HESI LPN
Adult Health 2 Final Exam
1. The healthcare professional is developing a care plan for a client with depression. What should be included in the plan?
- A. Regular physical activity
- B. Scheduled sleep patterns
- C. Social interaction with family and friends
- D. All of the above
Correct answer: D
Rationale: A comprehensive care plan for a client with depression should include multiple components to address various aspects of health. Regular physical activity can help improve mood and overall well-being. Scheduled sleep patterns are essential as sleep disturbances are common in depression and can worsen symptoms. Social interaction with family and friends provides emotional support and reduces feelings of isolation. Therefore, including all these aspects in the care plan can help support the client's recovery. Choice D, 'All of the above,' is the correct answer because all the options are important components of a holistic care plan for depression. Choices A, B, and C are incorrect because each of these elements plays a crucial role in managing depression.
2. A client with a chronic illness expresses frustration over their condition. What is the nurse's best response to support the client?
- A. Encourage joining a support group for emotional support
- B. Discuss the possibility of a cure in the future
- C. Suggest focusing on positive aspects of their life
- D. Validate their feelings and listen to their concerns
Correct answer: D
Rationale: The best response for the nurse to support a client expressing frustration over their chronic illness is to validate their feelings and listen to their concerns (Option D). This approach helps acknowledge the client's emotions, demonstrates empathy, and establishes a therapeutic relationship. By validating the client's feelings and actively listening to their concerns, the nurse offers a supportive environment for the client to express their frustrations. Choices A, B, and C are not the best responses in this situation. While joining a support group, discussing a cure, or focusing on positive aspects can be beneficial interventions, the immediate priority is to validate the client's feelings and provide a space for them to express their frustrations.
3. When counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse do?
- A. Recheck the radial pulse in thirty minutes
- B. Palpate the radial pulse for thirty seconds and double the rate
- C. Count the apical pulse rate for sixty seconds
- D. Compare the radial pulse rate bilaterally and record the higher rate
Correct answer: C
Rationale: The correct answer is to count the apical pulse rate for sixty seconds. The apical pulse is more accurate, especially when peripheral pulses are weak or irregular. Counting the apical pulse for a full minute provides a more precise heart rate measurement. Option A is incorrect because waiting for thirty minutes is unnecessary and could delay potential interventions. Option B is incorrect because doubling the radial pulse rate may not provide an accurate representation of the heart rate. Option D is incorrect because comparing radial pulses bilaterally does not give the most accurate heart rate measurement; the apical pulse is preferred in this situation.
4. A client is diagnosed with type 1 diabetes mellitus. Which instruction about insulin administration should the nurse emphasize?
- A. Rotate injection sites to prevent tissue damage
- B. Inject insulin into the same site to increase absorption
- C. Only use insulin pens
- D. Mix different types of insulin in the same syringe
Correct answer: C
Rationale: The correct answer is to only use insulin pens. This is because insulin pens provide a convenient and accurate way to administer insulin. Rotating injection sites is important to prevent tissue damage and promote consistent insulin absorption, making choice A incorrect. Injecting insulin into the same site can lead to lipodystrophy and is not recommended, making choice B incorrect. Mixing different types of insulin in the same syringe can alter their action profiles and is generally not recommended, making choice D incorrect.
5. A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?
- A. Administer oxygen as prescribed
- B. Perform an ECG
- C. Obtain a detailed health history
- D. Monitor vital signs regularly
Correct answer: B
Rationale: The priority nursing action in this scenario is to perform an ECG. An ECG is crucial in confirming myocardial infarction promptly and guiding immediate treatment decisions. Administering oxygen as prescribed is important but not the priority over confirming the diagnosis. Obtaining a detailed health history is relevant but does not take precedence over immediate diagnostic confirmation. While monitoring vital signs regularly is essential, performing an ECG is the priority action in this scenario to guide timely management.
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