HESI RN
HESI Community Health
1. During a home visit, a nurse observes an older client who is attempting to ambulate to the bathroom and notes that the client is unsteady and holds onto the furniture while refusing any assistance. Which action should the nurse implement?
- A. determine home navigational safety hazards
- B. maintain the client's privacy while in the bathroom
- C. recommend that the client obtain a walker
- D. encourage the client to obtain a medical alert device
Correct answer: A
Rationale: The correct action for the nurse to implement is to determine home navigational safety hazards. In this scenario, the client is unsteady and holds onto furniture while refusing assistance, indicating a risk of falls. By identifying and addressing home safety hazards, the nurse can help prevent potential accidents. Maintaining privacy in the bathroom (Choice B) is important but not the priority in this situation. Recommending a walker (Choice C) or a medical alert device (Choice D) may be appropriate interventions later but addressing home safety hazards is the immediate concern.
2. The public health nurse is evaluating resources in a rural community. Which healthcare resource is most important for the community?
- A. family planning center
- B. accessibility to trauma care
- C. annual health fair
- D. weather-related disaster plan
Correct answer: B
Rationale: In rural areas, accessibility to trauma care is the most critical healthcare resource due to the longer emergency response times. Trauma care can be life-saving in situations where immediate medical attention is required for severe injuries. The other options, such as a family planning center, annual health fair, and weather-related disaster plan, are important but not as crucial as trauma care in addressing urgent health needs in a rural community.
3. The healthcare professional is planning a health fair to promote cancer awareness and prevention. Which activity is most likely to increase participation?
- A. offering free cancer screenings
- B. distributing pamphlets on cancer prevention
- C. hosting a guest speaker who is a cancer survivor
- D. providing informational booths on different types of cancer
Correct answer: A
Rationale: Offering free cancer screenings is the most likely activity to increase participation in the health fair. Providing direct services such as screenings not only attracts participants but also promotes early detection, which is crucial in cancer prevention. Distributing pamphlets, hosting a guest speaker, or providing informational booths are informative but may not have the same impact in driving participation as the opportunity for free screenings.
4. A government office worker is seen in the emergency room after opening an envelope containing a powder-like substance which is being tested for anthrax. Which discharge instruction should the nurse provide the client concerning inhalation anthrax?
- A. return to the emergency room if flu-like symptoms develop within 42 days
- B. notify co-workers to get the anthrax vaccine at the public health department
- C. isolation from friends and family members is recommended for 3 weeks
- D. cleanse all surfaces touched with pre-moistened antibacterial wipes
Correct answer: A
Rationale: The correct answer is to instruct the client to return to the emergency room if flu-like symptoms develop within 42 days. Flu-like symptoms can be an early sign of inhalation anthrax, and prompt medical intervention is crucial. Choice B is incorrect because the focus should be on the affected individual seeking medical attention rather than vaccinating others. Choice C is incorrect as isolation from friends and family members is not a standard recommendation for inhalation anthrax. Choice D is also incorrect as cleansing surfaces is important for infection control but may not be the priority when facing potential exposure to anthrax.
5. The client is unable to void, and the plan of care sets an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document to indicate a successful outcome?
- A. Drinks adequate fluids.
- B. Void without difficulty.
- C. Feels less thirsty.
- D. Drinks 240 mL of fluid five times during the shift.
Correct answer: D
Rationale: The correct answer is D. Drinking 240 mL of fluid five times during the shift indicates a fluid intake of 1200 mL, which exceeds the minimum objective of at least 1000 mL. The client meeting or exceeding the fluid intake goal is a clear indicator of a successful outcome. Choices A, B, and C are incorrect because simply drinking adequate fluids, voiding without difficulty, or feeling less thirsty do not directly demonstrate meeting the specific objective of fluid intake set in the care plan.
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