HESI LPN
Adult Health 1 Exam 1
1. When observing a newly admitted elderly client with dementia resisting care, what approach should the nurse take to facilitate cooperation?
- A. Use short, simple sentences and maintain a calm demeanor
- B. Involve family members to provide reassurance
- C. Offer choices to empower the client
- D. All of the above
Correct answer: D
Rationale: When dealing with a newly admitted elderly client with dementia who is resistant to care, it is crucial to employ multiple strategies to facilitate cooperation. Using short, simple sentences and maintaining a calm demeanor can help the client better understand instructions and reduce agitation. Involving family members can provide comfort and reassurance to the client, potentially decreasing resistance. Offering choices allows the client to feel a sense of control and autonomy in their care, which can increase cooperation and reduce challenging behaviors. Therefore, a combination of clear communication, family involvement, and providing choices is essential to effectively engage and care for a client with dementia. Choices A, B, and C all play crucial roles in addressing the needs of the client, making 'All of the above' the correct answer.
2. A client with a diagnosis of schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?
- A. Ask the client to describe the voices and what they are saying.
- B. Tell the client that the voices are not real.
- C. Encourage the client to engage in reality-based activities.
- D. Ask the client to focus on positive thoughts instead of the voices.
Correct answer: C
Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage them to engage in reality-based activities. This intervention helps manage auditory hallucinations by redirecting the client's focus away from the hallucinations. Choice A is not recommended as it may exacerbate the hallucinations or distress the client. Choice B is incorrect because denying the reality of the voices can invalidate the client's experiences. Choice D, asking the client to focus on positive thoughts, may not be effective in addressing the auditory hallucinations directly.
3. The nurse is teaching a 27-year-old client with asthma about the management of their therapeutic regimen. Which statement would indicate the need for additional instruction?
- A. ''I should monitor my peak flow every day.''
- B. ''I should contact the clinic if I am using my medication more often.''
- C. ''I need to limit my exercise, especially activities such as walking and running.''
- D. ''I should learn stress reduction and relaxation techniques.''
Correct answer: C
Rationale: Exercise, especially aerobic activities, is beneficial for clients with asthma as long as it is well-managed. Limiting exercise is not generally recommended unless specifically advised by a healthcare provider, indicating a need for further instruction in this case. Monitoring peak flow, contacting the clinic for increased medication use, and learning stress reduction techniques are all appropriate self-management strategies for asthma, indicating good understanding by the client.
4. A healthcare professional is assessing an adult client who has been immobile for the past 3 weeks. The healthcare professional should identify that which of the following findings requires further intervention?
- A. Erythema on pressure points
- B. Lower-extremity pulse strength of 2+
- C. Fluid intake of 3,000 mL per day
- D. A bowel movement every other day
Correct answer: A
Rationale: Erythema on pressure points indicates potential skin breakdown due to prolonged immobility. It requires immediate intervention to prevent pressure ulcers. Lower-extremity pulse strength of 2+ is a normal finding, indicating adequate peripheral perfusion. Fluid intake of 3,000 mL per day is within the normal range and promotes hydration. A bowel movement every other day is a reasonable frequency for some individuals and does not necessarily indicate a need for immediate intervention in this scenario.
5. A client is prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication?
- A. “I will first dissolve the tablet in water.”
- B. “I will insert the tablet between my cheek and teeth.”
- C. “I will place the tablet under my tongue.”
- D. “I will chew the tablet.”
Correct answer: B
Rationale: The correct way to take buccal medications is to insert the tablet between the cheek and gums where it will dissolve slowly. Option A is incorrect because buccal medications are not meant to be dissolved in water. Option C is incorrect as sublingual medications are placed under the tongue. Option D is incorrect because chewing a buccal tablet is not the correct administration method.