in a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache the client is sitting in a wheelchair watchi
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Nursing Elites

HESI LPN

Community Health HESI Practice Exam

1. In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?

Correct answer: C

Rationale: These symptoms suggest autonomic dysreflexia, often triggered by bladder distention.

2. A client comes into the community health center upset and crying stating, “I will die of cancer now that I have this disease.” And then the client hands the nurse a paper with one word written on it: 'Pheochromocytoma.' Which response should the nurse state initially?

Correct answer: A

Rationale: The correct initial response for the nurse to provide in this situation is to offer reassurance. Stating that 'Pheochromocytomas usually aren't cancerous (malignant)' helps to alleviate the client's anxiety and fear of having cancer. This response also establishes a foundation for further discussion about the condition, allowing the nurse to address the client's concerns and provide accurate information. Choice B is incorrect as it focuses solely on the diagnostic tests for pheochromocytoma but does not address the client's emotional distress. Choice C is incorrect as it discusses imaging modalities without directly addressing the client's concerns. Choice D is also incorrect as it assumes symptoms without first addressing the client's emotional state and fear of cancer.

3. Which presentation of an infectious disease is acquired through an indirect transmission?

Correct answer: C

Rationale: The correct answer is C. Malaria is transmitted indirectly through mosquito bites. Choice A is incorrect as syphilis is acquired through direct contact with an infected sexual partner. Choice B is incorrect as measles can be transmitted through respiratory droplets in close contact settings like daycare centers. Choice D is incorrect as nosocomial influenza spreads within healthcare facilities through direct contact or droplets.

4. A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?

Correct answer: B

Rationale: The correct answer is to explain that this behavior is expected. At 16 months of age, children commonly experience separation anxiety, especially in unfamiliar environments like hospitals. It is important for the nurse to reassure the child and the parent that such behavior is normal. Option A is incorrect as there is no need to change client care assignments based on the child's behavior. Option C is not appropriate as discussing the use of 'time-out' is more relevant in behavior management for older children. Option D is incorrect as it does not address the underlying cause of the child's behavior related to separation anxiety.

5. The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

Correct answer: D

Rationale: In severe depression, the priority nursing diagnosis is safety. Individuals with severe depression are at risk of self-harm or suicide. Ensuring the client's safety by implementing measures to prevent harm to themselves or others is crucial. While nutrition, elimination, and activity are important aspects of care, ensuring the client's immediate safety takes precedence in this situation.

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