HESI RN
Community Health HESI
1. During a home health visit, the nurse notices that an older male client with type 2 diabetes mellitus is wearing loose cloth slippers. The client reports that he cannot comfortably wear other shoes because his toenails get in the way. The nurse inspects the client's feet and finds long thick nails that curl down under some of the toes. Which action should the nurse take?
- A. demonstrate proper foot care to the client and family
- B. have a home health aide assist the client with hygiene weekly
- C. schedule an appointment for the client with a podiatrist
- D. trim the client's toenails gradually over several visits
Correct answer: C
Rationale: Scheduling an appointment with a podiatrist is the most appropriate action in this scenario. For a client with long thick nails that curl under the toes, professional foot care by a podiatrist is necessary to prevent complications, especially in a client with diabetes mellitus. Demonstrating proper foot care (choice A) may not address the immediate need for nail trimming. Having a home health aide assist with hygiene weekly (choice B) may not be sufficient for managing the client's toenail issue effectively. Trimming the client's toenails gradually over several visits (choice D) should be performed by a professional like a podiatrist to avoid potential complications.
2. A female client reports to the nurse that her sleep was interrupted by 'thoughts of anger towards my husband.' What type of thoughts is the client having?
- A. Obsessive.
- B. Phobic.
- C. Delusional.
- D. Paranoid.
Correct answer: A
Rationale: The correct answer is A: Obsessive. Obsessive thoughts are recurring, unwanted, and intrusive thoughts that cause distress or anxiety. In this scenario, the client is experiencing repetitive thoughts of anger towards her husband, indicating an inability to control these thoughts. Choice B, Phobic, is incorrect as phobic thoughts are related to irrational fears. Choice C, Delusional, is incorrect as delusional thoughts involve fixed false beliefs. Choice D, Paranoid, is incorrect as paranoid thoughts involve irrational suspicions and mistrust.
3. The nurse is caring for a client with Addison's disease. Which finding requires immediate intervention?
- A. Hyperpigmentation of the skin.
- B. Low blood pressure.
- C. Nausea and vomiting.
- D. Hypoglycemia.
Correct answer: B
Rationale: Low blood pressure in a client with Addison's disease requires immediate intervention as it can indicate an Addisonian crisis, a life-threatening condition that necessitates prompt treatment. Hyperpigmentation of the skin is a characteristic finding in Addison's disease but does not require immediate intervention. Nausea and vomiting can be managed symptomatically in Addison's disease. While hypoglycemia needs attention, it is not the most critical finding requiring immediate intervention in this context.
4. The nurse is providing discharge teaching to a client with a new colostomy. Which statement by the client indicates a need for further teaching?
- A. I will avoid foods that cause gas.
- B. I will change my colostomy bag every week.
- C. I will use a skin barrier to protect the skin around the stoma.
- D. I will empty my colostomy bag when it is one-third full.
Correct answer: B
Rationale: The correct answer is B. Changing the colostomy bag every week is not sufficient; it should be changed more frequently to prevent leakage and skin irritation. Option A is correct as avoiding foods that cause gas can help manage colostomy-related symptoms. Option C is correct as using a skin barrier helps protect the skin around the stoma. Option D is correct as emptying the colostomy bag when it is one-third full helps prevent leakage and discomfort.
5. What is the most important information for a nurse to obtain when an older female client expresses not deserving to eat due to lack of money?
- A. Client's thoughts about wanting to hurt herself
- B. Medication history for antipsychotic agents
- C. Availability of family members to provide meals
- D. Community resources to provide financial aid
Correct answer: A
Rationale: The correct answer is A: Client's thoughts about wanting to hurt herself. When a client expresses not deserving to eat due to lack of money, it raises concerns about her mental and emotional well-being. Assessing for suicidal ideation is crucial in this situation to ensure the client's immediate safety. Options B, C, and D are not the most critical information to obtain in this scenario. While medication history, family support, and community resources are important aspects of care, in this context, the client's mental health and risk of self-harm take precedence.
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