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. What actions should the nurse take regarding an older adult male who had an abdominal cholecystectomy and has become increasingly confused and disoriented over the past 24 hours, found wandering into another client’s room and returned to his own room by the unlicensed assistive personnel (UAP)? (Select all that apply)

Correct answer: B

Rationale: In this situation, the appropriate action for the nurse to take is to report the mental status change to the healthcare provider. Confusion and disorientation post-surgery can be indicative of various factors, such as electrolyte imbalances or respiratory issues, necessitating comprehensive assessment by the healthcare team. Applying restraints and raising bed rails may not address the underlying cause of the confusion, and assigning the UAP to reassess the client's risk for falls does not directly address the cognitive changes observed.

3. A client prescribed warfarin is being taught about dietary modifications by a nurse. Which statement by the client indicates understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Consistency in vitamin K intake is crucial for clients on warfarin to maintain stable anticoagulation levels. Option A is incorrect as vitamin C does not directly interact with warfarin. Option C is incorrect because although leafy greens are high in vitamin K, excessive consumption can affect warfarin's effectiveness. Option D is incorrect as any changes in diet, particularly in vitamin K intake, can impact the efficacy of warfarin.

4. When the client asks the nurse if they have ever been with someone when they died, what is the nurse’s best response?

Correct answer: A

Rationale: Choice A is the best response as it acknowledges the client's question and opens the door for further discussion about dying if the client wishes to. It shows empathy and encourages the client to express any concerns they may have. Choices B and C do not directly address the client's question or offer an opportunity for him to explore his concerns. Choice D acknowledges the experience but fails to address the client's question directly and does not encourage further discussion.

5. Which intervention should the nurse include in the plan of care for a patient with tetanus?

Correct answer: C

Rationale: The correct intervention for a patient with tetanus is to minimize the amount of stimuli in the room. Tetanus can lead to muscle spasms and heightened sensitivity to stimuli, making it essential to reduce environmental triggers for the patient's comfort and safety. Opening window shades for natural light (Choice A) may exacerbate sensitivity to light and worsen symptoms. Encouraging coughing and deep breathing (Choice B) is not directly related to managing tetanus symptoms. While repositioning the patient every hour (Choice D) is important for preventing pressure ulcers, it is not the priority when managing tetanus, which requires a quiet, low-stimulus environment to minimize muscle spasms and discomfort.

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