HESI RN
Community Health HESI 2023
1. A client is suspected of being poisoned and presents with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth. The nurse should consider these findings consistent with which potential bioterrorism agent?
- A. ricin
- B. botulism toxin
- C. sulfur mustard
- D. yersinia pestis
Correct answer: B
Rationale: The correct answer is B: botulism toxin. The symptoms described, including symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth, are classic manifestations of botulism, which is caused by a toxin produced by Clostridium botulinum. This toxin affects the nervous system, leading to muscle weakness and paralysis. Choice A, ricin, typically presents with gastrointestinal symptoms and organ failure. Choice C, sulfur mustard, causes blistering skin and respiratory issues. Choice D, yersinia pestis, is associated with the plague and presents with fever, chills, weakness, and swollen lymph nodes.
2. The programs aimed at achieving total reproductive health as a social goal at the national level are called:
- A. Family organization
- B. Family planning
- C. Reproductive care
- D. Reproductive health
Correct answer: D
Rationale: The correct answer is D, 'Reproductive health.' Reproductive health programs focus on ensuring overall well-being in relation to reproduction, including access to reproductive services, education, and healthcare. Choice A, 'Family organization,' does not specifically address health aspects related to reproduction. Choice B, 'Family planning,' is more focused on birth control and family size rather than the broader aspects of reproductive health. Choice C, 'Reproductive care,' is limited to the aspect of medical care and does not encompass the comprehensive approach of reproductive health programs.
3. The healthcare provider is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg. Which action is the highest priority?
- A. Provide a quiet environment with subdued lighting.
- B. Have calcium gluconate immediately available.
- C. Assess deep tendon reflexes (DTRs) every 4 hours.
- D. Insert a Foley catheter with a urimeter to monitor hourly output.
Correct answer: B
Rationale: Having calcium gluconate readily available is crucial when administering magnesium sulfate, as it serves as the antidote in case of magnesium toxicity. Magnesium sulfate can lead to respiratory depression and cardiac arrest in cases of overdose or toxicity, making the prompt availability of calcium gluconate essential for immediate administration to counteract these effects. Providing a quiet environment with subdued lighting may be beneficial for the client's comfort but is not the highest priority in this situation. Assessing deep tendon reflexes every 4 hours is important when administering magnesium sulfate, but it is not the highest priority compared to having calcium gluconate available. Inserting a Foley catheter with a urimeter to monitor hourly output is not the highest priority when preparing to administer magnesium sulfate in this scenario.
4. An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
- A. administer the medication in 2 separate injections
- B. give the medication in the ventrogluteal site
- C. call to get a smaller volume ordered
- D. check with the pharmacy for a liquid form of the medication
Correct answer: A
Rationale: Administering the medication in 2 separate injections is the correct action. When the total volume of an injection is relatively large for a specific site, dividing it into smaller volumes and administering them separately is a safer practice to prevent discomfort, tissue damage, or absorption issues. Giving the medication in the ventrogluteal site can be appropriate for IM injections but does not address the issue of the total volume being too high for a single injection. Calling to get a smaller volume ordered may delay treatment and is not necessary when a safe administration method is available. Checking with the pharmacy for a liquid form of the medication does not directly address the issue of the total volume being too high for a single injection, and changing the formulation may not be necessary if the correct administration technique can be applied.
5. A client is being educated by a nurse about strategies for a safety plan for intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply)
- A. Have a bag ready that contains extra clothes for self and children.
- B. Establish a code with family and friends to signal violence.
- C. Purchase a gun for protection.
- D. Attend a self-defense course focused on self-protection.
Correct answer: A
Rationale: The correct strategies for a safety plan for a victim of intimate partner violence include having a bag ready with essentials for self and children and establishing a code with family and friends to signal danger. These strategies can help the client prepare for emergencies and seek help discreetly. Purchasing a gun (Choice C) is not a safe or recommended strategy as it can escalate violence and pose more significant risks. Additionally, taking a self-defense course focused on self-protection (Choice D) is important for self-defense, but it should not involve retaliatory actions against the abuser with the intent to cause harm.