HESI LPN
Adult Health Exam 1
1. To assess pedal pulses, which arterial sites should the nurse palpate? (Select all that apply)
- A. Posterior tibial artery
- B. Radial artery
- C. External iliac artery
- D. Dorsalis pedis artery
Correct answer: D
Rationale: The correct answer is D: Dorsalis pedis artery. When assessing pedal pulses, the nurse should palpate the dorsalis pedis artery and the posterior tibial artery. The radial artery is located in the wrist and is not a site for assessing pedal pulses. The external iliac artery is not a correct site for assessing pedal pulses in the lower extremities, making it the correct answer.
2. Why does a cleft lip predispose an infant to infection?
- A. Waste products accumulate along the defect.
- B. There is evidence of inadequate circulation in the defective area.
- C. Nutrition is inadequate due to ineffective feeding.
- D. Mouth breathing dries the oropharyngeal mucous membranes.
Correct answer: D
Rationale: The correct answer is D. Mouth breathing due to a cleft lip can dry the mucous membranes, making them more susceptible to infection. Choice A is incorrect because waste products do not accumulate along the defect to predispose the infant to infection. Choice B is incorrect as there is no evidence of inadequate circulation being a primary factor in infection predisposition in cleft lip cases. Choice C is incorrect because although ineffective feeding may lead to other issues, it is not the main reason for infection predisposition in infants with a cleft lip.
3. When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), which instruction is most important for the nurse to include?
- A. It may take 3 to 4 weeks to achieve therapeutic effects.
- B. Keep your dietary salt intake consistent.
- C. Avoid eating aged cheese and chicken liver.
- D. Eat foods high in fiber such as whole grain breads.
Correct answer: B
Rationale: The correct answer is B: 'Keep your dietary salt intake consistent.' Consistent salt intake is crucial when taking lithium carbonate to avoid lithium toxicity or ineffectiveness due to its renal excretion mechanism. Option A is incorrect because it focuses on the time to achieve therapeutic effects, which is important but not as critical as maintaining consistent salt intake. Option C is incorrect as it mentions avoiding aged cheese and chicken liver, which is more relevant for individuals taking MAOIs. Option D is incorrect as it suggests eating high-fiber foods, which is not directly related to lithium carbonate therapy.
4. A 70-year-old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain?
- A. Usual and current weight
- B. Color and amount of urine
- C. Number and frequency of stools
- D. Intake and output 24 hours prior to admission
Correct answer: A
Rationale: The correct answer is A: Usual and current weight. Weight changes are the most direct indicator of fluid status in a patient with acute diarrhea. Monitoring weight loss or gain can provide crucial information about fluid balance. Option B, color and amount of urine, though important for assessing renal function, is not as direct an indicator of fluid status as weight. Option C, number and frequency of stools, is relevant for assessing the severity of diarrhea but does not provide direct information on fluid status. Option D, intake and output 24 hours prior to admission, does not reflect the current fluid status and may not be accurate in a rapidly changing condition like acute diarrhea.
5. The PN is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the PN document in the medical record?
- A. Altered thought processes
- 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 heard words, is associated with disturbed thought processes, which are commonly seen in schizophrenia. Altered thought processes (Choice A) is a generic term and does not specifically address the behavior of repeating words. Impaired social interaction (Choice B) is not the primary concern when a client repeats the last words heard. Risk for self-directed violence (Choice C) is not directly related to the behavior of repeating words but focuses on the potential harm the client may cause to themselves.