a client with a history of alcohol abuse is admitted with cirrhosis which finding requires immediate intervention
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Nursing Elites

HESI RN

Community Health HESI 2023

1. A client with a history of alcohol abuse is admitted with cirrhosis. Which finding requires immediate intervention?

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. The healthcare provider is preparing to administer atropine, an anticholinergic, to a client scheduled for a cholecystectomy. The client asks the provider to explain the reason for the prescribed medication. What response is best for the provider to provide?

Correct answer: B

Rationale: Atropine, an anticholinergic medication, is used preoperatively to prevent bradycardia by increasing the automaticity of the sinoatrial node during surgical anesthesia. Choice A is incorrect because atropine does not affect gastric motility. Choice C is incorrect as atropine is not primarily used to reduce secretions. Choice D is also incorrect because preventing nausea and vomiting is not the primary purpose of administering atropine in this context.

3. The healthcare provider is developing a health education program for pregnant women on the importance of prenatal care. Which topic should be prioritized?

Correct answer: D

Rationale: Prioritizing the discussion on signs and symptoms of preterm labor is essential as it empowers pregnant women to recognize warning signs promptly and seek medical assistance to prevent potential complications. Understanding preterm labor signs, such as abdominal cramping, pelvic pressure, or vaginal bleeding, can lead to early intervention and improve maternal and fetal outcomes. While topics like breastfeeding benefits, nutrition during pregnancy, and fetal development stages are important, identifying signs of preterm labor takes precedence due to its immediate impact on maternal and fetal well-being.

4. 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.

5. A community health nurse is conducting a neighborhood discussion group about disaster planning. What information regarding transmission of anthrax should the nurse provide to the group?

Correct answer: A

Rationale: The correct answer is A: Infection is acquired when anthrax spores enter a host. Anthrax is primarily transmitted through spores entering the body, either through the skin, inhalation, or ingestion. Person-to-person transmission of anthrax is extremely rare and not a significant mode of transmission. Choices B and C are incorrect because mature anthrax bacteria do not live dormant on inanimate objects, and spores can survive for extended periods outside a living host. Choice D is incorrect as anthrax is not transmitted by respiratory droplets from person to person.

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