HESI LPN
HESI PN Nutrition Practice Exam
1. How should pain be assessed in a nonverbal child?
- A. Ask the parents about the child’s usual behavior
- B. Observe the child’s facial expressions and body movements
- C. Measure the child’s blood pressure
- D. Use a pain rating scale for older children
Correct answer: B
Rationale: Observing the nonverbal child's facial expressions and body movements is crucial in assessing pain. Nonverbal children may not be able to communicate their discomfort verbally, making it essential to rely on physical cues. Asking parents about the child's usual behavior (choice A) may provide some insight but observing the child directly is more direct and reliable. Measuring blood pressure (choice C) is not typically a direct method for assessing pain in nonverbal children. Using a pain rating scale designed for older children (choice D) is also inappropriate for nonverbal children who cannot participate in such self-reporting tools.
2. Tim, a 27-year-old man, has unusually narrow shoulders, low muscle mass, and has no facial and body hair. His doctor recently prescribed testosterone replacement therapy to him. Tim is most likely suffering from:
- A. Phenylketonuria (PKU).
- B. Cystic fibrosis.
- C. Klinefelter syndrome.
- D. Huntington’s disease (HD).
Correct answer: C
Rationale: Tim's physical characteristics, such as narrow shoulders, low muscle mass, and lack of facial and body hair, are typical signs of Klinefelter syndrome, a genetic condition where males have an extra X chromosome (XXY). This leads to underdeveloped testes and reduced testosterone production, resulting in features like gynecomastia, sparse facial and body hair, and reduced muscle mass. Testosterone replacement therapy is commonly used to address the hormonal imbalance in individuals with Klinefelter syndrome. Phenylketonuria (PKU) is a metabolic disorder unrelated to the symptoms described in Tim's case. Cystic fibrosis is a genetic respiratory condition that does not present with the physical characteristics mentioned. Huntington’s disease (HD) is a neurodegenerative disorder primarily affecting motor function and cognition, not physical appearance and muscle mass.
3. The caregiver is teaching the mother of a toddler about burn prevention. Which response by the mother indicates a need for further teaching?
- A. We will leave fireworks displays to the professionals.
- B. I will set our water heater at 130 degrees.
- C. All sleepwear should be flame retardant.
- D. The handles of pots on the stove should face inward.
Correct answer: B
Rationale: Setting the water heater at 130 degrees can lead to scald burns. The recommended temperature setting for water heaters is no higher than 120 degrees to prevent burns. Choice A is correct as it shows awareness of the risks of fireworks. Choice C is correct as flame-retardant sleepwear can help prevent burns. Choice D is correct as inward-facing pot handles prevent accidental spills and burns. Option B is incorrect due to the unsafe water heater temperature setting.
4. A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.)
- A. Portal hypertension.
- B. Sodium and water retention.
- C. Decreased serum albumin.
- D. All of the above
Correct answer: D
Rationale: In advanced liver failure related to chronic alcoholism, ascites and edema occur due to multiple pathophysiological mechanisms. Portal hypertension contributes to the development of ascites by increasing pressure in the portal venous system. Sodium and water retention exacerbate fluid accumulation in the third space. Decreased serum albumin levels lead to reduced oncotic pressure, contributing to the movement of fluid into the interstitial spaces. Abnormal protein metabolism further disrupts fluid balance. Therefore, all of the options (A, B, and C) are correct in this scenario, making choice D the correct answer. Choices A, B, and C alone do not fully explain the comprehensive pathophysiological mechanisms involved in the development of ascites and edema in this clinical context.
5. What is one of the most important factors that a healthcare professional must consider when parents of a toddler request to be present at a procedure occurring on the hospital unit?
- A. Type of procedure to be performed
- B. Individual assessment of the parents
- C. Whether the toddler wants the parents present
- D. Probable reaction to the toddler’s response to pain
Correct answer: B
Rationale: When parents of a toddler request to be present during a procedure, an individual assessment of the parents is crucial. This assessment helps healthcare professionals understand the parents' ability to cope with the situation, provide support to their child, and ensure a conducive environment for the procedure. Choice A is not as critical because the focus is on the parents' readiness rather than the specific procedure. Choice C, considering the toddler's desire, is important but not as crucial as assessing the parents. Choice D, anticipating the toddler's response to pain, is relevant but secondary to assessing the parents' readiness and support capabilities.