a young female adult wanders into the emergency department she is disheveled and confused and states my date must have put something in my drink he to a young female adult wanders into the emergency department she is disheveled and confused and states my date must have put something in my drink he to
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Nursing Elites

HESI LPN

HESI CAT Exam

1. A young female adult wanders into the Emergency Department. She is disheveled and confused and states, 'My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me.' How should the nurse respond?

Correct answer: D

Rationale: The correct response is to encourage the patient to share more about what she remembers. This approach helps gather crucial information, supports the patient in a non-judgmental manner, and allows the nurse to provide appropriate care. Choice A has been revised to be more sensitive by asking about resistance when feeling uncomfortable rather than placing blame. Choice B has been adjusted to show empathy and request more details without questioning the patient's account. Choice C, although empathetic, does not address the immediate need to collect information and support the patient.

2. What dietary modification is important for a child with celiac disease?

Correct answer: B

Rationale: The correct answer is B: Avoid gluten-containing foods. For a child with celiac disease, it is crucial to eliminate gluten from their diet to manage the condition effectively. Gluten triggers an immune response in individuals with celiac disease, leading to symptoms and damage to the small intestine. Choices A, C, and D are incorrect because increasing dairy intake, decreasing protein intake, or increasing fiber intake are not specific dietary modifications for managing celiac disease.

3. A client with a diagnosis of chronic heart failure is receiving digoxin. What is the most important assessment before administering this medication?

Correct answer: B

Rationale: The correct answer is to assess the heart rate. Before administering digoxin, it is essential to evaluate the heart rate as digoxin can cause bradycardia. While checking blood pressure, monitoring respiratory rate, and measuring oxygen saturation are important assessments in the care of a client with chronic heart failure, assessing the heart rate is particularly critical due to the medication's potential impact on heart rhythm.

4. What should be taught to the child and parents about using a peak flow meter for a child diagnosed with asthma?

Correct answer: C

Rationale: The correct answer is to 'Record the best of three attempts.' This method provides an accurate measure of peak expiratory flow using a peak flow meter. By taking the best of three attempts, the child and parents can obtain a more reliable assessment of the child's lung function. Choices A, B, and D are incorrect because using the device before taking medication, during asthma attacks, or after eating does not ensure an accurate measurement of peak flow, which is essential for managing asthma effectively. Monitoring peak flow regularly and accurately can help in adjusting asthma treatment plans and assessing response to medications.

5. Farah is viewing an exciting sports match of her favorite team and eating because of nervousness. Her food choice will most likely be based on ___.

Correct answer: C

Rationale: During stressful situations like watching an exciting sports match, individuals often seek emotional comfort through food. This emotional connection can lead Farah to choose foods that provide comfort or familiarity rather than being based on regional cuisines (choice A), general preferences (choice B), or positive associations (choice D). Farah's food choice is likely driven by the need for emotional comfort to alleviate her nervousness, making option C the most suitable answer.

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