HESI LPN
HESI PN Exit Exam 2023
1. The client with schizophrenia who continues to repeat the last words heard is exhibiting a sign of disturbed thought processes. Which nursing problem should the nurse document in the medical record?
- A. Altered sensory perception
- B. Impaired social interaction
- C. Risk for self-directed violence
- D. Disturbed thought processes
Correct answer: D
Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of words, is a sign of disturbed thought processes commonly seen in clients with schizophrenia. It reflects a disorganization in thinking rather than a sensory perception issue (Choice A). Impaired social interaction (Choice B) refers to difficulties in relating to others, which is not the primary concern in echolalia. Risk for self-directed violence (Choice C) focuses on potential harm to self, which is separate from the repetitive behavior of echolalia.
2. Which atrioventricular heart block is also referred to as Mobitz II?
- A. Third-degree atrioventricular heart block
- B. Second-degree atrioventricular heart block
- C. First-degree atrioventricular heart block
- D. Complete heart block
Correct answer: B
Rationale: The correct answer is B. Second-degree atrioventricular heart block is also known as Mobitz II. In Mobitz II, some atrial impulses are blocked from reaching the ventricles, resulting in occasional dropped beats. Third-degree atrioventricular heart block is known as complete heart block, where no atrial impulses reach the ventricles. First-degree atrioventricular heart block is a condition where there is delayed conduction between the atria and ventricles but all atrial impulses are eventually conducted to the ventricles.
3. Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?
- A. Delegates assessment of lung sounds to nursing assistive personnel
- B. Becomes solely responsible for modifying activities of daily living
- C. Consults physical therapy for strengthening exercises in the extremities
- D. Involves respiratory therapy for altered breathing from severe anxiety levels
Correct answer: C
Rationale: Consulting physical therapy for strengthening exercises in the extremities demonstrates a team approach in caring for a patient with mobility issues. Involving other healthcare professionals like physical therapists ensures a comprehensive and specialized approach to address the patient's mobility needs. This collaborative approach benefits the patient by providing specialized interventions. Choices A, B, and D do not exemplify a collaborative team approach. Delegating assessment tasks to nursing assistive personnel (Choice A) may not address the mobility issue directly. Becoming solely responsible for modifying activities of daily living (Choice B) limits the scope of interventions. Involving respiratory therapy for anxiety-related breathing issues (Choice D) addresses a different aspect of care and does not directly target mobility concerns.
4. After surgery to correct hypertrophic pyloric stenosis (HPS) in a 3-week-old infant who had been formula-fed, which postoperative feeding order is appropriate?
- A. Thickened formula 24 hours after surgery
- B. Withholding feedings for the first 24 hours
- C. Regular formula feeding within 24 hours after surgery
- D. Additional glucose feedings as desired after the first 24 hours
Correct answer: C
Rationale: Following surgery for hypertrophic pyloric stenosis (HPS) in infants, it is appropriate to resume regular formula feeding within 24 hours postoperatively to support recovery. This helps maintain adequate nutrition and hydration for the infant. Choice A is incorrect because thickened formula may not be necessary and could potentially cause issues postoperatively. Choice B is incorrect as withholding feedings for the first 24 hours can lead to nutritional deficiencies and delay recovery. Choice D is inappropriate as additional glucose feedings are not typically indicated postoperatively for infants with HPS and may not provide the necessary nutrition needed for recovery.
5. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has bilateral below-the-knee amputations and weak, thread pedal pulses. What action should the nurse take?
- A. Document that an accurate oxygen saturation reading cannot be obtained
- B. Elevate the client's hands for five minutes prior to obtaining a reading from the finger
- C. Increase the oxygen based on the client's breathing patterns and lung sounds
- D. Place the oximeter clip on the earlobe to obtain the oxygen saturation reading
Correct answer: D
Rationale: Placing the oximeter clip on the earlobe is appropriate for clients with poor peripheral circulation, such as those with weak and thread pedal pulses due to bilateral below-the-knee amputations. This placement can provide a more accurate reading of oxygen saturation in such clients. Choice A is incorrect because alternative methods, such as earlobe placement, can be used to obtain accurate readings. Choice B is unnecessary and not related to obtaining an accurate oxygen saturation reading. Choice C is incorrect because increasing oxygen without assessing the oxygen saturation level first can be detrimental and is not based on evidence-based practice.