a nurse is assessing the body alignment of a standing patient which finding will the nurse report as normal
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HESI LPN

Fundamentals of Nursing HESI

1. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?

Correct answer: A

Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.

2. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

Correct answer: D

Rationale: The first action the nurse should implement is to determine the size and depth of the skin breakdown over the sacral area. This initial assessment will provide crucial information on the extent of the damage and guide appropriate care interventions. Option A is not the priority in this scenario as the immediate concern is addressing the existing skin breakdown. Option B, completing a functional assessment, is important but should come after addressing the acute issue of skin breakdown. Option C, applying a barrier ointment, may be beneficial later but does not address the primary need of assessing the extent of the current skin damage.

3. A client has C-diff infection. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct answer is to initiate contact precautions when providing client care. C-diff (Clostridium difficile) is highly contagious, and contact precautions are necessary to prevent its spread. Giving the client chlorhexidine gluconate for hand hygiene (Choice A) is not specific to managing C-diff. Removing the protective gown first when exiting the client's room (Choice B) may increase the risk of contaminating oneself and the environment. Using alcohol-based hand rub when caring for the client (Choice C) is not sufficient to prevent the transmission of C-diff, as soap and water are more effective against this particular pathogen.

4. The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session?

Correct answer: C

Rationale: The correct answer is C. Head lice are highly contagious and can spread to furniture and other people if not treated promptly. Informing the parents about the potential spread of head lice emphasizes the importance of thorough treatment and prevention measures. Choice A is incorrect as regular shampoo is not typically effective in treating head lice. Choice B is incorrect as products containing lindane are not recommended due to safety concerns. Choice D is incorrect as manual removal, though labor-intensive, is a crucial step in effectively treating head lice infestations, but it is not the most pertinent information to include in the teaching session.

5. During an integumentary assessment for a group of clients, a healthcare professional notes various skin findings. Which of the following findings should the professional recognize as requiring immediate intervention?

Correct answer: B

Rationale: Cyanosis, a bluish discoloration of the skin, indicates inadequate oxygenation and requires immediate intervention. It suggests a severe lack of oxygen in the blood, which can be life-threatening. Pallor and jaundice are concerning findings but may not indicate an immediate life-threatening situation. Pallor can be a sign of anemia or low blood pressure, while jaundice may indicate liver dysfunction. Erythema, which is redness of the skin, is typically not an emergency and can be caused by various factors such as inflammation or increased blood flow to the area.

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