HESI Quizlet Fundamentals

HESI RN

1. A client in the early stages of Alzheimerâ€™s disease is very anxious and frequently asks about her deceased parents. Which intervention should the nurse implement to reduce the clientâ€™s anxiety?

A. Remind the client that her parents have passed away
B. Ask the client about her favorite memories with her parents
C. Engage the client in an activity to distract her from thinking about her parents
D. Reorient the client to the present reality and surroundings

Correct answer: C

Rationale: Engaging the client in an activity to distract her from thinking about her deceased parents is the most appropriate intervention to reduce anxiety. This approach helps shift the focus away from distressing thoughts and can provide comfort and a sense of calm to the client.

2. During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?

A. Release the suction by opening the vent.
B. Continue suctioning to remove obstruction.
C. Increase the pressure.
D. Suction deeper.

Correct answer: A

Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.

3. The client is reviewing the signed operative consent with a nurse, who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement?

A. Notify the surgical team of the clientâ€™s confusion
B. Have the client sign a new surgical consent
C. Add the correct leg information to the consent form
D. Inform the surgeon about the clientâ€™s concern

Correct answer: D

Rationale: In this scenario, the nurse should inform the surgeon about the clientâ€™s concern immediately. This is important to ensure that the correct procedure is performed on the intended leg. Communication with the surgeon is crucial to address any discrepancies in the consent form and prevent errors during the surgical procedure. Having the surgeon clarify and correct the consent form is essential to maintain patient safety and uphold the principles of informed consent.

4. A client is diagnosed with primary hypertension. Which assessment finding is most commonly associated with this diagnosis?

A. Headache
B. Dizziness
C. Fatigue
D. Edema

Correct answer: A

Rationale: Headache (A) is the most commonly associated symptom with primary hypertension due to increased pressure in the blood vessels, leading to headaches. While dizziness (B), fatigue (C), and edema (D) may also occur in hypertension, headache is the most frequently reported symptom among individuals with primary hypertension.

5. A Native American individual presents to the clinic with complaints of frequent abdominal cramping and nausea. They state that they have chronic constipation and have not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the healthcare provider to implement?

A. Evaluate the stool samples for the presence of blood
B. Assess for the presence of an impaction
C. Determine which home remedies were used
D. Obtain a list of prescribed medications

Correct answer: C

Rationale: It is crucial to determine which home remedies the individual has tried to avoid interactions with prescribed treatments and consider cultural practices that may influence their healthcare choices. Understanding the home remedies used can provide insights into the individual's health beliefs, preferences, and potential interactions with conventional treatments, allowing for a more holistic approach to their care.