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RN HESI Exit Exam Bundle
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2017 Mental Health PN Hesi Specialty V1
2017 Mental Health PN Hesi Specialty V1 2017 Mental Health PN Hesi Specialty V1 1. The LPN/LVN calls security and has physical restrains applied wh... [Show More] en a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1) Libel 2) Battery 3) Assault 4) Slander 5) False Imprisonment Correct Answer: 2) Battery 3) Assault 5) False Imprisonment 2) A nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship? 1) Exploring the client's ability to function 2) Exploring the client's potential for self-harm 3) Inquiring about the client's perception of appraisal of the neighbor's death 4) Inquiring about and examine the client's feelings that may block adaptive coping Correct Answer:4) Inquiring about and examine the client's feelings that may block adaptive coping 3) A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism? 1) Denial 2) Projection 3) Rationalization 4) Intellectualization Correct Answer:1) Denial 4) Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship? 1) Working 2) Trusting 3) Orientation 4) Termination Correct Answer: 4) Termination 5) Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? 1) "Autonomy is the fundamental right of each and every client." 2) "A client's rights are guaranteed by both state and federal laws." 3) "Being respectful and concerned will ensure that I'm attentive to my clients' rights." 4) "Regardless of the client's condition, all nurses have the duty to respect client rights." Correct Answer: 3) "Being respectful and concerned will ensure that I'm attentive to my clients' rights." 6) A LPN/LVN employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurses's role in the termination stage of group development is to: 1) Encourage problem solving 2) Encourage accomplishment of the group's work 3) Acknowledge the contributions of each group member 4) Encourage members to become acquainted with one another Correct Answer: 3) Acknowledge the contributions of each group member 7) A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to: 1) Move the client next to the nurse's station 2) Use an indirect light source and turn off the television 3) Keep the television and a soft light on during the night 4) Play soft music during the night, and maintain a well-lit room 2) Use an indirect light source and turn off the television 8) A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The client became blind after witnessing a hit-and-run car accident, when a family of three was killed. A LPN/LVN suspects that the client may be experiencing a: 1) Psychosis 2) Repression 3) Conversion Disorder 4) Dissociative Disorder Correct Answer: 3) Conversion Disorder 9) A manic client announces to everyone in the day room that a stripper is coming to perform this evening. When a nurse firmly states that this is inappropriate and will not happen, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the LPN/LVN determines that the appropriate action would be to: 1) Orient the client to time, person, and place 2) Tell the client that the behavior is inappropriate 3) Escort the manic client to her room, with assistance 4) Tell the client that smoking privileges are revoked for 24 hours Correct Answer: 3) Escort the manic client to her room, with assistance 10) A LPN/LVN observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: 1) Provide safety for the client and other clients on the unit 2) Provide the clients on the unit with a sense of comfort and safety 3) Assist the staff in caring for the client in a controlled environment 4) Offer the client a less stimulated area to calm down and gain control Correct Answer: 1) Provide safety for the client and other clients on the unit 11) Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select all that apply. 1) Communicate expected behaviors to the client 2) Ensure that the client knows that he or she is not in charge of the nursing unit 3) Assist the client in identifying ways of setting limits on personal behaviors 4) Follow through about the consequences of behavior in a non punitive manner 5) Enforce rules and inform the client that he or she will not be allowed to attend therapy groups 6) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior Correct Answer: 1) Communicate expected behaviors to the client 3) Assist the client in identifying ways of setting limits on personal behaviors 4) Follow through about the consequences of behavior in a non punitive manner 6) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior 12) A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say: 1) "I no longer feel that I deserve the meetings my husband inflicts on me." 2) "My attendance at the meetings has helped me to see that I provoke my husbands violence." 3) "I enjoy attending the meetings because they get me out of the house and away from my husband." 4) "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics." Correct Answer: 1) "I no longer feel that I deserve the meetings my husband inflicts on me." 13) An LPN/LVN is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by: 1) Witnessing a murder 2) The death of a loved one 3) A fire that destroyed the client's home 4) A recent rape episode experienced by the client Correct Answer: 2) The death of a loved one 14) An LPN/LVN is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that lead to the crisis, the appropriate question to ask is: 1) "With whom do you live?" 2) "Who is available to help you?" 3) "What leads you to seek help now?" 4) "What do you usually do to feel better?" Correct Answer: 3) "What leads you to seek help now?" 15) A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse "I'm finally cured." The LPN/LVN interprets this behavior as a cue to modify the treatment plan by: 1) Suggesting a reduction of medication 2) Allowing increased "in-room" activities 3) Increasing the level of suicide precautions 4) Allowing the client off-unit privileges as needed Correct Answer: 3) Increasing the level of suicide precautions 16) An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions? 1) Information regarding shelters 2) Instructions regarding calling the police 3) Instructions regarding self-defense classes 4) Explaining the importance of leaving the violent situation Correct Answer: 1) Information regarding shelters 17) A female victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. The appropriate nursing response is which of the following? 1) "You need to try and be realistic. The rape did not just occur." 2) "It will take some time to get over these feelings about your rape." 3) "Tell me more about the incident that causes you to feel like the rape just occurred." 4) "What do you think that you can do to alleviate some of your fears about being raped again?" Correct Answer: 3) "Tell me more about the incident that causes you to feel like the rape just occurred." 18) A LPN/LVN is preparing to care for a dying client, and several family members are at the client' bedside. Select the therapeutic techniques that the nurse would use when communicating with the family. Select all that apply. 1) Discourage reminiscing 2) Make decisions for the family 3) Encourage expression of feelings, concerns, and fears 4) Explain everything that is happening to all family members 5) Touch and hold the client's or family member's hands if appropriate 6) Be honest and let the client and family know that they will not be abandoned by the nurse Correct Answer: 3) Encourage expression of feelings, concerns, and fears 5) Touch and hold the client's or family member's hands if appropriate 6) Be honest and let the client and family know that they will not be abandoned by the nurse 19) A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose: 1) On an empty stomach 2) At the same time each evening 3) Evenly spaced around the clock 4) As needed when the client complains of depression Correct Answer: 2) At the same time each evening 20) A LPN/LVN is preforming a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side effects of the medication? 