an adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discour
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Nursing Elites

HESI LPN

HESI Fundamentals 2023 Test Bank

1. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

Correct answer: A

Rationale: The correct approach for the nurse is to ask the client to elaborate on how their friends discourage them. By doing so, the nurse shows empathy, encourages the client to express their feelings, and gains insight into the situation. This open-ended question can help the nurse understand the specific issues the client is facing and work towards finding solutions collaboratively. Choices B, C, and D do not effectively address the client's concerns or encourage further discussion. Choice B is directive and may come off as judgmental, choice C assumes the friends are not supportive without exploring further, and choice D dismisses the client's feelings and the impact of peer influence.

2. A healthcare provider is assessing a client with a diagnosis of acute pancreatitis. Which laboratory value would be most concerning?

Correct answer: D

Rationale: In acute pancreatitis, hypocalcemia (low serum calcium) is a critical finding that is associated with a poor prognosis and requires immediate attention. Serum amylase and lipase are typically elevated in acute pancreatitis due to pancreatic inflammation, but they are not indicators of severity. Blood glucose levels may be elevated due to stress or underlying conditions but are not directly related to the severity of acute pancreatitis. Therefore, the most concerning value in this scenario is the low serum calcium level, which can have significant implications for the client's prognosis.

3. When should discharge planning for a client experiencing an exacerbation of heart failure be initiated?

Correct answer: A

Rationale: Discharge planning for a client with an exacerbation of heart failure should begin during the admission process. Initiating discharge planning early ensures a smooth transition and continuity of care for the client. Option B, after the client is stabilized, is not ideal because planning should start early to address potential barriers to discharge. Option C, when the client expresses readiness to go home, may be too late as discharge planning is a proactive process. Option D, just before the expected discharge date, does not allow enough time for comprehensive planning and coordination of post-discharge care needs.

4. A client is prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication?

Correct answer: B

Rationale: The correct way to take buccal medications is to insert the tablet between the cheek and gums where it will dissolve slowly. Option A is incorrect because buccal medications are not meant to be dissolved in water. Option C is incorrect as sublingual medications are placed under the tongue. Option D is incorrect because chewing a buccal tablet is not the correct administration method.

5. When changing the client's dressing, which observation should the nurse report to the client's surgeon for a client recovering from an appendectomy for a ruptured appendix with a surgical wound healing by secondary intention?

Correct answer: A

Rationale: A halo of erythema on the surrounding skin may indicate an infection or inflammation of the wound site, which is critical to report to the surgeon. Erythema, redness, and warmth are signs of inflammation that could potentially be a sign of an infected wound. Serous drainage is a common and expected finding in healing wounds, indicating a normal healing process. Edema around the wound might be expected due to the body's response to tissue injury. The absence of granulation tissue in a wound healing by secondary intention may not be an immediate concern as it forms during the later stages of wound healing.

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