Questions 9

HESI LPN

HESI LPN Test Bank

HESI CAT Questions

Question 1 of 5

The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

Correct Answer: B

Rationale: Pheochromocytoma is associated with severe hypertension due to excessive catecholamine release. Monitoring blood pressure frequently is the priority intervention to assess for hypertensive crises and prevent complications like stroke, heart attack, or organ damage. While recording urine output every hour, evaluating neurological status, and maintaining seizure precautions are important aspects of care, they are not the highest priority in a client with pheochromocytoma.

Question 2 of 5

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all that apply)

Correct Answer: B

Rationale: The correct interventions to include when a client with heart failure is being treated with diuretics for fluid volume excess are to observe for evidence of hypokalemia. Diuretics can lead to potassium loss, resulting in hypokalemia. Monitoring for this electrolyte imbalance is crucial. Encouraging oral fluid intake of 3,000 ml/day may exacerbate fluid volume excess in a client with heart failure. Teaching the client how to restrict dietary sodium is important in managing heart failure, but it is not directly related to the use of diuretics for fluid volume excess. Monitoring PTT, PT, and INR lab values is not typically associated with diuretic therapy for heart failure but rather with anticoagulant therapy.

Question 3 of 5

A male client approaches the nurse with an angry expression on his face and raises his voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out." The nurse recognizes that the client is using which defense mechanism?

Correct Answer: C

Rationale: The client is projecting his feelings of anger and frustration onto his roommate, attributing his own feelings to the other person. Projection is a defense mechanism where individuals attribute their thoughts, feelings, or motives onto another person. In this scenario, the client is displacing his anger onto his roommate, thereby using projection as a defense mechanism. Denial (choice A) is refusing to acknowledge an aspect of reality. Splitting (choice B) involves viewing people as all good or all bad. Rationalization (choice D) is creating logical explanations to justify unacceptable behavior.

Question 4 of 5

The client is assessing a client who was recently diagnosed with heart failure and is on a low-sodium diet. Which statement by the client indicates a need for further teaching?

Correct Answer: C

Rationale: The correct answer is C. Some salt substitutes can be high in potassium, which may not be suitable for clients with heart failure. Option A is correct as using lemon juice and herbs for flavoring is a good low-sodium alternative. Option B is also correct as canned soups and frozen dinners are typically high in sodium content. Option D is correct as checking food labels for sodium content is an essential part of managing a low-sodium diet. Therefore, the client's statement about using salt substitutes needs correction as it can introduce high levels of potassium, which may not be recommended for individuals with heart failure.

Question 5 of 5

What is the best response when a two-year-old boy begins to cry when his mother starts to leave?

Correct Answer: B

Rationale: The best response in this situation is to offer a distraction to the child. Reading a book can help soothe the child during separation from the parent by redirecting their attention. Choice A might not be as effective as providing a distraction like reading a book. Choice C dismisses the child's feelings and generalizes behavior, which is not helpful. Choice D diminishes the child's emotions and does not provide a constructive way to help the child cope with the separation anxiety.

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