1) Cardiovascular symptoms 2) Gastrointestinal dysfunctions 3) Problems with mouth dryness 4) Problems with excessive sweating Correct Answer: 2) Gastrointestinal dysfunctions 21) A LVN/LPN is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by: 1) Engaging in immoral acts 2) Always reinforcing self-approval 3) Observing rigid rules and regulations 4) Having the need always to make the right decision Correct Answer: 3) Observing rigid rules and regulations 22) A LPN/LVN is caring for a suicidal client. The appropriate nursing intervention in dealing with this client is to: 1) Demonstrate confidence in the client's ability to deal with stressors 2) Provide hope and reassurance that the problems will resolve themselves 3) Display an attitude of detachment, confrontation, and efficiency 4) Provide authority, action, and participation Correct Answer: 4) Provide authority, action, and participation 23) A client in a long-term care facility who has multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope? 1) Keep the client in her room as much as possible 2) Assist the client with all activities of daily living 3) Tell the client that many of the people in the facility have these same sorts of problems 4) Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily Correct Answer: 4) Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily 24) On admission assessment, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the LVN/LPN is the most therapeutic? 1) "I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care." 2) "This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment." 3) "I am a professional registered nurse, and, as such, I'll have you know that all your information is certainly kept confidential." 4) "I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality." Correct Answer: 4) "I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality." 25) The LPN/LVN should include which information in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)? Select all that apply. 1) The medical diagnosis of the client 2) Individualized goals and objectives 3) Attendance at group therapy sessions 4) Self-care measures to improve hygiene 5) Interruption of all compulsive behaviors Correct Answer: 2) Individualized goals and objectives 3) Attendance at group therapy sessions 4) Self-care measures to improve hygiene 26) A client in the mental health unit believes that the food is being poisoned. What intervention(s) would be helpful when attempting to encourage the client to eat? Select all that apply. 1) Use open-ended questions to encourage client dialogue 2) Offer opinions about the necessity for adequate nutrition 3) Focus on the client's self-disclosure about food preferences 4) Identify the reasons the client has for not wanting to eat 5) Offer the client food in closed containers, such as in cans that have to be opened Correct Answer: 1) Use open-ended questions to encourage client dialogue 5) Offer the client food in closed containers, such as in cans that have to be opened 27) A client with a leg amputation is upset about his appearance. The LPN/ LVN intends to address which most closely associated psychosocial problem? 1) Inability to be mobile 2) Isolating self from others 3) Inability to tolerate activity 4) Concern about body persona Correct Answer: 4) Concern about body persona 28) A client with an eating disorder is planning to attend group meetings with Overeaters Anonymous. The LPN/LVN describes this group to the client, knowing that which finding(s) are characteristic of this form of self-help group? Select all that apply. 1) A common goal is shared by all members 2) Members are required to remain anonymous 3) The leader is a professional mental health care provider 4) Attendance must be prescribed by the health care provider 5) The program is designed to provide support and bring about personal change 6) The group is composed of individuals who are experiencing similar problems Correct Answer: 1) A common goal is shared by all members 5) The program is designed to provide support and bring about personal change 6) The group is composed of individuals who are experiencing similar problems 29) A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the LPN/LVN include in the plan of care? Select all that apply. 1) Avoid laughing when near the client 2) Whisper when communicating near the client 3) Increase socialization of the client among his peers 4) Have the client sign a written release of information form 5) Provide food items that are in containers that need to be opened 6) Begin to educate the client about social supports in the community Correct Answer: 1) Avoid laughing when near the client 5) Provide food items that are in containers that need to be opened 30) A client is preparing to attend at Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. Number in order of priority how the steps would be addressed. 1) Admitting to oneself and to another human being the exact nature of one's wrongs 2) Acknowledging that one is entirely ready to have his or her defects of character removed 3) Admitting that oneself is powerless over gambling and that one's life has become unmanageable 4) Making an effort to practice the 12-step principles in all affairs, and to carry out this message to other compulsive gamblers 5) Making direct amends wherever possible to all people that have been hurt, expect when to do so would further harm them or others Correct Answer: 3) Admitting that oneself is powerless over gambling and that one's life has become unmanageable 1) Admitting to oneself and to another human being the exact nature of one's wrongs 2) Acknowledging that one is entirely ready to have his or her defects of character removed 5) Making direct amends wherever possible to all people that have been hurt, expect when to do so would further harm them or others 4) Making an effort to practice the 12-step principles in all affairs, and to carry out this message to other compulsive gamblers 31) An outpatient clinic who has been receiving haloperidol (Haldol) for 2 days develops muscular rigidity, altered consciousness, a temperature of 103, and trouble breathing on day 3. The LPN/LVN interest these findings as indicating which of the following. 1) Neuroleptic Malignant Syndrome 2) Tardive dyskinesia 3) Extrapyramidal adverse effects 4) Drug-induced parksonism Correct Answer: 1) Neuroleptic Malignant Syndrome 32) A newly admitted client describes her mission in life as one of saving her son by eliminating the "provocative sluts" of the world. There are several attractive young women on the unit. What should the LPN/LVN do first? 1) Ask the client for her definition of "provocative sluts" 2) Ask the young female clients on the unit to dress less provocatively 3) Ask the client to discuss her concerns in the next group session 4) Ask the client to inform the staff if she has negative thoughts about other clients Correct Answer: 4) Ask the client to inform the staff if she has negative thoughts about other clients 33) The wife of a client diagnosed with paranoid schizophrenia visits 2 days after her husband;s admission and states to the nurse, "Why isn' he eating? He's still talking about his food being poisoning." With of the following appraisals by the LPN/LVN is most accurate? 