a nurse is assessing an older adult client who was brought to the emergency department by his son who reports that the client fell at home the nurse s

HESI LPN

HESI Leadership and Management Quizlet

1. A nurse is assessing an older adult client who was brought to the emergency department by his son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?

A. File an incident report.
B. Ask the client about his injuries with the son present.
C. Ask the client's son to go to the waiting area.
D. Treat and discharge the client

Correct answer: C

Rationale: The correct action for the nurse to take is to ask the client's son to go to the waiting area. This allows the nurse to interview the client independently to assess for signs of elder abuse without the son's potential influence. Filing an incident report may be necessary later but is not the immediate action required. Asking about injuries with the son present could lead to biased responses or intimidation. Treating and discharging the client without addressing the suspicion of elder abuse would neglect the nurse's responsibility to ensure the client's safety.

2. What is an episiotomy?

A. A surgical incision of the perineum to prevent tearing during delivery.
B. Releasing the red plug from the cervix just before crowning occurs.
C. An incision in the abdomen with which the baby can be delivered through.
D. The severance of the umbilical cord between mother and child.

Correct answer: A

Rationale: An episiotomy is a surgical incision of the perineum to prevent tearing during delivery. This procedure is performed to widen the vaginal opening and facilitate childbirth. Choice B is incorrect as it describes the expulsion of the mucus plug, not an episiotomy. Choice C is incorrect as it refers to a different procedure, a cesarean section, where the baby is delivered through an incision in the abdomen. Choice D is incorrect as it pertains to cutting the umbilical cord, which is not related to an episiotomy.

3. What is the primary focus of primary healthcare?

A. Emergency care
B. Preventive care
C. Specialized treatment
D. Hospital-based services

Correct answer: B

Rationale: The correct answer is B: Preventive care. Primary healthcare emphasizes preventive care, which includes promoting overall health, preventing diseases, and providing early intervention to avoid the progression of illnesses. Emergency care (choice A) is focused on immediate medical attention for urgent health situations but is not the primary focus of primary healthcare. Specialized treatment (choice C) refers to care provided by specialists for specific health conditions, which is not the main focus of primary healthcare. Hospital-based services (choice D) involve inpatient care provided in a hospital setting, which is not the primary focus of primary healthcare that aims to provide comprehensive and accessible care at the community level.

4. What are the six levels of consciousness from the most to the least responsive level of consciousness? Number all six using 1 as the most conscious and 6 as the least conscious.

A. Obtunded, Confused, Lethargic, Comatose, Stuporous, Alert
B. Confused, Lethargic, Obtunded, Stuporous, Comatose, Alert
C. Lethargic, Obtunded, Confused, Stuporous, Comatose, Alert
D. Alert, Confused, Lethargic, Obtunded, Stuporous, Comatose

Correct answer: D

Rationale: The correct order of the six levels of consciousness from most to least responsive is Alert, Confused, Lethargic, Obtunded, Stuporous, Comatose. Choice A is incorrect because it starts with Obtunded, which is less responsive than Alert. Choice B is incorrect as it doesn't follow the correct order. Choice C is incorrect as Lethargic is more responsive than Obtunded. Therefore, the correct answer is D.

5. Your client is adversely affected with fever, night sweats, occult hematuria, tenderness of the spleen, and Osler's nodes. What disorder would you most likely suspect?

A. Tuberculosis
B. AIDS/HIV
C. Pericarditis
D. Endocarditis

Correct answer: D

Rationale: The client is likely suffering from endocarditis based on the symptoms described. Endocarditis is characterized by fever, night sweats, hematuria, splenomegaly (tenderness of the spleen), and Osler's nodes (painful nodules on the pads of the fingers or toes). While tuberculosis and AIDS/HIV can present with some similar symptoms, the presence of Osler's nodes is more specific to endocarditis. Pericarditis typically presents with chest pain, not the combination of symptoms seen in this case.