HESI LPN
HESI PN Exit Exam 2023
1. Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?
- A. I don't have any use for those who say the disease is going to win
- B. I've found the support I need from my faith and family
- C. I think I've had this disease for a long time, but the doctor did not find it
- D. I understand that this is a disease that occurs mostly in older men
Correct answer: B
Rationale: The correct answer is B because finding support in faith and family is a common way for individuals to cope with serious illnesses and come to terms with their prognosis. This statement indicates that the client has found a source of strength and comfort to deal with their situation. Choice A reflects defiance rather than acceptance. Choice C suggests denial or disbelief in the diagnosis. Choice D shows factual knowledge about the disease but does not necessarily indicate acceptance of the prognosis.
2. The clinician is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing?
- A. Covering the wound with a dry dressing
- B. Using hydrogen peroxide soaks
- C. Leaving the area open to dry
- D. Applying a hydrocolloid or foam dressing
Correct answer: D
Rationale: Applying a hydrocolloid or foam dressing is the most effective treatment to promote healing for a Stage 2 skin ulcer. These dressings create a moist environment that supports healing and prevents further tissue damage. Option A (covering the wound with a dry dressing) can lead to drying out the wound bed, hindering healing. Option B (using hydrogen peroxide soaks) can be too harsh and may damage the surrounding healthy tissue. Option C (leaving the area open to dry) can delay healing as it does not provide the necessary moist environment for optimal wound healing.
3. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client used to run a year ago, his spouse states that the client no longer runs but sits and watches television most of the day. Which is most important for the nurse to include in this client’s plan of care for today?
- A. Assist the client in identifying goals for the day
- B. Encourage the client to participate in a team sport for one hour
- C. Schedule the client for a group session that focuses on self-esteem
- D. Help the client develop a list of daily affirmations
Correct answer: A
Rationale: Assisting the client in identifying goals for the day is the most important aspect of the plan of care for a client with severe depression. Setting achievable daily goals helps engage the client in activities and promotes a sense of accomplishment, which can contribute to gradual improvement in their condition. Encouraging participation in team sports may be overwhelming for a client with severe depression as it requires a significant level of energy and motivation that the client may not possess at this time. Group sessions focusing on self-esteem and daily affirmations are beneficial interventions, but they may not have an immediate impact compared to setting achievable daily goals that can provide a sense of purpose and achievement for the client.
4. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?
- A. Notify the nursing manager.
- B. Document the client's condition and communication with the surgeon.
- C. Administer additional fluids as per standard procedure.
- D. Call the surgeon back immediately to ensure timely intervention.
Correct answer: B
Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.
5. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?
- A. Excessive work activity.
- B. Decreased need for sleep.
- C. Medication management.
- D. Inflated self-esteem.
Correct answer: D
Rationale: The priority is to manage the client's medication adherence to prevent escalation of manic behavior. Inflated self-esteem is the highest priority as it indicates the client's potential for harmful behaviors due to lack of medication compliance. While excessive work activity and decreased need for sleep are characteristics of mania, they are not as immediately concerning as the risk of harm related to inflated self-esteem.