1) The wife's inquiry is reasonable 2) Education about her husband's medication is needed 3) Her expectations of her husband are realistic 4) An increase in the client's medication is needed Correct Answer: 2) Education about her husband's medication is needed 34) A client states that she hears God's voice telling her that she has sinned and needs to punish herself. Which response by the LPN/LVN is most important? 1) "How do you think you will be punished?" 2) "Please tell staff when you think you need to punish yourself." 3) "What exactly do you think you have done to be punished?" 4) "Let's talk about your strengths" Correct Answer: 2) "Please tell staff when you think you need to punish yourself." 35) A client diagnosed with paranoid schizophrenia is still withdrawn, unkept, and unmotivated to get out of bed. A mental health aide asks the nurse why the client is this way after being on fluphenazine (Prolix) 10 mg for 7 days. The LPN/LVN should tell the health aide: 1) "Prolixin is the most effective with positive symptoms of schizophrenia." 2) "The client will be less withdrawn and unmotivated when the Prolixin takes effect." 3) "The client's Prolix dose probably needs to be increased again." 4) "Lack of motivation is a common side effect of the Prolixin." Correct Answer: 1) "Prolixin is the most effective with positive symptoms of schizophrenia." 36) A client is being successfully treated with clozapine (Clozaril). Which of the following statements by the client reflects a need for further teaching about managing the drug's adverse effects? 1) "If I eat too many fruits, I'll get constipated." 2) I need to take the medicine with food to avoid nausea." 3) "I have to get up slowly so I don't get dizzy." 4) "Sometimes I have to push myself because I'm sleepy." Correct Answer: 1) "If I eat too many fruits, I'll get constipated." 37) The LPN/LVN is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention? 1) Very high temperature 2) Muscular rigidity 3) Tremors 4) Altered consciousness Correct Answer: 1) Very high temperature 38) A client diagnosed with undifferentiated schizophrenia is being discharged on aripiprazole (Ability) 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select all that apply. 1) Headaches that will subside in a few weeks 2) Transient mild anxiety 3) Insomnia 4) Torticollis Correct Answer: 4) Pill rolling movements 1) Headaches that will subside in a few weeks 2) Transient mild anxiety 3) Insomnia 39) An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and instance, the daughter calls the nurse to report her mother's behavior. Which of the following would the nurse suspect as the cause of the mother's behavior and what action should she suggest? 1) The client is manic and may need a sleeping pill 2) The client is experiencing a medication interaction and should go to the ED 3) The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately 4) The client is overcome by grief and probably needs an antidepressant Correct Answer: 3) The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately 40) When caring for a client who has overdosed on PCP, the nurse should be especially caucus about which of the following client behaviors? 1) Visual hallucinations 2) Violent behavior 3) Bizarre behavior 4) Loud screaming 41) A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the LPN/LVN take? 1) Notify the healthcare provider immediately and prepare for administration of an antidote. 2) Notify the healthcare provider of the symptoms prior to the next administration of the drug. 3) Record the symptoms as normal side effects and continue administration of the prescribed dosage. 4) Hold the medication and refuse to administer additional amounts of the drug. Correct Answer(s): 2) Notify the healthcare provider of the symptoms prior to the next administration of the drug. 42) The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents? 1) If he has seemed depressed recently. 2) If a drug overdose has ever occurred before. 3) If he might have taken any other drugs. 4) If he has a desire to quit taking drugs. Correct Answer(s): 3) If he might have taken any other drugs. 43) The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the LPN/LVN to provide to this family member? 1) It sounds like you're worried about your husband. Let's sit down and talk. 2) It is a chemical imbalance in the brain that causes disorganized thinking. 3) Your husband will be just fine if he takes his medications regularly. 4) I think you should talk to your husband's psychologist about this question. Correct Answer(s): 2) It is a chemical imbalance in the brain that causes disorganized thinking. 44) 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? 1) Excessive work activity. 2) Decreased need for sleep. 3) Medication management. 4) Inflated self-esteem. Correct Answer(s): 3) Medication management. 45) At a support meeting of parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information? 1) Addiction is a chronic, incurable disease. 2) Tolerance to the effects of drugs causes feelings of depression. 3) Feelings of depression frequently lead to drug abuse and addiction. 4) Careful monitoring should be provided during withdrawal from the drugs. Correct Answer(s): 4) Careful monitoring should be provided during withdrawal from the drugs. 46) The LPN/LVN observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make? 1) What do you believe the news commentator said to you? 2) Let's watch news on a different television channel. 3) Does the news commentator have plans to harm you or others? 4) The news commentator is not talking to you. Correct Answer(s): 1) What do you believe the news commentator said to you? 47) At the first meeting of a group of older adults at a daycare center for the elderly, the LPN/LVN asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best response for the nurse to make? 1) Yes, I am the leader today. Would you like to be the leader tomorrow? 2) Yes, I will be leading this group. What would you like to accomplish during this time? 3) Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks. 4) Yes, I am the leader. You seem angry about not being the leader yourself. Correct Answer(s): 2) Yes, I will be leading this group. What would you like to accomplish during this time? 48) The LPN/LVN is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning? 1) Ineffective denial related to situational anxiety. 2) Ineffective coping related to inadequate support. 3) Social isolation related to difficult interactions. 4) Self-care deficit related to cognitive impairment. Correct Answer(s): 1) Ineffective denial related to situational anxiety. 49) Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? 1) Hamburger, French fries, and chocolate milkshake. 2) Liver and onions, broccoli, and decaffeinated coffee. 3) Pepperoni and cheese pizza, tossed salad, and a soft drink. 4) Roast beef, baked potato with butter, and iced tea. Correct Answer(s): 4) Roast beef, baked potato with butter, and iced tea. 50) An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the LPN/ LVN to provide? 1) Orient the client to the time, place, and person. 2) Tell the client that the nurse is there and will help her. 3) Remind the client that her mother is no longer living. 4) Explain the seriousness of her injury and need for hospitalization. Correct Answer(s): 2) Tell the client that the nurse is there and will help her. 51) The LPN/LVN is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam? 1) Acute psychiatric illnesses impair intelligence. 2) Intelligence is influenced by social and cultural beliefs. 3) Poor concentration skills suggests limited intelligence. 4) The inability to think abstractly indicates limited intelligence. Correct Answer(s): 2 52) The LPN/LVN should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.) 1) Permit rest periods as needed. 2) Speaking slowly and simply. 3) Place the client on suicide precautions. 