HESI LPN
Adult Health 2 Exam 1 Questions
Question 1 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 2 of 5
A client with a leg fracture reports increased pain and swelling. What should the nurse suspect?
Correct Answer: A
Rationale: Increased pain and swelling in a fracture could indicate compartment syndrome, a serious condition requiring urgent care. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to compromised blood flow and potential tissue damage. Deep vein thrombosis is less likely in this scenario as the symptoms are more indicative of compartment syndrome. Wound infection would typically present with localized signs of infection at the wound site, such as redness, warmth, and purulent drainage, rather than diffuse pain and swelling.
Question 3 of 5
A client with a history of seizure disorder who is receiving phenytoin (Dilantin) is being discharged. Which instruction should the nurse provide?
Correct Answer: B
Rationale: The correct answer is to instruct the client to monitor drug levels regularly. This is crucial for phenytoin (Dilantin) to ensure that the medication levels are within the therapeutic range and to prevent toxicity. Choice A, taking the medication at bedtime, is not specifically required for phenytoin administration. Choice C, avoiding alcohol, is generally a good practice with medications but is not as critical as monitoring drug levels for phenytoin. Choice D, taking the medication at the same time every day, is important for consistency but does not address the specific monitoring needs of phenytoin.
Question 4 of 5
The healthcare provider is assessing a client who has just undergone a thoracentesis. Which finding should be reported immediately?
Correct Answer: D
Rationale: Shortness of breath should be reported immediately as it may indicate a pneumothorax, a potential complication of thoracentesis. Diminished breath sounds on the affected side, pain at the procedure site, and blood-tinged sputum are common findings post-thoracentesis and do not necessarily indicate immediate complications like a pneumothorax.
Question 5 of 5
The client with a new colostomy is being taught about colostomy care. Which statement by the client indicates effective learning?
Correct Answer: C
Rationale: The correct answer is C because inspecting the stoma daily is crucial in identifying any early signs of complications or infections. Choice A is incorrect because changing the colostomy bag daily is not necessary unless there is a specific reason to do so. Choice B is incorrect as a low-fiber diet is not usually recommended for colostomy care. Choice D is incorrect because colostomy care should be performed regularly regardless of how the client feels.