HESI LPN
HESI CAT
1. In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?
- A. Ineffective coping related to uncertainty of disease progression
- B. Imbalanced nutrition: less than body requirements related to impaired swallowing reflex
- C. Ineffective breathing pattern related to ascending paralysis
- D. Impaired physical mobility related to asymmetrical descending paralysis
Correct answer: C
Rationale: Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.
2. A client has a new diagnosis of chlamydia. Which of the following actions should the nurse take?
- A. Report the infection to the local health department
- B. Apply an antiviral cream to lesions
- C. Instruct the client to use condoms until the treatment is completed
- D. Initiate contact precautions
Correct answer: A
Rationale: The correct answer is to report the infection to the local health department. Chlamydia is a reportable disease, meaning healthcare providers are required to report cases to public health authorities for tracking and control measures. Choice B is incorrect because chlamydia is a bacterial infection, not a viral infection, so antiviral cream would not be effective. Choice C is important advice for preventing the spread of chlamydia but is not the priority in this scenario. Choice D is not necessary for chlamydia, as it is primarily transmitted through sexual contact.
3. What is a common symptom of a vitamin D deficiency in children?
- A. Frequent infections
- B. Bone pain and tenderness
- C. Excessive thirst
- D. Unexplained bruising
Correct answer: B
Rationale: Bone pain and tenderness are indeed common symptoms of vitamin D deficiency in children. Vitamin D plays a crucial role in bone health and growth. The deficiency can lead to weakened bones, causing pain and tenderness. Choices A, C, and D are incorrect. Frequent infections are not a typical symptom of vitamin D deficiency in children; excessive thirst is more commonly associated with conditions like diabetes, and unexplained bruising is not directly linked to vitamin D deficiency.
4. A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?
- A. Patient is lying on side.
- B. Patient is lying on back.
- C. Patient is lying semiprone.
- D. Patient is lying on abdomen.
Correct answer: A
Rationale: The correct answer is A: 'Patient is lying on side.' In the side-lying (or lateral) position, the patient rests on the side with the major portion of body weight on the dependent hip and shoulder. Choice B, 'Patient is lying on back,' is incorrect as it describes a supine position. Choice C, 'Patient is lying semiprone,' is incorrect as it refers to a position where the patient is partially lying on the abdomen. Choice D, 'Patient is lying on abdomen,' is incorrect as it describes a prone position where the patient is lying face down.
5. The nurse is assessing a newborn the day after birth. A high-pitched cry, irritability, and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?
- A. Reduce the environmental stimuli
- B. Offer formula every 2 hours
- C. Talk to the newborn while feeding
- D. Rock the baby frequently
Correct answer: A
Rationale: The correct intervention is to reduce the environmental stimuli. In this scenario, the newborn is displaying signs of overstimulation and distress, which can be exacerbated by environmental factors. Offering formula every 2 hours (Choice B) may not address the underlying issue of overstimulation. Talking to the newborn while feeding (Choice C) and rocking the baby frequently (Choice D) may further stimulate the newborn, which is not appropriate in this case.