HESI LPN
HESI Fundamentals Exam Test Bank
1. The nurse is assessing a client with a diagnosis of pheochromocytoma. Which symptom should the nurse expect to find?
- A. Hypertension
- B. Bradycardia
- C. Hypoglycemia
- D. Weight gain
Correct answer: A
Rationale: The correct answer is A: Hypertension. Pheochromocytoma is characterized by the overproduction of catecholamines, leading to symptoms such as hypertension. Bradycardia (Choice B) is not typical in pheochromocytoma as increased catecholamines usually lead to tachycardia. Hypoglycemia (Choice C) and weight gain (Choice D) are not commonly associated symptoms of pheochromocytoma.
2. Prior to giving digoxin, the PN assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?
- A. Withhold the medication and notify the charge nurse
- B. Give the medication and document the heart rate
- C. Withhold the medication until the next scheduled dose
- D. Request the charge nurse to administer the medication
Correct answer: B
Rationale: A heart rate of 120 beats per minute is within the normal range for a 2-month-old infant. Therefore, it is safe to administer the digoxin and document the heart rate as part of routine care. Choice A is incorrect as withholding the medication is not necessary since the heart rate is normal. Choice C is incorrect as there is no need to delay the administration until the next scheduled dose when the heart rate is within the normal range. Choice D is incorrect as the primary nurse is not needed to administer the medication since the heart rate is normal and falls within the safe range for administration.
3. Congenital heart defects have traditionally been divided into acyanotic or cyanotic defects. Based on the nurse’s knowledge of congenital heart defects, this system in clinical practice is
- A. helpful because it explains the hemodynamics involved
- B. helpful because children with cyanotic defects are easily identified
- C. problematic because cyanosis is rarely present in children
- D. problematic because children with acyanotic heart defects may develop cyanosis
Correct answer: D
Rationale: The classification system of congenital heart defects into acyanotic or cyanotic defects is problematic because children with acyanotic heart defects may develop cyanosis, complicating the differentiation. Cyanosis can occur in some acyanotic defects due to various reasons such as right-to-left shunting or decreased pulmonary blood flow, making the classification based solely on cyanosis misleading. Choice A is incorrect because while the classification may involve hemodynamics, the main issue lies in the potential for acyanotic defects to develop cyanosis. Choice B is incorrect as the ease of identifying children with cyanotic defects does not address the main problem with the classification system. Choice C is also incorrect as the presence of cyanosis is not the only factor determining the classification's validity.
4. A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?
- A. Remind the client that his suspicions are not true
- B. Ask one nurse to spend time with the client daily
- C. Encourage the client to participate in group activities
- D. Assign the client to a room closest to the activity room
Correct answer: B
Rationale: The correct intervention for a client diagnosed with paranoid schizophrenia who believes in paranoid delusions is to ask one nurse to spend time with the client daily. Establishing a trusting relationship with a consistent caregiver can help reduce anxiety and foster a sense of security. Choice A is incorrect because directly challenging the client's beliefs may increase distress. Choice C might overwhelm the client with paranoia in a group setting. Choice D does not address the need for a trusting relationship with a specific caregiver.
5. A nurse is assessing a day-old infant for jaundice. Which of the following is the best method for this?
- A. Applying pressure over a bony area such as the forehead and evaluating the skin color after the pressure is removed
- B. Assessing the color of the infant’s hands and feet
- C. Assessing the infant’s tongue
- D. Assessing the infant’s arms and legs
Correct answer: A
Rationale: The correct answer is A. Applying pressure over a bony area and evaluating the skin color after the pressure is removed is the most accurate method for assessing jaundice in a day-old infant. This technique helps in identifying any yellowing of the skin, which is a key indicator of jaundice. Choices B, C, and D are less effective methods for assessing jaundice in a newborn. Assessing the color of the hands and feet may not give a reliable indication of jaundice, while evaluating the tongue, arms, and legs are not as specific or accurate as applying pressure over a bony area.