4) Allow the client extra time to complete tasks. 5) Observe and encourage food and fluid intake. 6) Encourage mild exercise and short walks on the unit Correct Answer(s): 1, 2, 4, 5, 6 53) An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the LPN/ LVN to provide? 1) Anywhere you want to stand as long as you do not get hurt by those in the parade. 2) You are confused because of all the activity in the hall. There is no parade. 3) Let us go back to the activity room and see what is going on in there. 4) Remember I told you that this is a nursing home and I am your nurse. Correct Answer(s): 3) Let us go back to the activity room and see what is going on in there. 54) Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen? 1) Signs and symptoms of extrapyramidal effects (EPS). 2) Information about substance abuse and schizophrenia. 3) The effects of alcohol and drug interaction. 4) The availability of support groups for those with dual diagnoses. Correct Answer(s): 3) The effects of alcohol and drug interaction. 55) An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the LPN/LVN to provide? 1) You are in the hospital, and I am the nurse caring for you. 2) It must be difficult for you to control your anxious feelings. 3) Go to occupational therapy and start a project. 4) You are not in a war area now; this is the United States. Correct Answer(s): 3) Go to occupational therapy and [Show Less]
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2017 PN Hesi Exit V3 New Question & Answer Updated
2017 PN Hesi Exit V3 Q&A 1) The LPN/LVN receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nur... [Show More] se implement? A.Hang the solution at the current rate. B.Refrigerate the solution until needed. C.Prepare the solution with new tubing. D.Return the solution to the pharmacy. Correct Answer: D Return the solution to the pharmacy. 2) A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A.Immediately after feeding B.Just prior to tube feeding C.Continuous inflation is required D.Inflation is not required Correct Answer: B Just prior to tube feeding 3) A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? A.Administer lidocaine,75 mg intravenous push. B.Perform synchronized cardioversion. C.Defibrillate the client as soon as possible. D.Administer atropine, 0.4 mg intravenous push. Correct Answer: B Perform synchronized cardioversion. 4) A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? A. Pedal pulses will be weak or absent in the left foot. B. The client will state that the left foot is usually warm. C. Flexion and extension of the left foot will be limited. D.Capillary refill of the client's left toes will be brisk. Correct Answer: A Pedal pulses will be weak or absent in the left foot. 5) A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A.Avoid high-carbohydrate foods. B.Decrease intake of fat-soluble vitamins. C.Decrease caloric intake. D.Restrict salt and fluid intake. Correct Answer: D Restrict salt and fluid intake. 6) During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose levels. D.Evaluate the client's oxygen saturation and breath sounds. Correct Answer: C Monitor the client's serum potassium and blood glucose levels. 7) A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client? A.Determine if all employees have had the hepatitis B vaccine series. B.Explain that this type of hepatitis can be transmitted when feeding the client. C.Assure the employees that they cannot contract hepatitis B when providing direct care. D.Tell the employees that wearing gloves and a gown are required when providing care. Correct Answer: A Determine if all employees have had the hepatitis B vaccine series. 8) The LPN/LVN notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C.Milk the tube to remove any excessive blood clot buildup. D.Assess for kinks or dependent loops in the tubing. Correct Answer: D Assess for kinks or dependent loops in the tubing. 9) The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding? A.Myocardial infarction 2 months ago B.Anorexia and vomiting for the past 2 days C.Recently diagnosed type 2 diabetes mellitus D.Skeletal traction for a right hip fracture Correct Answer: B Anorexia and vomiting for the past 2 days 10) The nurse is reviewing routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question? A.Antianginal with a therapeutic effect of vasodilation B.Anticholinergic with a side effect of pupillary dilation C.Antihistamine with a side effect of sedation D.Corticosteroid with a side effect of hyperglycemia Correct Answer:B Anticholinergic with a side effect of pupillary dilation 11) A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine? A. The vaccine is given annually before the flu season to those older than 50 years. B. The immunization is administered once to older adults or those at risk for illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years. Correct Answer: B The immunization is administered once to older adults or those at risk for illness. 12) The nurse is assessing a male client with acute pancreatitis. Which finding requires the MOST immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home. Correct Answer: B While the nurse is taking the client's blood pressure, he has a carpal spasm. 13) During assessment of a client in the intensive care unit, the nurse notes that the client's ARE CLEAR UPON AUSCULTATION, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A.Prepare the client for a pericardial tap. B.Administer intravenous furosemide (Lasix). C.Assist the client to cough and breathe deeply. D.Instruct the client to restrict the oral fluid intake. Correct Answer: A. Prepare the client for a pericardial tap. 14) After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation? A. Switch to skim milk. B. Switch to orange juice. C. Add a source of protein. D. Add herbal tea. Correct Answer: A Switch to skim milk. 15) A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first? A. Support the client to a sitting position. B. Ask the client to walk slowly back to the room. C.Administer a sublingual nitroglycerin tablet. D.Provide oxygen via nasal cannula. Correct Answer: A. Support the client to a sitting position. 16) A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse? A. Fever of 102° F B. Blood pressure of 150/90 mm Hg C.Abdominal cramping D.Dry mucous membranes Correct Answer: A Fever of 102° F 17) A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit implement first? A. Instruct the nursing staff to close all window blinds and curtains in clients' rooms. B. Move clients and visitors into the hallways and close all doors to clients' rooms. C. Visually confirm the location of the tornado by checking the windows on the unit. D. Assist all visitors with evacuation down the stairs in a calm and orderly manner. Correct Answer: B. Move clients and visitors into the hallways and close all doors to clients' rooms. 18) A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A.Vitamin K1 (AquaMEPHYTON), 5 mg IM daily B.High-calorie, low-sodium diet C.Fluid restriction to 1500 mL/day D.Pentobarbital (Nembutal sodium) at bedtime for rest Correct Answer: D. Pentobarbital (Nembutal sodium) at bedtime for rest 19) A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? A.Azotemia B.Oliguria C.Hyperkalemia D.Nephron obstruction Correct Answer: D Nephron obstruction 20) Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome? A. "Get immunization against human papillomavirus (HPV)." B. "Change your tampon frequently." C. "Empty your bladder after intercourse." D. "Obtain a yearly flu vaccination." Correct Answer: B. "Change your tampon frequently." 