HESI LPN
Medical Surgical HESI
1. When selecting patient problems for the 4-year-old child with nephrosis, what should be a priority for the nurse?
- A. Impaired body image
- B. Skin impairment
- C. Nutritional deficit
- D. Injury
Correct answer: B
Rationale: The correct answer is B: Skin impairment. Nephrosis is characterized by gross edema, making skin care a priority. Skin impairment can result from the edema and needs close monitoring and management. While nutritional deficit and injury are important considerations in patient care, they are not the priority when dealing with a child with nephrosis. Impaired body image is not typically a priority in the immediate care of a young child with nephrosis.
2. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
- A. Daily weight
- B. Vital signs
- C. Level of consciousness
- D. Bowel sounds
Correct answer: A
Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.
3. The nurse is caring for a client with a suspected stroke. Which assessment finding is most indicative of a stroke?
- A. Chest pain
- B. Sudden confusion and difficulty speaking
- C. Gradual onset of weakness in the legs
- D. Nausea and vomiting
Correct answer: B
Rationale: The correct answer is B: Sudden confusion and difficulty speaking. These are classic signs of a stroke, indicating a neurological deficit that requires urgent medical attention. Choices A, C, and D are less indicative of a stroke. Chest pain is more commonly associated with cardiac issues, gradual onset of weakness in the legs could be related to other conditions like peripheral neuropathy, and nausea/vomiting may suggest gastrointestinal problems rather than a stroke.
4. A woman with chronic osteoarthritis is complaining of knee pain. Which pathophysiological process is contributing to her pain?
- A. Inflammation of the synovial membrane.
- B. Degeneration of the cartilage in the joint.
- C. Joint inflammation occurs when chondrocyte injury destroys joint cartilage, producing osteophytes.
- D. Formation of uric acid crystals in the joint space.
Correct answer: C
Rationale: The correct answer is C. In osteoarthritis, the breakdown of cartilage in the joints leads to chondrocyte injury, which results in the destruction of joint cartilage and the production of osteophytes. This process causes joint inflammation and pain. Choice A is incorrect because osteoarthritis primarily involves the articular cartilage rather than the synovial membrane. Choice B is incorrect as it describes the degeneration of cartilage but does not explain the specific pathophysiological process contributing to pain in osteoarthritis. Choice D is incorrect as the formation of uric acid crystals is characteristic of gout, not osteoarthritis.
5. What is the main characteristic of cystic fibrosis?
- A. Multiple upper respiratory infections
- B. An underproduction of exocrine glands
- C. Excessive, thick mucus
- D. An overproduction of thin mucus
Correct answer: C
Rationale: The main characteristic of cystic fibrosis is the production of excessive, thick mucus. This thick mucus leads to blockages in the airways, digestive system, and other organs. Choice A is incorrect because while individuals with cystic fibrosis are more prone to respiratory infections, the main characteristic is the mucus production. Choice B is incorrect as cystic fibrosis is characterized by the overproduction, not underproduction, of exocrine glands. Choice D is also incorrect as the mucus produced in cystic fibrosis is thick, not thin.
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