HESI LPN
HESI Fundamentals Exam Test Bank
1. The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?
- A. Our child had chickenpox 6 months ago.
- B. Strep throat went through all the children at the day care last month.
- C. Both ears were infected over 3 months ago.
- D. Last week both feet had a fungal skin infection.
Correct answer: B
Rationale: The correct answer is B. Rheumatic fever often follows a strep throat infection, which is why the nurse should suspect this association. Strep throat is caused by Group A Streptococcus bacteria, which can trigger an abnormal immune response leading to rheumatic fever. Choices A, C, and D are incorrect because chickenpox, ear infections, and fungal skin infections are not typically associated with rheumatic fever.
2. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?
- A. I will avoid foods high in vitamin K.
- B. I will take my medication at the same time every day.
- C. I will use a soft toothbrush to prevent gum bleeding.
- D. I can take aspirin if I have a headache.
Correct answer: D
Rationale: The correct answer is 'D: I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or any other medications that can increase the risk of bleeding without consulting their healthcare provider. Choices A, B, and C are correct statements that demonstrate understanding of warfarin therapy and its potential side effects. Avoiding foods high in vitamin K helps maintain the effectiveness of warfarin, taking medication at the same time every day ensures consistent therapeutic levels, and using a soft toothbrush helps prevent gum bleeding, which can be a side effect of warfarin therapy.
3. What is a priority goal of involuntary hospitalization of the severely mentally ill client?
- A. Re-orientation to reality
- B. Elimination of symptoms
- C. Protection from harm to self or others
- D. Development of self-care skills
Correct answer: C
Rationale: The correct answer is C: 'Protection from harm to self or others.' Involuntary hospitalization is primarily aimed at ensuring the safety of the individual and others. Re-orientation to reality (choice A) may be a goal of treatment but not the primary goal of involuntary hospitalization. Elimination of symptoms (choice B) and development of self-care skills (choice D) are important aspects of treatment but are secondary to the immediate priority of ensuring safety in cases of severe mental illness.
4. A client with major depressive disorder is started on fluoxetine (Prozac). What should the nurse include in the client's discharge teaching?
- A. It may take 4-6 weeks for the medication to be effective.
- B. You should take this medication at bedtime.
- C. Avoid consuming dairy products while taking this medication.
- D. You can stop taking the medication once you feel better.
Correct answer: A
Rationale: The correct answer is A: "It may take 4-6 weeks for the medication to be effective." SSRIs like fluoxetine typically take 4-6 weeks to reach their full effect, so clients should be informed to expect a gradual improvement in symptoms. Choice B is incorrect because fluoxetine is usually taken in the morning to prevent sleep disturbances. Choice C is incorrect as there is no specific need to avoid consuming dairy products while taking fluoxetine. Choice D is incorrect because clients should never stop taking antidepressants abruptly, as it can lead to withdrawal symptoms and worsening of the condition.
5. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?
- A. "It must be difficult to care for someone who is confined to bed."
- B. "It is important to keep the client clean to avoid infections."
- C. "I understand that this is challenging; let’s work together to ensure comfort."
- D. "The smell is quite strong; we need to address this immediately."
Correct answer: C
Rationale: The correct response is C: "I understand that this is challenging; let’s work together to ensure comfort." This response acknowledges the difficulty the partner is facing, shows empathy, and offers to collaborate in providing care. Choice A is incorrect because it does not directly address the partner's feelings of embarrassment or offer support. Choice B, while true, does not address the partner's emotional state and may come across as directive rather than supportive. Choice D is also incorrect as it focuses solely on the smell without addressing the partner's emotions or offering assistance in managing the situation with empathy.