HESI RN
Community Health HESI
1. A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?
- A. Facial weakness and difficulty speaking.
- B. Decreased deep tendon reflexes in the legs.
- C. Inability to move the eyes.
- D. Respiratory distress and cyanosis.
Correct answer: B
Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.
2. A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, 'Why do you have to wear a gown and mask when you are in my room?' How should the nurse respond?
- A. To protect myself from your germs.
- B. To protect you because you can get an infection very easily.
- C. Until your white blood cell count increases.
- D. To keep others from getting your infection.
Correct answer: B
Rationale: Reverse isolation precautions protect the client from exposure to microorganisms from others.
3. Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
- A. To bond with the baby.
- B. To help the baby latch on better.
- C. To stimulate contraction of the uterus.
- D. To promote milk production.
Correct answer: C
Rationale: The correct answer is C: 'To stimulate contraction of the uterus.' After delivery, breastfeeding helps in stimulating the release of oxytocin, which triggers the contraction of the uterus. This contraction is crucial to prevent uterine hemorrhage and facilitate the involution process. Choices A, B, and D are incorrect. While breastfeeding can indeed help in bonding with the baby and promoting milk production, in the immediate postpartum period after a Cesarean section, the priority is to ensure uterine contraction to prevent complications.
4. A client with a history of atrial fibrillation is receiving warfarin (Coumadin) therapy. Which laboratory result indicates that the therapy is effective?
- A. International normalized ratio (INR) of 1.0.
- B. Prothrombin time (PT) of 12 seconds.
- C. Partial thromboplastin time (PTT) of 60 seconds.
- D. International normalized ratio (INR) of 2.5.
Correct answer: D
Rationale: An International Normalized Ratio (INR) of 2.5 indicates that warfarin therapy is within the therapeutic range for a client with atrial fibrillation. A lower INR (such as 1.0) would suggest subtherapeutic levels, risking blood clots. Prothrombin time (PT) and partial thromboplastin time (PTT) are not specific to monitoring warfarin therapy.
5. Which client has the highest risk for developing community-acquired pneumonia?
- A. a 40-year-old first-grade teacher who works with underprivileged children
- B. a 75-year-old retired secretary with exercise-induced wheezing
- C. a 60-year-old homeless person who is an alcoholic and smokes
- D. a 35-year-old aerobics instructor who skips meals and eats only vegetables
Correct answer: C
Rationale: The correct answer is C, a 60-year-old homeless person who is an alcoholic and smokes. This client has the highest risk of developing community-acquired pneumonia due to multiple factors such as homelessness, substance abuse, and smoking. Homelessness can lead to poor living conditions and limited access to healthcare, increasing susceptibility to infections. Alcoholism and smoking weaken the immune system, making individuals more vulnerable to respiratory infections like pneumonia. Choices A, B, and D do not present the same level of risk factors for pneumonia compared to choice C.
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