HESI RN
HESI 799 RN Exit Exam Capstone
1. A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care?
- A. Social isolation related to hearing loss
- B. Risk for injury related to vertigo
- C. Impaired verbal communication
- D. Impaired hearing related to ear disease
Correct answer: B
Rationale: Vertigo is the primary symptom of Meniere's disease and can lead to falls and other injuries. Ensuring safety and addressing the risk of injury is the nurse's top priority. While social isolation and impaired hearing are significant concerns associated with Meniere's disease, the immediate danger of falls due to vertigo takes precedence in the plan of care. Impaired verbal communication, although important, is not as urgent as preventing injuries caused by vertigo.
2. Which strategy should the nurse implement when teaching a client with low literacy about a new diagnosis of hypertension?
- A. Provide a detailed handout with complex terms
- B. Use simple language and visual aids
- C. Encourage the client to research the diagnosis online
- D. Incorporate medical jargon to explain the condition
Correct answer: B
Rationale: The correct strategy for teaching a client with low literacy about a new diagnosis of hypertension is to use simple language and visual aids. This approach helps ensure better understanding of the diagnosis and treatment plan by making the information clear and accessible. Providing a detailed handout with complex terms (Choice A) would not be suitable as it may confuse the client further. Encouraging the client to research the diagnosis online (Choice C) could lead to misinformation and overwhelm the client with information they may not understand. Incorporating medical jargon to explain the condition (Choice D) would not be helpful for a client with low literacy as it may complicate rather than clarify the information.
3. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?
- A. An 8-year-old living in a housing project.
- B. A 2-year-old playing on aging playground equipment.
- C. An adolescent working in a paint factory.
- D. A 10-year-old with Type 1 diabetes.
Correct answer: B
Rationale: The correct answer is B. Young children, like the 2-year-old playing on aging playground equipment, are more susceptible to lead poisoning from environmental sources due to their behaviors like hand-to-mouth contact and exploratory behaviors. Choices A, C, and D are less likely to be at high risk for lead poisoning compared to young children due to differences in exposure levels and behaviors related to potential sources of lead contamination.
4. A client with chronic obstructive pulmonary disease (COPD) is being discharged home. What should the nurse include in the discharge teaching?
- A. Limit fluid intake to prevent lung congestion
- B. Avoid all physical activity to conserve energy
- C. Perform pursed-lip breathing during activities
- D. Increase oxygen flow rate if shortness of breath occurs
Correct answer: C
Rationale: The correct answer is C. Pursed-lip breathing helps control breathing and improves oxygen exchange in clients with COPD. It can ease shortness of breath during activities and should be included in discharge teaching to manage symptoms. Option A is incorrect as adequate fluid intake is important for thinning mucus in COPD. Option B is wrong as physical activity, as tolerated, is beneficial for COPD patients. Option D is also incorrect because changing oxygen flow rate without healthcare provider guidance can be dangerous.
5. A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting milk products arrives at the clinic accompanied by the parents. Which type of testing should the nurse educate the toddler's family about?
- A. Complete blood count
- B. Lactose tolerance test
- C. Skin allergy testing
- D. Serum immunoglobulin E
Correct answer: D
Rationale: The correct answer is D, Serum immunoglobulin E (IgE) testing. This test can help diagnose food allergies, including milk protein allergies, in toddlers presenting with symptoms like skin rashes, hives, abdominal pain, and vomiting after consuming milk products. Skin allergy testing is used for allergies but may not be suitable for this age group due to developmental factors. Lactose intolerance, which is different from a milk allergy, is assessed through a lactose tolerance test, not IgE testing. A complete blood count (CBC) would not provide specific information related to food allergies.
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