a client who has a body mass index bmi of 30 is requesting information on the initial approach to a weight loss plan which action should the nurse rec
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Nursing Elites

HESI RN

HESI Quizlet Fundamentals

1. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

Correct answer: C

Rationale: Keeping a food diary is a good first step to understand eating habits before making any dietary or activity changes.

2. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?

Correct answer: C

Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. This finding indicates dehydration and the need to restore the client's fluid volume. Therefore, the appropriate action for the nurse is to continue the planned nursing interventions aimed at addressing the fluid deficit. Choice A is incorrect as jugular vein distention is associated with fluid overload, not deficit. Choice B is incorrect as offering high-protein snacks does not directly address the fluid volume deficit. Choice D is incorrect as the priority is to address the fluid deficit before addressing skin integrity issues.

3. A client is admitted with a diagnosis of acute pancreatitis. Which assessment finding is most indicative of this diagnosis?

Correct answer: A

Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. While abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis, they are less specific and may be seen in various other gastrointestinal conditions. Therefore, the most indicative finding for acute pancreatitis is epigastric pain that radiates to the back.

4. The client reports still being unable to sleep a week after learning progressive muscle relaxation techniques. Which action should the nurse take first?

Correct answer: D

Rationale: The nurse should first assess the client's adherence to the original instructions. By asking the client to describe the routine, the nurse can evaluate if the technique is being correctly implemented before considering further interventions. This choice is correct as it focuses on assessing the client's current practice. Option A is incorrect as adding regular exercise may not address the issue with the relaxation technique. Option B is incorrect as determining if the client has been keeping a sleep diary does not directly address the efficacy of the relaxation technique. Option C is incorrect as blindly encouraging the client to continue may not be the best approach without understanding how the technique is being practiced.

5. A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?

Correct answer: B

Rationale: When a client expresses the desire to not be resuscitated, it is essential to inquire if this decision has been discussed with their healthcare provider. This is important to ensure that the client's wishes are appropriately documented and legally binding through the healthcare provider's guidance. It is crucial that healthcare decisions, especially those involving life-saving measures, are well-communicated and documented to respect the client's autonomy and ensure their wishes are honored. Option A is not the best action as it does not address the need to verify discussion with the healthcare provider. Option C is incorrect as it overemphasizes the need for a notarized advance directive, which may not be immediately feasible or necessary in this urgent situation. Option D is not the most appropriate action at this time since the immediate focus should be on clarifying if the decision has been communicated with the healthcare provider.

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