21) A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse? A.Hypoactive bowel sounds with abdominal distention B.Client reports continued pain of 8 on a 10-point scale C.Respiratory rate of 12 breaths/min, with O2 saturation of 85% D.Client reports nausea after receiving the medication Correct Answer: C Respiratory rate of 12 breaths/min, with O2 saturation of 85% 22) A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family? A.Follow exposure precautions. B.Encourage regular meals. C.Collect all urine. D.Avoid touching the client. Correct Answer: A.Follow exposure precautions. 23) An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to implement for this client? A. Initiate airborne infection precautions. B. Place a surgical mask on the client. C. Don an isolation gown and latex gloves. D. Start protective (reverse) isolation precautions. Correct Answer: A.Initiate airborne infection precautions. 24) Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A.Hypokalemia B.Microalbuminuria C.Elevated serum lipid levels D.Ketonuria Correct Answer: B.Microalbuminuria 25) An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A.Leukocytosis and febrile B.Polycythemia and crackles C.Pharyngitis and sputum production D.Confusion and tachycardia Correct Answer: D Confusion and tachycardia 26) Which nursing action is necessary for the client with a flail chest? A.Withhold prescribed analgesic medications. B.Percuss the fractured rib area with light taps. C.Avoid implementing pulmonary suctioning. D.Encourage coughing and deep breathing. Correct Answer: D Encourage coughing and deep breathing. 27) When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A.A young adult with bacterial meningitis with recent seizures B.An older adult client with pneumonia and viral meningitis C.A female client in isolation with meningococcal meningitis D.A male client 1 day postoperative after drainage of a brain abscess Correct Answer: B An older adult client with pneumonia and viral meningitis 28) When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching? A.Recommend that the client carry suction equipment at all times. B.Instruct the client to have writing materials with him at all times. C.Tell the client to carry a medical alert card that explains his condition. D.Caution the client not to travel outside the United States alone. Correct Answer: C. Tell the client to carry a medical alert card that explains his condition. 29) A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A. Assess for signs of jugular venous distention. B. Obtain the needed intravenous solution. C. Flush the line with heparinized solution. D. Flush the line with normal saline. Correct Answer: D.Flush the line with normal saline. 30) In caring for a client with acute diverticulitis, which assessment data warrants immediate nursing intervention? A. The client has a rigid hard abdomen and elevated WBC. B. The client has left lower quadrant pain and an elevated temperature. C. The client is refusing to eat any of the meal and is complaining of nausea. D. The client has not had a bowel movement in 2 days and has a soft abdomen. Correct Answer: A.The client has a rigid hard abdomen and elevated WBC. 31) The nurse is giving preoperative instructions to a 14-year-old client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? A. "I will read all the teaching booklets you gave me before surgery." B. "I have had surgery before, so I know what to expect afterward." C. "All the things people have told me will help me take care of my back." D. "Let me show you the method of turning I will use after surgery." Correct Answer: D."Let me show you the method of turning I will use after surgery." 32) The nurse on a medical surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain? A. If suctioning will be needed for drainage of the wound B. If the family would prefer a private or semiprivate room C. If the client also has a Hemovac in place D. If the client's wound is infected Correct Answer: D If the client's wound is infected 33) The nurse is completing an admission interview for a client with Parkinson's disease. Which question will provide additional information about manifestations that the client is likely to experience? A. "Have you ever experienced any paralysis of your arms or legs?" B. "Do you have frequent blackout spells?" C. "Have you ever been frozen in one spot, unable to move?" D. "Do you have headaches, especially ones with throbbing pain?" Correct Answer: C. "Have you ever been frozen in one spot, unable to move?" 34) A hospitalized client is receiving nasogastric tube feedings via a small- bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take FIRST? A.Auscultate the client's breath sounds. B.Turn off the continuous feeding pump. C.Check placement of the nasogastric tube. D.Measure the amount of residual feeding. Correct Answer: B.Turn off the continuous feeding pump. 35) The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A.Increased serum albumin level B.Decreased serum creatinine C.Decreased serum ammonia level D.Increased liver function test results Correct Answer: C.Decreased serum ammonia level 36) During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take? A. Continue with the shift report and talk to the nurse about the incident at a later time. B. Ask the nurse to call the house supervisor to see if she must be reassigned. C. Stop the shift report and remind the nurse that all staff are floated equally. D. Inform the nurse that her behavior is disruptive to the rest of the staff. Correct Answer: A.Continue with the shift report and talk to the nurse about the incident at a later time. 37) The LPN/LVN is administering a nystatin suspension (Mycostatin) for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A. "Hold the medication in your mouth for a few minutes before swallowing it." B. "Do not drink or eat milk products for 1 hour prior to taking this medication." C. "Dilute the medication with juice to reduce the unpleasant taste and odor." D. "Take the medication before meals to promote increased absorption." Correct Answer: "Hold the medication in your mouth for a few minutes before swallowing it." 38) Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? A.Stress incontinence B.Infection C.Painless gross hematuria D.Peritonitis Correct Answer: B.Infection 39) A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A. Replace the stoma appliance every day. B. Use warm tap water to irrigate the ileostomy. C. Change the bag when the seal is broken. D. Measure and record the ileostomy output. Correct Answer: C.Change the bag when the seal is broken. 40) In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the ABSENCE of a thrill or bruit at the shunt site. What action should the nurse take? A.Advise the client that the shunt is intact and ready for dialysis as scheduled. B.Encourage the client to keep the shunt site elevated above the level of the heart. C.Notify the health care provider of the findings immediately. D.Flush the site at least once with a heparinized saline solution. Correct Answer: C.Notify the health care provider of the findings immediately. 41) The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan? A.Reduce the daily intake of animal fat to 10% of the diet within 6 weeks. B.Exhibit regular, soft-formed stool within 1 month. C.Demonstrate the irrigation procedure correctly within 1 week. D.Attend an ostomy support group within 2 weeks. Correct Answer: D.Attend an ostomy support group within 2 weeks. 