HESI LPN
Practice HESI Fundamentals Exam
1. When caring for a patient diagnosed with diabetes mellitus and circulatory insufficiency, experiencing peripheral neuropathy and urinary incontinence, on which areas does the nurse focus care?
- A. Decreased pain sensation and increased risk of skin impairment
- B. Decreased caloric intake and accelerated wound healing
- C. High risk for skin infection and low saliva pH level
- D. High risk for impaired venous return and dementia
Correct answer: A
Rationale: The nurse should focus on decreased pain sensation and increased risk of skin impairment due to the patient's conditions. Peripheral neuropathy can lead to decreased pain sensation, making the patient more prone to injuries without realizing it. Additionally, the combination of circulatory insufficiency, peripheral neuropathy, and urinary incontinence can increase the risk of skin breakdown and impaired healing. Choices B, C, and D are incorrect because they do not address the specific issues related to the patient's diagnoses and symptoms.
2. What is a common sign of congenital hip dysplasia in infants?
- A. Symmetrical hip movement
- B. Limited range of motion in the hip
- C. Swelling of the knees
- D. Dislocated patella
Correct answer: B
Rationale: Limited range of motion in the hip, often noted as a limitation in abduction, is a common sign of congenital hip dysplasia. This limitation is due to the abnormal development of the hip joint, affecting its movement. Symmetrical hip movement (Choice A) is not a characteristic sign of congenital hip dysplasia. Swelling of the knees (Choice C) is not typically associated with this condition. Dislocated patella (Choice D) refers to a different anatomical structure and is not a common sign of congenital hip dysplasia.
3. During auscultation of a client experiencing chest pain worsened by inspiration, a nurse hears a high-pitched scratching sound in both systole and diastole with the diaphragm of the stethoscope placed at the left sternal border. Which of the following heart sounds should the nurse document?
- A. Pericardial friction rub
- B. Murmur
- C. S1 and S2
- D. Bruit
Correct answer: A
Rationale: The correct answer is 'Pericardial friction rub.' A pericardial friction rub is a high-pitched, scratching sound heard in both systole and diastole, which is characteristic of pericardial inflammation. This sound is different from a murmur, which is a swooshing or blowing sound due to turbulent blood flow. S1 and S2 are normal heart sounds, and a bruit is a whooshing sound caused by turbulent blood flow in an artery, not related to pericardial inflammation.
4. A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care?
- A. Adolescent
- B. Preschooler
- C. Older adult
- D. Adult
Correct answer: B
Rationale: The correct answer is B: Preschooler. Family customs have a significant impact on hygiene practices during childhood, especially in the early years. Preschoolers are at an age where they are learning and forming habits, and family customs play a crucial role in establishing routines such as bathing and brushing teeth. Adolescents, older adults, and adults are more likely to have established their own hygiene routines that may not be as heavily influenced by family customs as in early childhood. Therefore, the nurse is most likely providing care to a preschooler in this scenario.
5. A child with suspected Kawasaki disease is being assessed. What clinical manifestation is the nurse likely to observe?
- A. Generalized rash
- B. Peeling skin on the hands and feet
- C. High fever
- D. Low-grade fever
Correct answer: B
Rationale: Peeling skin on the hands and feet is a characteristic clinical manifestation of Kawasaki disease, known as desquamation. This occurs during the convalescent phase of the illness, typically around 2-3 weeks after the onset of symptoms. While a generalized rash can be present in Kawasaki disease, peeling skin on the hands and feet is a more specific and distinctive feature. High fever is also a common symptom of Kawasaki disease, usually lasting for at least 5 days, while a low-grade fever is not typically associated with this condition. Therefore, the nurse is more likely to observe peeling skin on the hands and feet in a child suspected of having Kawasaki disease, making option B the correct choice.