HESI Fundamentals Test Bank

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A 2-year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?

  • A. Place the child on clear liquids and gelatin for 24 hours
  • B. Continue with the regular diet and include oral rehydration fluids
  • C. Give bananas, apples, rice, and toast as tolerated
  • D. Place NPO for 24 hours, then rehydrate with milk and water
Correct Answer: B

Rationale: In managing mild diarrhea in a 2-year-old child, it is important to maintain their regular diet and include oral rehydration fluids. Choice A of placing the child on clear liquids and gelatin for 24 hours may not provide adequate nutrition and can lead to further electrolyte imbalances. Choice C of giving bananas, apples, rice, and toast as tolerated is a part of the BRAT diet, which is not recommended as the primary approach anymore due to its limited nutritional value. Choice D of placing the child NPO for 24 hours and then rehydrating with milk and water is not appropriate as it can worsen dehydration and delay recovery. Therefore, the best option is to continue the child's regular diet while incorporating oral rehydration fluids to prevent dehydration and maintain nutritional status.

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A client is admitted with acute pyelonephritis. Which symptom should the nurse expect the client to report?

  • A. Flank pain
  • B. Pedal edema
  • C. Hypotension
  • D. Weight gain
Correct Answer: A

Rationale: Flank pain is a classic symptom of acute pyelonephritis, which is a bacterial infection of the kidney. It occurs due to inflammation and irritation of the renal capsule, leading to pain in the flank region. Pedal edema (swelling in the feet and ankles) is more commonly associated with conditions like heart failure or kidney disease, not typically seen in acute pyelonephritis. Hypotension (low blood pressure) is a systemic symptom that may occur with severe infections but is not a specific hallmark of pyelonephritis. Weight gain is also not a typical symptom of acute pyelonephritis; instead, patients may experience weight loss due to decreased appetite and systemic effects of infection.

A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?

  • A. Establish goals that are measurable and realistic.
  • B. Set goals that are a little beyond the capabilities of the patient.
  • C. Use the nurse's own judgment and not be swayed by family desires.
  • D. Explain that without taking alignment risks, there can be no progress.
Correct Answer: A

Rationale: When developing an individualized plan of care for a patient, the nurse must set goals that are specific, measurable, achievable, realistic, and time-bound (SMART). Choice A is correct as it emphasizes the importance of establishing goals that are measurable and realistic, ensuring they are attainable within a specific timeframe. Setting goals that are beyond the capabilities of the patient (Choice B) can lead to frustration and lack of progress. Using only the nurse's judgment and disregarding family desires (Choice C) may not consider important aspects of the patient's social support and preferences. Explaining that progress requires taking alignment risks (Choice D) is not a standard approach in nursing care planning and may confuse the patient or hinder trust in the nurse's decision-making.

Twenty minutes after starting a heat application, the client mentions that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN?

  • A. That indicates you have derived the maximum benefit, and the heat can be removed.
  • B. Your blood vessels are dilating and removing the heat from the site.
  • C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
  • D. The body's receptors adapt over time as they are exposed to heat.
Correct Answer: D

Rationale: Choice D is the correct response. The body's receptors adapt to the heat over time, which can explain why the client no longer perceives the warmth from the heating pad. This phenomenon is known as thermal adaptation. Choices A, B, and C are incorrect. Choice A is inaccurate because the client not feeling the warmth does not necessarily mean they have derived the maximum benefit. Choice B incorrectly states that blood vessels dilating remove heat, which is not accurate. Choice C suggests increasing the temperature when the pad no longer feels warm, which could potentially lead to burns or discomfort for the client.

A client reports constipation, and a nurse is providing dietary teaching. Which of the following foods should the nurse recommend?

  • A. Macaroni and cheese
  • B. One medium apple with skin
  • C. One cup of plain yogurt
  • D. Roast chicken and white rice
Correct Answer: B

Rationale: The correct answer is B: One medium apple with skin. Foods high in fiber, like apples with skin, are recommended to relieve constipation due to their fiber content, which aids in bowel regularity. Macaroni and cheese, yogurt, and roast chicken with white rice do not provide as much fiber and are less effective in alleviating constipation. While yogurt can sometimes contain probiotics that support gut health, it is not as effective in treating constipation as high-fiber foods like apples.

Nurse talking with a client's partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this?

  • A. Role overload
  • B. Role conflict
  • C. Role ambiguity
  • D. Role strain
Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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