a young adult woman visits the clinic and learns that she is positive for brca1 gene mutation and asks the nurse what to expect next how should the nu
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Nursing Elites

HESI LPN

HESI CAT Exam 2024

1. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?

Correct answer: A

Rationale: The correct answer is A because counseling will help the woman understand her risk and options for surveillance or preventive measures. At this point, it is crucial to address the woman's immediate concerns related to the BRCA1 gene mutation. Choice B is incorrect as the focus should be on the woman's individual risk due to the specific gene mutation she carries. Choice C is not the priority as treatment options come after assessing the risk and deciding on surveillance or preventive measures. Choice D is incorrect because discussing survival rates is not the immediate need for someone who has just received information about having a genetic mutation.

2. The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Correct answer: D

Rationale: Engaging the client in a non-threatening conversation is crucial as it can help build trust and provide support, addressing the client's withdrawal. This intervention focuses on establishing a therapeutic relationship and giving the client an opportunity to express their feelings. Choices A, B, and C do not directly target the client's need for communication and may not address the underlying issues contributing to her withdrawal. Encouraging the client's family to visit more often (Choice A) may add pressure or discomfort to the client. Scheduling a daily conference with the social worker (Choice B) may not address the client's immediate need for communication. Encouraging the client to participate in group activities (Choice C) may be overwhelming for the client and not address her withdrawal directly.

3. In what order should the nurse assess a lethargic one-hour-old infant brought to the nursery?

Correct answer: D

Rationale: When assessing a lethargic one-hour-old infant, the nurse should prioritize assessing the most critical parameters first. Temperature and heart rate are vital signs that provide immediate information about the infant's well-being. Therefore, the correct order of assessment should be temperature, heart rate, respirations, and then a heel stick. Temperature is crucial to determine if the infant is hypothermic or hyperthermic, while heart rate gives insight into the circulatory system's function. Respirations follow to evaluate the infant's breathing pattern. Lastly, the heel stick is important for certain screenings but is not as urgent as evaluating temperature and heart rate in a lethargic infant.

4. Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever?

Correct answer: D

Rationale: The correct answer is D: Positive ASO titer. A positive ASO titer indicates recent streptococcal infection, which is associated with acute rheumatic fever. Thrombocytopenia (choice A) is not a typical laboratory finding in acute rheumatic fever. Polycythemia (choice B) refers to an increased red blood cell count, which is not typically seen in acute rheumatic fever. Decreased ESR (choice C) is not a common laboratory finding in acute rheumatic fever; in fact, ESR is often elevated in inflammatory conditions like rheumatic fever.

5. An older male client with a history of type 1 diabetes has not felt well for the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?

Correct answer: D

Rationale: Administering IV fluids is crucial to address potential dehydration and electrolyte imbalances, especially if the client is unable to provide a clear history. Starting an IV infusion of normal saline will help rehydrate the client and address any electrolyte imbalances, which are common in clients with diabetes experiencing symptoms like abdominal cramping and vomiting. Obtaining a serum potassium level can be important but is not the priority when the client is showing signs of dehydration and confusion. Administering insulin should only be done after addressing hydration and electrolyte status. Assessing pupillary response to light is not the most critical action in this situation compared to addressing dehydration and potential electrolyte imbalances.

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