42) A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take? A.Administer the prescribed dose at the scheduled time. B.Hold the dose and contact the health care provider. C.Hold the dose and recheck the blood pressure in 1 hour. D.Check the health care provider's prescription to clarify dose. Correct Answer: A.Administer the prescribed dose at the scheduled time. 43) A client with type 2 diabetes takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? A.NPO except for metformin and regular snacks B.NPO except for oral antidiabetic agent C.Novolin N insulin subcutaneously twice daily D.Regular insulin subcutaneously per sliding scale Correct Answer: D.Regular insulin subcutaneously per sliding scale 44) The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an OLDER adult most likely to exhibit? A.Polyuria B.Polydipsia C.Weight loss D.Infection Correct Answer: D.Infection 45) The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food item(s) chosen by the client INDICATES UNDERSTANDING of the teaching? (Select all that apply.) A. White bread B.Salmon C.Broccoli D.Whole milk E.Banana Correct Answer: B, C, E B. Salmon C.Broccoli E.Banana 46) A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision? A. Notify the family that the resident will have to be discharged if his behavior does not improve. B. Notify administration of the PN's insubordination and need for counseling about her statements. C. Ask the PN what she has done to encourage the resident to believe that she is his daughter. D. Reassign the PN until the resident can be assessed more completely for reality orientation. Correct Answer: D Reassign the PN until the resident can be assessed more completely for reality orientation. 47) The nurse is preparing a teaching plan for a group of healthy adults. Which individual is most likely to maintain optimum health? A.A teacher whose blood glucose levels average 126 mg/dL daily with oral anti diabetic drugs B.An accountant whose blood pressure averages 140/96 mm Hg and who says he does not have time to exercise C.A stock broker whose total serum cholesterol level dropped to 290 mg/dL with diet modifications D.A recovering IV heroin user who contracted hepatitis more than 10 years ago Correct Answer: A.A teacher whose blood glucose levels average 126 mg/dL daily with oral anti diabetic drugs 48) What is the most important nursing priority for a client who has been admitted for a possible kidney stone? A.Reducing dairy products in the diet B.Straining all urine C.Measuring intake and output D.Increasing fluid intake Correct Answer: B.Straining all urine 49) A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority? A. Place the client on NPO status. B. Assess the client's temperature. C. Obtain a stool specimen. D.Administer IV fluids. Correct Answer: A.Place the client on NPO status. 50) The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis? A.Fluid volume deficit B.Self-care deficit C.Risk for infection D.Impaired nutrition Correct Answer: C.Risk for infection 51) A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique? A. Turns on the continuous wall suction to −190 mm Hg B. Inserts the catheter until resistance or coughing occurs C.Withdraws the catheter while maintaining suctioning D.Reclears the tracheostomy after suctioning the mouth Correct Answer: B.Inserts the catheter until resistance or coughing occurs 52) A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A.Hypophosphatemia B.Hypocalcemia C.Hyponatremia D.Hypokalemia Correct Answer: B Hypocalcemia 53) As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is a goal of the report? 1. To reprimand the involved staff members for their actions 2. To identify the learning needs of staff to prevent incident recurrences 3. To reprimand the nurse-manager responsible for the unit 4. To hold people accountable for their actions Correct Answer: 2 54) As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy? 1. Decreased appetite 2. Inadequate fluid intake 3. Prolonged gastric emptying 4. Reduced intestinal motility Correct Answer: 4 Reduced intestinal motility 55) An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatment approach would be most effective for this client? 1. Administering insulin once per day 2. Administering multiple doses of insulin 3. Limiting dietary fat intake 4. Substituting an oral anti diabetic agent for insulin Correct Answer: 2. Administering multiple doses of insulin 56) A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing? 1. Planning 2. Data collection 3. Evaluation 4. Implementation Correct Answer: 2. Data collection 57) The physician prescribes meperidine (Demerol), 1.1 mg/kg I.M., for a 16- month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size? 1. 18G 2. 20G 3. 23G 4. 27G Correct Answer: 3 23G 58) Which finding in a neonate suggests hypothermia? 1. Bradycardia 2. Hyperglycemia 3. Metabolic alkalosis 4. Shivering Correct Answer: 1 Bradycardia 59) Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which complaints? 1. Headache, blurred vision, and facial and extremity swelling 2. Abdominal pain, urinary frequency, and pedal edema 3. Diaphoresis, nystagmus, and dizziness 4. Lethargy, chest pain, and shortness of breath Correct Answer: 1. Headache, blurred vision, and facial and extremity swelling 60) The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter? 1. Family history of pressure ulcers 2. Presence of existing pressure ulcers 3. Potential areas of pressure ulcer development 4. Overall risk of developing pressure ulcers Correct Answer: 4. Overall risk of developing pressure ulcers 61) The nurse is preparing to boost a client up in bed. She instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? 1. Friction 2. Impaired circulation 3. Localized pressure 4. Shearing forces Correct Answer: 4. Shearing forces 62) A geriatric client with Alzheimer's disease has been living with his grown child's family for the last 6 months. He wanders at night and needs help with activities of daily living. Which statement by his child suggests that the family is successfully adjusting to this living arrangement? 1. "It's difficult dealing with Dad. It's a thankless job." 2. "We had no idea this would be so difficult. It's our cross to bear." 3. "Dad really seems to be making progress. We're hoping he'll be able to move back into his house soon." 4. "Dad has presented many challenges. We have alarms on all the outside doors now. Respite care gives us a break." Correct Answer: 4 "Dad has presented many challenges. We have alarms on all the outside doors now. Respite care gives us a break." 63) The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal age-related change is: 1. cloudy vision. 2. incontinence. 3. diminished reflexes. 4. tremors. Correct Answer: 3 diminished reflexes. 64) An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, andangina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute [Show Less]
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LATEST FUNDAMENTAL PN HESI SPECIALTY V2
LATEST FUNDAMENTAL PN HESI SPECIALTY V2 LATEST FUNDAMENTAL PN HESI SPECIALTY V2 1) During the initial physical assessment of a newly admitted client ... [Show More] with a pressure ulcer, a LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? A The nurse also should have instituted a plan to increase activity. B The nurse provided supportive nursing care for the well-being of the client. C Debridement of the pressure ulcer should have been done before the dressing was applied. D Treatment should not have been instituted until the health care provider's prescriptions were received. Correct Answer: B 2) A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take? A Ask the client if he is okay. B Call security from the room. C Find out if there is anyone else in the room. D Ask security to make sure the room is safe Correct Answer: D 3) To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the LPN should change the administration set every: A 4 to 8 hours B 12 to 24 hours C 24 to 48 hours D 72 to 96 hours Correct Answer: D 4) A LPN/LVN is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. A Ask the client what is the client's acceptable level of pain. B Eliminate all activities that precipitate the pain. C Administer the pain medications regularly around the clock. D Use a different pain scale each time to promote patient education. E Assess the client's pain every 15 minutes Correct Answer: A, C 5) The LPN/LVN is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. A Allergy to the medication B Itching in the ear canal C Drainage from the ear canal D Tympanic membrane rupture E Partial hearing loss in the affected ear Correct Answer: A, C, D 6) What clinical indicators should the LPN/LVN expect a client with hyperkalemia to exhibit? Select all that apply. A Tetany B Seizures C Diarrhea D Weakness E Dysrhythmias [Show Less]
