HESI LPN
HESI Fundamentals 2023 Quizlet
1. Which anatomical location is associated with the deep tendon reflex known as the patellar reflex?
- A. Knee picture
- B. Ankle picture
- C. Elbow picture
- D. Wrist picture
Correct answer: A
Rationale: The patellar reflex, also called the knee-jerk reflex, is elicited by tapping the patellar tendon just below the patella. This reflex involves the quadriceps muscle and the femoral nerve. The correct answer is 'A: Knee picture' because the patellar reflex is associated with the knee joint. Choices B, C, and D are incorrect as they do not correspond to the anatomical location involved in the patellar reflex.
2. What is the priority intervention for a client with major depressive disorder admitted to the psychiatric unit with suicidal ideation?
- A. Conduct a thorough suicide risk assessment.
- B. Encourage the client to verbalize their feelings.
- C. Provide the client with positive affirmations.
- D. Refer the client to group therapy.
Correct answer: A
Rationale: The correct answer is to conduct a thorough suicide risk assessment. When a client with major depressive disorder presents with suicidal ideation, the priority is to assess the level of risk to ensure the client's safety. This assessment helps determine the appropriate interventions, level of care, and monitoring needed. Encouraging the client to verbalize their feelings (choice B) is important, but not the priority when immediate safety is a concern. Providing positive affirmations (choice C) and referring the client to group therapy (choice D) may be beneficial interventions later on but do not address the immediate risk of harm to the client.
3. A client is receiving chemotherapy for breast cancer. Which laboratory value would be most important for the nurse to monitor?
- A. White blood cell count
- B. Hemoglobin level
- C. Serum creatinine
- D. Blood glucose level
Correct answer: A
Rationale: The correct answer is to monitor the white blood cell count. Chemotherapy can lead to neutropenia, which is a decrease in white blood cells, particularly neutrophils. Neutropenia increases the risk of infections, making it crucial to monitor the white blood cell count during chemotherapy. Monitoring hemoglobin level is important but not as critical as white blood cell count in this scenario. Serum creatinine and blood glucose levels are not directly impacted by chemotherapy for breast cancer, making them less relevant to monitor in this situation.
4. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement?
- A. Administer a prescribed sedative
- B. Encourage client to drink water
- C. Apply a high flow venturi mask
- D. Assist her to an upright position
Correct answer: D
Rationale: Assisting the client to an upright position is the most appropriate intervention in this situation. Placing the client upright helps improve lung expansion by reducing diaphragmatic pressure, facilitating better air exchange, and increasing oxygenation. This position also aids in easing breathing efforts. Administering a sedative (Choice A) may further depress the respiratory system, worsening the breathing problem. Encouraging the client to drink water (Choice B) may not directly address the respiratory distress caused by COPD. Applying a high flow venturi mask (Choice C) may be beneficial in some cases but assisting the client to an upright position should be the priority to optimize respiratory function.
5. The nurse is caring for a client with a suspected stroke. Which assessment finding is most indicative of a stroke?
- A. Chest pain
- B. Sudden confusion and difficulty speaking
- C. Gradual onset of weakness in the legs
- D. Nausea and vomiting
Correct answer: B
Rationale: The correct answer is B: Sudden confusion and difficulty speaking. These are classic signs of a stroke, indicating a neurological deficit that requires urgent medical attention. Choices A, C, and D are less indicative of a stroke. Chest pain is more commonly associated with cardiac issues, gradual onset of weakness in the legs could be related to other conditions like peripheral neuropathy, and nausea/vomiting may suggest gastrointestinal problems rather than a stroke.