an older female client living in a low income apartment complex tells the home health nurse that she is concerned about her 81 year old neighbor a wid
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Nursing Elites

HESI LPN

HESI CAT Exam 2022

1. An older female client living in a low-income apartment complex tells the home health nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer?

Correct answer: C

Rationale: The correct response is to provide the number for Adult Protective Services so the client can report any suspicion of elder abuse. This action allows for an official investigation into possible elder abuse or neglect, ensuring the neighbor’s safety and well-being. Choice A is incorrect because assuming dementia without evidence is premature and could lead to overlooking potential abuse. Choice B is incorrect as the situation raises concerns about possible neglect or abuse, which should be reported promptly to the appropriate authorities. Choice D is incorrect as it dismisses the importance of ensuring the safety and well-being of the neighbor in need.

2. A 17-year-old adolescent is brought to the emergency department by both parents because the adolescent has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first?

Correct answer: B

Rationale: The correct intervention for the nurse to implement first is to place a mask on the client's face. This is crucial to prevent the potential spread of infectious agents to others in the emergency department, considering the presenting symptoms of coughing and fever. Placing a mask helps in containing respiratory secretions and reducing the risk of airborne transmission. Assessing the client’s temperature or blood pressure can be done after ensuring infection control measures. Obtaining a chest X-ray would be a secondary intervention once immediate infection control is addressed.

3. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

Correct answer: C

Rationale: The correct answer is C. Left chest wall pain could indicate ongoing cardiac issues or instability, which needs to be assessed before proceeding with the procedure. This pain could be related to the heart and may suggest a potential risk during the angioplasty. Options A, B, and D do not directly relate to cardiac complications during the procedure, making them less urgent for immediate assessment. Fear of confined spaces, drinking water, and facial swelling after eating crab are not immediate risks to the client's safety in the context of a cardiac catheterization procedure.

4. The nurse is preparing to administer an IM injection to a 6-month-old child. Which injection site is best for the nurse to use?

Correct answer: A

Rationale: The vastus lateralis is the preferred site for IM injections in infants due to their limited muscle mass and safety. Infants do not have well-developed muscle mass, making the vastus lateralis the best option for IM injections. The deltoid muscle is typically used for older children and adults. Ventrogluteal and dorsogluteal sites are not recommended for infants due to safety concerns, including the risk of damaging the sciatic nerve. Therefore, the correct choice is the vastus lateralis for IM injections in infants.

5. While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witnesses the event take?

Correct answer: C

Rationale: The correct action for the nurse to take when a pregnant woman is choking and unable to speak is to perform the Heimlich maneuver using subdiaphragmatic thrusts. This technique is recommended for a pregnant woman to prevent harm to the fetus. Option A, cardiopulmonary resuscitation with uterine tilt, is not indicated for a choking episode. Option B, the Heimlich maneuver using chest thrusts, can potentially harm the gravid uterus. Option D, calling 911 immediately before providing assistance, can lead to a delay in addressing the immediate choking emergency.

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