HESI RN
Community Health HESI 2023
1. A client with a history of alcohol abuse is admitted with cirrhosis. Which finding requires immediate intervention?
- A. Jaundice.
- B. Ascites.
- C. Peripheral edema.
- D. Spider angiomas.
Correct answer: C
Rationale: Peripheral edema in a client with cirrhosis can indicate fluid overload and worsening liver function, necessitating immediate intervention to prevent further complications such as respiratory distress, cardiac issues, or renal impairment. Jaundice (choice A) is a common manifestation of cirrhosis but may not require immediate intervention unless severe. Ascites (choice B) is also a common complication of cirrhosis that may require intervention but is not as urgent as addressing peripheral edema. Spider angiomas (choice D) are typically benign skin lesions associated with cirrhosis but do not require immediate intervention unless bleeding or rupture occurs.
2. A community health nurse is addressing the issue of elder abuse in the community. Which intervention should be prioritized?
- A. providing education on the signs of elder abuse
- B. setting up a support group for elder abuse survivors
- C. partnering with local law enforcement to increase patrols
- D. creating a confidential hotline for reporting abuse
Correct answer: D
Rationale: The prioritized intervention for addressing elder abuse in the community should be the creation of a confidential hotline for reporting abuse. A confidential hotline offers a safe and accessible way for individuals to report elder abuse and seek help promptly. Providing education on the signs of elder abuse (Choice A) is important but may not directly address immediate reporting and intervention needs. Setting up a support group for elder abuse survivors (Choice B) is beneficial for emotional support but may not address the primary need for reporting abuse. Partnering with local law enforcement to increase patrols (Choice C) focuses on prevention rather than providing a direct reporting mechanism for victims.
3. A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?
- A. Ineffective coping related to denial.
- B. Risk for impaired cardiac function.
- C. Noncompliance related to lack of knowledge.
- D. Anxiety related to hospitalization.
Correct answer: A
Rationale: The correct answer is A: Ineffective coping related to denial. The client's desire to leave the hospital shortly after a myocardial infarction despite the severity of the condition indicates denial and ineffective coping. This behavior could lead to complications as the client may not adequately address his health needs. Choice B, Risk for impaired cardiac function, is not the most appropriate nursing problem in this scenario as the client's behavior is more indicative of psychological coping issues rather than a direct physiological risk at this moment. Choice C, Noncompliance related to lack of knowledge, does not align with the client's behavior of wanting to leave the hospital. Choice D, Anxiety related to hospitalization, may not be the best option as the client's behavior is more suggestive of denial rather than anxiety about being hospitalized.
4. What recommendation should the PN provide to help a 5-year-old girl who has started wetting the bed again after being dry at night for several months?
- A. Explain that bedwetting is normal in children and will pass with time.
- B. Advise limiting fluids in the evening and before bedtime.
- C. Suggest punishing the child for wetting the bed to prevent recurrence.
- D. Encourage the child to use the bathroom immediately before bed.
Correct answer: D
Rationale: Encouraging the child to use the bathroom before bed is a helpful recommendation to prevent nighttime bedwetting. Bedwetting can sometimes reoccur due to stress or other factors, and ensuring the child empties their bladder before sleeping may reduce the likelihood of bedwetting episodes. Choice A is incorrect because while bedwetting is common in children, it is essential to provide practical solutions rather than just reassurance. Choice B is not the best option for a child who has recently started bedwetting again after being dry, as it may not address the underlying cause. Choice C is inappropriate and harmful as punishing the child for bedwetting can lead to psychological distress and worsen the situation.
5. The nurse is performing an admission assessment of an older client who has difficulty swallowing and has a history of aspiration pneumonia. Which action should the nurse implement first?
- A. Obtain a speech therapy consult
- B. Elevate the head of the bed
- C. Check the client's lung sounds
- D. Implement aspiration precautions
Correct answer: B
Rationale: The correct action for the nurse to implement first is to elevate the head of the bed. Elevating the head of the bed helps prevent aspiration in clients with swallowing difficulties by reducing the risk of food or fluids entering the airway. While obtaining a speech therapy consult (Choice A) is important, the immediate priority is to ensure the client's safety by positioning them properly. Checking the client's lung sounds (Choice C) and implementing aspiration precautions (Choice D) are also essential steps but should follow the immediate intervention of elevating the head of the bed to prevent aspiration.