HESI LPN
Pediatrics HESI 2023
1. A 6-year-old with muscular dystrophy was recently injured falling out of bed at home. What intervention should the nurse suggest to prevent further injury?
- A. Recommend raising the bed's side rails when a caregiver is not present.
- B. Suggest a caregiver be present continuously to prevent falls from bed.
- C. Encourage the use of loose restraints while in bed.
- D. Recommend raising the bed's side rails throughout the day and night.
Correct answer: A
Rationale: In this scenario, the most appropriate intervention to prevent further injury is to raise the bed's side rails when a caregiver is not present. This measure helps in preventing falls without the need for constant supervision. Choice B is not practical as continuous caregiver presence may not always be feasible. Choice C is unsafe as loose restraints can pose a strangulation risk. Choice D does not address the need for intervention when a caregiver is absent, potentially leading to an increased risk of falls.
2. Refers to the nurses in the local/national health departments or public schools:
- A. Public health nursing
- B. Public health nurse
- C. Registered midwives
- D. Registered nurses
Correct answer: B
Rationale: The correct term for nurses working in local/national health departments or public schools is 'public health nurse.' This term specifically refers to individual nurses in those settings. Choice A, 'Public health nursing,' is a broader term that refers to the field of nursing focused on improving community health. Choices C and D, 'Registered midwives' and 'Registered nurses,' do not specifically indicate the nurses working in local/national health departments or public schools, making them incorrect.
3. How should hydration status in a child with fever and vomiting be assessed?
- A. Monitor skin turgor and mucous membranes
- B. Measure blood glucose levels
- C. Check for signs of jaundice
- D. Assess respiratory rate
Correct answer: A
Rationale: To assess hydration status in a child with fever and vomiting, monitoring skin turgor and mucous membranes is essential. Skin turgor refers to the skin's ability to change shape and return to normal; poor skin turgor can indicate dehydration. Mucous membranes, such as the mouth and eyes, can also provide valuable information about hydration levels. Measuring blood glucose levels (Choice B) is not directly related to assessing hydration status. Checking for signs of jaundice (Choice C) is important for liver-related issues, not hydration assessment. Assessing respiratory rate (Choice D) is crucial for evaluating respiratory function, not hydration status.
4. A client with a history of deep vein thrombosis is prescribed apixaban. The nurse should monitor for which potential adverse effect?
- A. Increased risk of bleeding
- B. Decreased risk of bleeding
- C. Increased risk of infection
- D. Decreased risk of infection
Correct answer: A
Rationale: The correct answer is A: Increased risk of bleeding. Apixaban is an anticoagulant medication that works by preventing blood clots. While this is beneficial for individuals with a history of deep vein thrombosis, it also increases the risk of bleeding. Therefore, the nurse should monitor the client for signs of bleeding, such as easy bruising, prolonged bleeding from cuts, or blood in the urine or stool. Monitoring for bleeding is crucial to ensure the client's safety and to take appropriate actions if necessary. Choices B, C, and D are incorrect because apixaban does not decrease the risk of bleeding, increase the risk of infection, or decrease the risk of infection. The primary concern when administering apixaban is monitoring for potential bleeding complications.
5. The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention would be best in helping this client deal with his depression?
- A. Ensure that the client's day is filled with group activities.
- B. Assist the client in exploring feelings of shame, anger, and guilt.
- C. Allow the client to initiate and determine activities of daily living.
- D. Encourage the client to explore the rationale for his depression.
Correct answer: B
Rationale: Assisting the client in exploring feelings of shame, anger, and guilt (B) is the most appropriate intervention for acute depression as it helps address core emotions that may be contributing to the condition. Focusing on these emotions can aid the client in processing and coping with their feelings. Ensuring that the client's day is filled with group activities (A) might overwhelm the client, as they may not be ready for social interactions during this sensitive time. Allowing the client to initiate and determine activities of daily living (C) is more suitable for chronic cases where the client needs to regain autonomy. Encouraging the client to explore the rationale for his depression (D) is less effective in acute cases, as the focus should be on immediate emotional support and understanding rather than cognitive analysis.