a client with a head injury is admitted to the hospital which finding indicates a need for immediate intervention
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Nursing Elites

HESI RN

Community Health HESI 2023

1. A client with a head injury is admitted to the hospital. Which finding indicates a need for immediate intervention?

Correct answer: C

Rationale: In a client with a head injury, being drowsy but still arousable can be a sign of increased intracranial pressure, which necessitates immediate intervention. This presentation may indicate a deterioration in neurological status, requiring prompt assessment and management to prevent further complications. Choices A, B, and D are not indicative of an immediate need for intervention in this scenario. A Glasgow Coma Scale (GCS) score of 15 indicates the highest level of consciousness; pupils being equal and reactive to light suggest intact cranial nerve function, and memory loss about the injury event is common in head injuries and does not necessarily warrant immediate intervention.

2. A client with a history of asthma is admitted with shortness of breath. Which assessment finding requires immediate intervention?

Correct answer: C

Rationale: The correct answer is C: Absence of breath sounds. This finding is concerning in a client with asthma as it may indicate a severe asthma exacerbation, airway obstruction, or pneumothorax, all of which require immediate intervention. Absence of breath sounds suggests a lack of airflow in the lungs, which is a critical sign that should prompt immediate action. Expiratory wheezes (choice A) are common in asthma and may not warrant immediate intervention unless severe. An increased respiratory rate (choice B) is expected in a client with asthma experiencing shortness of breath, but it does not indicate an immediate threat to the airway. Frequent coughing (choice D) is a common symptom in asthma exacerbations but does not signify an immediate need for intervention as it can be managed with appropriate asthma treatments.

3. The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention?

Correct answer: C

Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.

4. The client with liver cirrhosis needs immediate intervention for which abnormal laboratory result?

Correct answer: D

Rationale: An elevated ammonia level of 80 mcg/dL indicates hepatic encephalopathy, a serious complication of liver cirrhosis that requires immediate intervention. Ammonia is a neurotoxin that accumulates in the blood due to impaired liver function, leading to cognitive impairment and altered mental status. Monitoring and lowering ammonia levels are crucial in managing hepatic encephalopathy to prevent further neurological deterioration. Prothrombin time, bilirubin, and albumin levels are important parameters in assessing liver function and overall health status in clients with liver cirrhosis, but an elevated ammonia level poses an immediate threat to neurological function and warrants prompt attention.

5. The nurse is providing discharge teaching to a client with a new diagnosis of diabetes mellitus. Which statement by the client indicates a need for further teaching?

Correct answer: B

Rationale: The correct answer is B. The statement 'I will follow a diet low in carbohydrates' indicates a need for further teaching. In diabetes mellitus, it is essential to follow a balanced diet that includes carbohydrates, proteins, and fats. Carbohydrates are a major source of energy and should be included in moderation to help manage blood sugar levels. Monitoring blood sugar levels daily (A), rotating injection sites for insulin (C), and exercising regularly (D) are all appropriate self-management strategies for individuals with diabetes mellitus.

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