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HESI Fundamentals 47 Test Bank New Question & Answers
Hesi Fundamentals 47 Test Bank Q&A 1. Wheezing is often associated with asthma- assess breathing patterns and learn about any precipitating fac... [Show More] tors that caused the onset of the wheezing 2. A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he does for the swelling in his leg. Which should the nurse implement? ✓ -instruct the client to flex both of his feet several times a day 3. A client at an outpatient clinic submits a clean-catch midstream urine specimen for routine urinalysis. In later review of the client’s medical record, which data indicates to the nurse that the specimen collection should be repeated? ✓ -the urine specimen shows multiple organisms in low colony counts Rationale: *often indicates that a contaminated specimen was obtained 4. During the admission assessment of a terminally ill male client, the client states that he is an agnostic. What is the best nursing action in response to this statement? ✓ -document the statement in the client’s spiritual assessment 5. The nurse observes a newly admitted older adult female take short stems and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? ✓ -complete a full fall risk assessment of the client 6. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs should the nurse obtain first? ✓ -respiratory rate Rationale: *cyanosis is a bluish discoloration, an indication of hypoxemia 7. A middle-aged male client tells the nurse that two weeks ago, he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes him an hour to fall asleep at night. Which action should the nurse implement? ✓ -ask the client to describe the exercise schedule that he has been following Rationale: *to determine if he is exercising too close to bedtime 8. While suctioning a client's nasopharynx, the nurse observes that the patient's oxygen saturation remains at 94%, which is the same reading obtained before starting the procedure. What action should the nurse take in response to this finding? ✓ -complete the intermittent suction of nasopharynx *suctioning can be continued if the client’s oxygen saturation remains above 90% or does not decrease 5% from the initial baseline 9. An older male client returns to the clinic for chronic pain management after taking morphine sulfate (MS Contin) 25 mg every 12 hours. He states he took the medication only when the pain was too severe to sleep. What action should the nurse implement? ✓ -instruct the client to take the MS Contin every 12 hours as prescribed 10. A female, unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take first? ✓ -instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client Rationale: *a particulate filter mask is indicated for clients with airborne precautions 11. The community health nurse is making a home visit when the client, who is sitting at the kitchen table, begins to have a seizure. What action should the nurse take first? ✓ -assist the client to the floor 12. A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries in the client’s room. In which order should the nurse perform the interventions? ✓ -restart the IV, perform tracheostomy care, change the coccyx dressing 13. A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider? ✓ -Potassium 3.1 mEq/L (3.1 mmol/L) 14. A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops, pilocarpine HCl (Pilocarpine). What instructions should the nurse plan to include in the client’s teaching? ✓ - “do not allow the dropper bottle to touch the eye.” 15. *Sleeping side ✓ lying with hips and knees flexed prevents unnecessary pressure on support muscles, ligaments, and lumbosacral joints and reduces low back pain 16. *Obesity ✓ a BMI greater than 30 17. *Hygiene self-care deficit ✓ evaluate the client’s participation in self-care to an optimal level of capacity is the best goal to evaluate progress in recovery 18. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement s of several clients. Which descriptions warrant additional follow-up by the nurse? ✓ -multiple hard pellets, tarry appearance, and brown liquid 19. A client with a gastronomy tube is recovering a continuous feeding, and the nurse suspects that the client has aspirated some of the feedings. What is the action by the nurse? ✓ -stop the tube feeding and assess the client 20. *it is the best response for the nurse to provide a response that reflects what the client stated and confirms their condition is serious. 21. The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry his feet. While drying the client’s feet, the nurse should emphasize the need to thoroughly dry which area of the feet? ✓ -between the toes 22. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? ✓ -position the client supine for a few minutes 23. A client who lives in an assisted living facility develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should the nurse contact? ✓ -a daughter-in-law designated as the client’s Durable Power of Attorney (DPOA) 24. A 24-hour urine specimen is being collected for analysis of creatinine clearance. After explaining the procedure, the client tells the nurse that the first sample is in the urinal. When discarding this specimen, what action should the nurse take? ✓ -check the sample’s pH and specific gravity 25. A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for the nurse to include in the teaching plan? ✓ -toxicity 26. A postoperative client has three different PRN analgesics prescribed for varying levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take first? ✓ -assess for side effects/adverse effects of the medication 27. Which landmarks are useful to the nurse when administering an intramuscular injection in the ventrogluteal site? ✓ -the greater trochanter and anterior superior iliac spine 28. To assess the quality of an adult client’s pain, what approach should the nurse use? ✓ -ask the client to describe the pain 29. The home health nurse is reviewing the personal care needs of an elderly client who lives alone. Which client assessment findings indicate the need to assign unlicensed assistive personnel (UAP) to provide routine foot care and file the client’s toenails? (Select all that apply) ✓ -diminished visual activity ✓ syncope (dizziness) when bending ✓ hand tremors 30. The nurse measures the client’s blood pressure (PB) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply) ✓ -retake the client’s blood pressure in the opposite arm, determine the client’s activity and feeling prior to the BP measurement 31. