HESI LPN
HESI Test Bank Medical Surgical Nursing
1. The cognitive impairment is classified into four levels based on the intelligence quotient (IQ). How is a child with an IQ of 45 classified?
- A. Within the normal low range
- B. Educable
- C. Trainable
- D. Severe
Correct answer: C
Rationale: A child with an IQ of 45 is classified as 'Trainable' in the context of cognitive impairment levels. This category is determined by an IQ range of 35 to 55. Choice A ('Within the normal low range') is incorrect as an IQ of 45 falls within the range associated with the 'Trainable' level, not the 'Normal low range.' Choice B ('Educable') is incorrect because this classification typically corresponds to individuals with slightly higher IQs that allow for academic progress with support. Choice D ('Severe') is incorrect as it does not align with the IQ level of 45, which falls within the 'Trainable' category.
2. What action is best for the community health nurse to take if the nurse suspects that an infant is being physically abused?
- A. Follow agency protocols to report suspected abuse.
- B. Report suspicions to the local child abuse reporting hotline.
- C. Educate the child's caregivers about growth and development issues.
- D. Call the police department to have the child removed from the home.
Correct answer: A
Rationale: When a community health nurse suspects that an infant is being physically abused, the best course of action is to follow agency protocols to report the suspected abuse. This is essential to ensure that the appropriate authorities are informed, and proper interventions can be initiated. Reporting suspicions to the local child abuse reporting hotline (Choice B) can be a part of the agency protocols but may not cover all necessary steps. Educating the child's caregivers about growth and development (Choice C) is not appropriate in cases of suspected abuse, as the immediate focus should be on the safety and well-being of the infant. Calling the police department to have the child removed from the home (Choice D) is not the primary role of the nurse; the proper authorities should handle the removal process after an investigation.
3. A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labor with misoprostol?
- A. A client who has active genital herpes
- B. A client who has gestational diabetes mellitus
- C. A client who has a previous uterine incision
- D. A client who has placenta previa
Correct answer: B
Rationale: Misoprostol can be used for induction in clients with gestational diabetes mellitus. Choice A, a client with active genital herpes, is not a candidate for misoprostol induction due to the risk of viral shedding and transmission. Choice C, a client with a previous uterine incision, may be at risk for uterine rupture with misoprostol use. Choice D, a client with placenta previa, is not an appropriate candidate for misoprostol induction due to the risk of increased bleeding associated with the condition.
4. The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month-old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the Center for Disease Control (CDC)?
- A. 13 to 18 years of age.
- B. 11 to 12 years of age.
- C. 18 to 24 months of age.
- D. 4 to 6 years of age.
Correct answer: D
Rationale: The correct answer is D: 4 to 6 years of age. The CDC recommends the MMR booster for children in this age group. Choice A (13 to 18 years of age) is incorrect as it is not the recommended age range for the MMR booster. Choice B (11 to 12 years of age) is also incorrect as it does not align with the CDC guidelines for the MMR booster. Choice C (18 to 24 months of age) is not the correct age range for the MMR booster according to CDC recommendations.
5. When caring for a 2-year-old girl who is wheezing and has difficulty breathing, which interview question would provide the most useful information related to the symptoms of the child?
- A. Inquiring about child safety in the home
- B. Asking about the temperament of the child
- C. Asking about the child's diet
- D. Asking the parents if they smoke in the home
Correct answer: D
Rationale: Asking the parents if they smoke in the home is the most relevant question as exposure to secondhand smoke can exacerbate respiratory symptoms like wheezing and difficulty breathing in children. Smoking indoors can worsen the child's condition and is crucial information for the healthcare provider to assess and address. Inquiring about child safety in the home, asking about the child's temperament, and questioning the child's diet are important aspects of care but are not directly linked to the immediate respiratory symptoms the child is experiencing.