HESI LPN
HESI Fundamentals 2023 Test Bank
1. During an admission history, a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress?
- A. Blood glucose - a common stress response.
- B. Intestinal peristalsis - should decrease due to stress.
- C. Peripheral blood vessels diameter - can vary in response to stress.
- D. Urine output - may vary but not a typical stress response.
Correct answer: A
Rationale: The correct answer is A. Stress typically increases blood glucose levels due to the release of stress hormones like cortisol and adrenaline. Elevated blood glucose helps provide energy for the body to cope with the stressful situation. Choice B is incorrect because intestinal peristalsis, the movement of the intestines, is more likely to decrease under stress due to the 'fight or flight' response. Choice C is incorrect as peripheral blood vessels' diameter may vary in response to stress, with both constriction and dilation possible. Choice D is incorrect as urine output may increase or decrease depending on individual differences and the specific stress response, but it is not a typical or direct physiological response to stress.
2. What is the most important information the nurse should teach a diabetic client about foot care?
- A. Inspect feet daily
- B. Wear cotton socks
- C. Use lukewarm water to wash feet
- D. Cut nails straight across
Correct answer: A
Rationale: The correct answer is to inspect feet daily. For diabetic clients, daily foot inspection is crucial in preventing complications like infections and ulcers. By checking their feet regularly, clients can identify any issues early and seek appropriate medical care. The other choices are important aspects of foot care for diabetic clients but not as critical as daily foot inspections. Wearing cotton socks helps in moisture control, using lukewarm water to wash feet helps prevent skin damage, and cutting nails straight across prevents ingrown nails. However, daily foot inspection is the most vital as it allows for early detection of any potential problems, which is key in diabetic foot care.
3. A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client’s serum laboratory value requires intervention by the nurse?
- A. Total calcium 9 mg/dl (2.25 mmol/L SI)
- B. Creatinine 4 mg/dl (354 micromol/L SI)
- C. Phosphate 4 mg/dl (1.293 mmol/L SI)
- D. Fasting glucose 95 mg/dl (5.3 mmol/L SI)
Correct answer: B
Rationale: An elevated creatinine level indicates possible renal impairment, which requires intervention. High creatinine levels are associated with decreased kidney function, and in this case, it suggests potential renal issues due to long-term corticosteroid therapy. Monitoring renal function is crucial in clients with osteoporosis on corticosteroid therapy to prevent further complications. Total calcium levels within the normal range are suitable for a client with osteoporosis receiving calcium carbonate. Phosphate and fasting glucose levels do not directly indicate renal impairment in this scenario.
4. What is the typical therapeutic management treatment for children with Hirschsprung disease?
- A. Daily enemas
- B. Low-fiber diet
- C. Permanent colostomy
- D. Surgical removal of affected section of bowel
Correct answer: D
Rationale: The most common treatment for Hirschsprung disease is the surgical removal of the affected section of the bowel. This procedure entails excising the part of the colon that lacks nerve cells crucial for normal bowel function. Daily enemas (Choice A) can offer temporary relief for constipation but do not address the root cause of the condition, which is the absence of nerve cells. A low-fiber diet (Choice B) is not a primary therapy for Hirschsprung disease and may not effectively manage the disorder. A permanent colostomy (Choice C) is typically considered in severe cases where other interventions have failed and is not the standard management approach for Hirschsprung disease.
5. A child is being assessed for suspected intussusception. What clinical manifestation is the healthcare provider likely to observe?
- A. Projectile vomiting
- B. Currant jelly stools
- C. Abdominal distension
- D. Constipation
Correct answer: C
Rationale: The correct clinical manifestation the healthcare provider is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception involves one portion of the intestine telescoping into another, causing obstruction. Abdominal distension is a common symptom due to the obstruction and buildup of gas and fluid in the affected area. While projectile vomiting can occur, it is not as specific to intussusception as abdominal distension. Currant jelly stools, which are stools containing blood and mucus, are a classic sign of intussusception but are not a clinical manifestation observable on assessment. Constipation is not typically associated with intussusception, as this condition often presents with symptoms of bowel obstruction rather than constipation.