HESI LPN
Adult Health 2 Exam 1 Questions
Question 1 of 5
How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?
Correct Answer: C
Rationale: Observing the lips and mucous membranes provides a reliable indicator of cyanosis in clients with dark skin tones.
Choice A is incorrect because cyanosis can be assessed in clients with dark skin by observing other body areas.
Choice B is incorrect as blanching the soles of the feet is not a relevant method for assessing cyanosis.
Choice D is incorrect as cyanosis is not typically seen in the sclera in clients with dark skin.
Question 2 of 5
The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the most important teaching point?
Correct Answer: D
Rationale: The correct answer is D: 'Report any thoughts of self-harm immediately.' Clients prescribed SSRIs should be educated to report any thoughts of self-harm promptly, as these medications can initially increase suicidal ideation.
Choice A is incorrect because SSRIs are usually taken on an empty stomach.
Choice B is incorrect as it takes several weeks for SSRIs to reach their full effectiveness.
Choice C is irrelevant to SSRI therapy.
Question 3 of 5
After delivering a healthy newborn, a client is experiencing postpartum hemorrhage. What initial intervention should the nurse implement?
Correct Answer: B
Rationale: The correct initial intervention for postpartum hemorrhage is to perform a uterine massage. This action helps the uterus contract, controlling bleeding. Administering IV fluids may be necessary but is not the initial intervention. Monitoring the newborn's vital signs is important but not the priority when managing postpartum hemorrhage. Notifying the healthcare provider can be done after initiating immediate interventions to address the hemorrhage.
Question 4 of 5
What is the most important information for the nurse to provide to a client with a diagnosis of major depressive disorder who is started on a selective serotonin reuptake inhibitor (SSRI)?
Correct Answer: C
Rationale: The correct answer is C: 'Report any thoughts of self-harm immediately.' When starting an SSRI, clients should be informed to report any thoughts of self-harm promptly. SSRIs can initially increase suicidal ideation, especially in the early stages of treatment. This information is crucial for the client's safety and well-being.
Choices A, B, and D are incorrect because taking the medication with food, avoiding foods high in tyramine, and expecting immediate improvement within 24 hours are not the most critical pieces of information for a client starting on an SSRI.
Question 5 of 5
The healthcare provider is assessing a client with a suspected diagnosis of appendicitis. Which symptom is most indicative of this condition?
Correct Answer: C
Rationale: Rebound tenderness at McBurney's point is a classic sign of appendicitis. This symptom is due to irritation of the peritoneum when pressure is released during palpation. Right upper quadrant pain (
Choice
A) is more commonly associated with gallbladder issues. Nausea and vomiting (
Choice
B) can occur in various abdominal conditions and are not specific to appendicitis. Hematuria (
Choice
D) is the presence of blood in the urine and is not a typical symptom of appendicitis.