HESI LPN
Adult Health 2 Final Exam
1. The wife is observed shaving her husband's beard with a safety razor. What should the nurse do?
- A. Advise the wife to shave against the hair growth
- B. Teach the wife to keep the skin loose to avoid cuts
- C. Encourage the wife to continue shaving her husband
- D. Demonstrate the correct procedure to the wife
Correct answer: C
Rationale: In this situation, the nurse should encourage the wife to continue shaving her husband. The rationale behind this is that the wife is already performing the task, so abrupt interference may lead to potential harm or emotional distress. It is crucial for the nurse to carefully observe the situation and assess for any safety concerns. While teaching proper techniques (Choice B) is important, it can be addressed later in a non-critical manner to prevent skin irritation and injury. Advising to shave against the hair growth (Choice A) may cause skin irritation and cuts. Although demonstrating the correct procedure (Choice D) may be helpful, it is essential to consider the current dynamics and respect the wife's autonomy in caring for her husband.
2. When teaching a group of school-aged children how to reduce the risk for Lyme disease, which instruction should the camp nurse include?
- A. Wash hands frequently.
- B. Avoid drinking lake water.
- C. Do not share personal products.
- D. Wear long sleeves and pants.
Correct answer: D
Rationale: The correct answer is 'Wear long sleeves and pants.' This instruction is crucial in reducing the risk of Lyme disease because it helps minimize exposure to ticks that carry the disease. Ticks are commonly found in grassy and wooded areas, so covering up with long sleeves and pants can act as a physical barrier and prevent ticks from attaching to the skin. Choices A, B, and C are not directly related to preventing Lyme disease. Washing hands frequently is important for general hygiene but not specifically for preventing tick bites. Avoiding drinking lake water is more about preventing waterborne illnesses rather than Lyme disease. Not sharing personal products is important for preventing the spread of infections but is not directly related to Lyme disease prevention.
3. The nurse is caring for a client with a diagnosis of bipolar disorder who is taking lithium. What is the most important information the nurse should provide?
- A. Take the medication on an empty stomach.
- B. Monitor sodium intake.
- C. Report any signs of weight gain.
- D. Avoid excessive caffeine intake.
Correct answer: B
Rationale: The correct answer is B: 'Monitor sodium intake.' Sodium levels can affect lithium levels in the body, so it is crucial to maintain a consistent sodium intake to prevent toxicity or subtherapeutic levels. Option A is incorrect because lithium is usually recommended to be taken on an empty stomach to enhance absorption. Option C, reporting signs of weight gain, is relevant but not as critical as monitoring sodium intake. Option D, avoiding excessive caffeine intake, is important for some individuals but not as essential as monitoring sodium levels when taking lithium.
4. What safety measure should be implemented when administering chemotherapy?
- A. Use protective gloves and gown
- B. Prepare the medication in a designated area
- C. Administer the medication at the appropriate rate
- D. Verify the two client identifiers
Correct answer: A
Rationale: When administering chemotherapy, it is crucial to use protective gloves and a gown to protect against exposure to hazardous drugs that can be harmful through skin contact. Choice B is incorrect because chemotherapy medication should be prepared in a designated area to prevent contamination and ensure accurate preparation. Choice C is incorrect as chemotherapy should be administered at the appropriate rate to ensure patient safety and avoid adverse effects. Choice D is incorrect as verifying client identifiers is important for medication administration in general but not a specific safety measure related to chemotherapy administration.
5. The client with high blood pressure is being taught by the nurse to avoid adding salt during cooking. What effect does sodium have on blood pressure?
- A. It decreases the viscosity of blood
- B. It leads to increased fluid retention
- C. It causes vasoconstriction of the blood vessels
- D. It enhances the excretion of potassium
Correct answer: C
Rationale: The correct answer is C: 'It causes vasoconstriction of the blood vessels.' Sodium can lead to vasoconstriction, which narrows the blood vessels, increasing resistance to blood flow and subsequently raising blood pressure. Choices A, B, and D are incorrect. Sodium does not decrease blood viscosity, but it can lead to fluid retention, which increases blood volume and pressure. It does not enhance the excretion of potassium; instead, high sodium intake can lead to potassium excretion by the kidneys.
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