zinc oxide to treat it. What does the nurse suggest to aid in the removal of the zinc oxide?
- A. Mild soap and water
- B. A cotton ball
- C. Mineral oil
- D. Alcohol swabs
Correct answer: C
Rationale: To completely remove ointment, especially zinc oxide, mineral oil should be used. Mineral oil helps in gently breaking down and lifting the ointment without causing irritation. Mild soap and water (Choice A) may not be effective in completely removing zinc oxide. A cotton ball (Choice B) may not provide the necessary lubrication to aid in the removal process. Alcohol swabs (Choice D) can be harsh on the skin and are not recommended for this purpose.
4. What are early signs of varicella disease?
- A. High fever over 101°F (38.3°C)
- B. General malaise
- C. Increased appetite
- D. Crusty sores
Correct answer: B
Rationale: The correct early sign of varicella disease is general malaise. During the prodromal period, patients may experience low-grade fever, malaise, and anorexia. Increased appetite and crusty sores are not typically early signs of varicella. The appearance of lesions occurs later in the course of the disease.
5. When assessing an adolescent with depression, what is the most important question for the nurse to ask?
- A. What is causing your feelings of depression?
- B. Have you ever thought about suicide?
- C. What actions can we take to improve your mood?
- D. Would you like your friends to come over?
Correct answer: B
Rationale: The correct answer is B: 'Have you ever thought about suicide?' When assessing an adolescent with depression, it is crucial to ask direct questions about suicidal thoughts. This helps determine the severity of the situation, especially if the person has considered or planned to harm themselves. Choice A is not as direct and specific to suicidal ideation. Choice C focuses on improving mood rather than assessing the risk of harm. Choice D is unrelated to assessing suicidal ideation and the severity of the depression.
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