HESI LPN
HESI Mental Health 2023
1. An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the LPN/LVN to provide?
- A. Anywhere you want to stand as long as you do not get hurt by those in the parade.
- B. You are confused because of all the activity in the hall. There is no parade.
- C. Let us go back to the activity room and see what is going on in there.
- D. Remember I told you that this is a nursing home and I am your nurse.
Correct answer: C
Rationale: Redirecting the client to a less confusing environment can help reduce anxiety and reorient her to reality.
2. What is a common sign of congenital hip dysplasia in infants?
- A. Symmetrical hip movement
- B. Limited range of motion in the hip
- C. Swelling of the knees
- D. Dislocated patella
Correct answer: B
Rationale: Limited range of motion in the hip, often noted as a limitation in abduction, is a common sign of congenital hip dysplasia. This limitation is due to the abnormal development of the hip joint, affecting its movement. Symmetrical hip movement (Choice A) is not a characteristic sign of congenital hip dysplasia. Swelling of the knees (Choice C) is not typically associated with this condition. Dislocated patella (Choice D) refers to a different anatomical structure and is not a common sign of congenital hip dysplasia.
3. A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should alert the nurse to perform a further assessment?
- A. Flat occiput
- B. Small, low-set ears
- C. Circumoral cyanosis
- D. Protruding furrowed tongue
Correct answer: C
Rationale: Circumoral cyanosis should alert the nurse to perform a further assessment because it may indicate inadequate oxygenation or circulation, potentially related to cardiac or respiratory issues. Flat occiput (choice A) is a common finding in infants and is not typically concerning. Small, low-set ears (choice B) are common in Down syndrome and not specifically indicative of an acute issue requiring immediate further assessment. Protruding furrowed tongue (choice D) is also commonly seen in infants with Down syndrome and typically does not warrant immediate further assessment unless associated with other concerning signs or symptoms.
4. The PN observes a UAP bathing a bedfast client with the bed in the high position. Which action should the PN take?
- A. Remain in the room to supervise the UAP
- B. Determine if the UAP would like assistance
- C. Assume care of the client immediately
- D. Instruct the UAP to lower the bed for safety
Correct answer: D
Rationale: The correct action for the PN to take in this situation is to instruct the UAP to lower the bed for safety. Keeping the bed in the lowest position during care activities is crucial for preventing falls and injuries to both the client and the caregiver. Instructing the UAP to lower the bed addresses the immediate safety concern. Choice A is incorrect because simply supervising the UAP without addressing the unsafe bed height does not ensure the client's safety. Choice B is incorrect as the priority is to address the safety concern rather than offering assistance to the UAP. Choice C is incorrect as assuming care of the client immediately does not address the root issue of the high bed position.
5. The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long-term control of diabetes?
- A. The fasting blood sugar was 120 mg/dL this morning
- B. Urine ketones have been negative for the past 6 months
- C. The hemoglobin A1C was 6.5% last week
- D. No diabetic ketoacidosis has occurred in 6 months
Correct answer: C
Rationale: An A1C level of 6.5% indicates good long-term control of diabetes as it reflects the average blood sugar levels over the past 2-3 months. Monitoring fasting blood sugar provides immediate information about the current blood sugar level, while the absence of urine ketones indicates short-term control. Although the absence of diabetic ketoacidosis is positive, it doesn't specifically reflect long-term control like the A1C level does.