HESI LPN
HESI CAT Exam
1. The nurse assesses a 5-year-old child who has been experiencing frequent headaches and vomiting. The nurse notices that the child is lethargic and has a positive Brudzinski sign. Which action should the nurse implement first?
- A. Perform a complete neurological examination
- B. Measure the child’s head circumference
- C. Check the child’s blood glucose level
- D. Notify the healthcare provider immediately
Correct answer: D
Rationale: The correct action for the nurse to implement first is to notify the healthcare provider immediately. The presence of lethargy and a positive Brudzinski sign in a child experiencing frequent headaches and vomiting may indicate a serious condition like meningitis. Prompt notification of the healthcare provider is crucial for timely evaluation and initiation of appropriate treatment. Choice A is incorrect because while a neurological examination may be necessary, it is not the priority when a potentially serious condition like meningitis is suspected. Choice B is incorrect as measuring the child's head circumference is not the most immediate action to take in this situation. Choice C is also incorrect as checking the child's blood glucose level, although important in some cases, is not the priority when a child presents with symptoms suggestive of meningitis.
2. A child with a diagnosis of gastroesophageal reflux disease (GERD) is being discharged. What dietary instructions should the nurse provide?
- A. Avoid spicy foods
- B. Avoid gluten
- C. Avoid high-fat foods
- D. Avoid dairy products
Correct answer: C
Rationale: The correct dietary instruction for a child with GERD is to avoid high-fat foods. High-fat foods can relax the lower esophageal sphincter, leading to increased reflux. While avoiding gluten may be necessary for individuals with gluten sensitivity or celiac disease, it is not a standard recommendation for GERD. Avoiding spicy foods and dairy products may help some individuals with GERD, but the most crucial dietary advice is to avoid high-fat foods.
3. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?
- A. Notify the nursing manager.
- B. Document the client's condition and communication with the surgeon.
- C. Administer additional fluids as per standard procedure.
- D. Call the surgeon back immediately to ensure timely intervention.
Correct answer: B
Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.
4. A client with schizophrenia is receiving haloperidol (Haldol). The nurse should monitor the client for which of the following side effects?
- A. Tachycardia
- B. Hypotension
- C. Extrapyramidal symptoms
- D. Hyperglycemia
Correct answer: C
Rationale: The correct answer is C: Extrapyramidal symptoms. Haloperidol is a first-generation antipsychotic that can lead to extrapyramidal symptoms such as tardive dyskinesia and akathisia. These side effects are common with the use of typical antipsychotics. Choice A, Tachycardia, is not a common side effect of haloperidol. Choice B, Hypotension, is also not a typical side effect associated with haloperidol use. Choice D, Hyperglycemia, is not directly linked to haloperidol administration, as it is more commonly associated with other medications like atypical antipsychotics or certain medical conditions.
5. A client is post-operative day two from an abdominal surgery and reports feeling weak and lightheaded when attempting to get out of bed. What is the nurse's priority action?
- A. Encourage the client to drink fluids.
- B. Assist the client back to bed and monitor vital signs.
- C. Administer a prescribed antiemetic.
- D. Notify the healthcare provider.
Correct answer: B
Rationale: The nurse's priority action should be to assist the client back to bed and monitor vital signs. The client's symptoms of feeling weak and lightheaded could indicate potential issues like hypotension or dehydration, which need to be assessed promptly. Encouraging fluids (Choice A) could be beneficial but is not the immediate priority. Administering an antiemetic (Choice C) may not address the underlying cause of the client's symptoms. Notifying the healthcare provider (Choice D) can be done after the client has been stabilized and assessed.