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement? ✓ assess for the presence of an impaction Rationale: *it is common for cultures, such as Native Americans, to believe in using home remedies and herbs before seeking medical attention. The herbal remedies used for constipation and nausea 32. A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room? ✓ -paper mask and gown 33. The home care nurse is teaching a client how to change the dressing on a new venous stasis ulcer. The client has a history of deep vein thrombosis and is allergic to latex. When removing the adhesive bandages, the nurse observes skin redness surrounding the dressing wound. What action should the nurse implement? ✓ -replace dressing with cotton pads and silk tape Rationale: *the skin redness surrounding the wound may be due to latex in the adhesive bandages, so the bandage should be replaced with non-latex dressing, such as cotton pads and silk tape. A culture is not indicated. A topical antibiotic ointment may be used if the wound appears infected, but is not indicated for inflammatory redness created by the latex dressing. Ankle- brachial pressure index compares the ratio of blood pressure in lower legs to blood pressure in arms and is used to assess circulation prior to applying compression stockings, which should not be applied since the client has an open wound. 34. An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take firs? ✓ -discuss with the client her meaning of heroic measures 35. A male client has right-sided hemoglobin following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take? ✓ -place the wheelchair on the client’s left side 36. A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). What intervention is most important for the nurse to implement before leaving the client alone? ✓ -elevate the head of the bead to a 45-degree angle 37. While interviewing a client, the nurse records the assessment in the electronic health record. which statement is most accurate regarding electronic documentation during an interview a- the client's comfort level is increased when the nurse breaks eye contact to type notes into the record b- the interview process is enhanced with electronic documentation and allow the client to speak at a normal pace c- completing the electronic record during the interview is a legal obligation of the examining nurse d- the nurse has limited ability to observe nonverbal communication while entering the assessment electronically 38. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client’s oxygen saturation level is 92%. What intervention should the nurse implement? ✓ -place padding around the cannula tubing *reddened areas on the cheekbones are the result of pressure from the cannula tubing. Padding the tubing of the nasal cannula helps reduce the excessive pressure 39. A client on a prescribed full liquid diet has a nursing diagnosis of “Risk for impaired skin integrity related to reduced oral intake”. What snack is best to provide this client? a. beef broth, or chicken broth b. purified lowfat milk c. apple or grapefruit juice d. ensure, a liquid supplement 40. A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client’s care? ✓ -measure the client’s vital signs before the client walks; report the onset of any dizziness or light headedness; offer to assist the client to void prior to walking in the hall Rationale: *assessment, including need for a gait belt, and teaching should be performed by the nurse and not delegated to the UAP. 41. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with the client. When the family leaves, what action should the nurse take first? ✓ -Reassess the client to determine the need for continuing restraints. 42. While planning care for a client experiencing pain, which outcome statement should the nurse include in the plan of care? ✓ -report a 5-point decrease on a 1 to 10 pain scale one hour after analgesia 43. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. What action should the nurse implement? ✓ apply a hydrocolloidal gel (Duoderm) dressing 44. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first? ✓ -complete a functional assessment of the client’s self-care abilities 45. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures he taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a “do not resuscitate” (DNR) prescription. What action should the nurse take? ✓ -initiate an ethics committee review of the case 46. A male client who had emergency gallbladder surgery yesterday is getting ready for discharge. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home? ✓ -have the client demonstrate prescribed wound care 47. A female client’s significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? ✓ -communicate the client’s wishes to all members of the multi- disciplinary team [Show Less]
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Hesi Fundamentals Practice
Hesi Fundamentals Practice NR 226 NUR 282 Hesi Fundamentals Practice Which drug does a nurse anticipate may be prescribed to produce diuresis and inhib... [Show More] it formation of aqueous humor for a client with glaucoma? Chlorothiazide (Diuril) Acetazolamide (Diamox) Bendroflumethiazide (Naturetin) Demecarium bromide (Humorsol) A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? Tell the client it is nothing to worry about. Talk with the client further to identify the specific cause of the problem. Instruct the client to attempt to avoid situations that cause irritation. Interview the client to determine whether other mood swings are being experienced. A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? Tell the client it is nothing to worry about. Talk with the client further to identify the specific cause of the problem. Instruct the client to attempt to avoid situations that cause irritation. Interview the client to determine whether other mood swings are being experienced. The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: Promote equalization of osmotic pressures. Prevent hypoxia associated with diaphoresis. Promote integrity of intracerebral neurons. Reduce brain metabolism and limit hypoxia. A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. mL 1.5 The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? Risk for pressure ulcer Risk for impaired skin integrity Impaired skin integrity, related to infrequent turning and repositioning Impaired skin integrity, related to the effects of pressure and shearing force A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? Stage I Stage II Stage III Unstageable A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed. A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply. After reporting severe pain On admission to the hospital Upon entering the operating room Before transfer to a rehabilitation facility At time of scheduling for the surgical procedure Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted. A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? White blood cell (WBC) count of 15,000 mm3 Negative protein in the urine Blood urea nitrogen (BUN) of 20 mg/dL Prothrombin of 12.0 seconds White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are normal values. Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? Anger Denial Depression Acceptance In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs. The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. Whole grains Cooked fruit and vegetables Nuts and seeds Lean red meats Milk and eggs With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats. A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. Pain history, including location, intensity, and quality of pain Client's purposeful body movement in arranging the papers on the bedside table Pain pattern, including precipitating and alleviating factors Vital signs such as increased blood pressure and heart rate The client's family statement about increases in pain with ambulation Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members. While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? Immediately stop the infusion. Lower the height of the enema bag. Advance the enema tubing 2 to 3 inches. Clamp the tube for 2 minutes, then restart the infusion. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps [Show Less]
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