the nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarct
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Nursing Elites

HESI LPN

Community Health HESI Practice Exam

1. When the nurse identifies what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction, the first action the nurse should perform is to

Correct answer: D

Rationale: The correct first action for the nurse to take when identifying what appears to be ventricular tachycardia in a client being evaluated for possible myocardial infarction is to assess the client's airway, breathing, and circulation. This step is crucial to determine the client's stability and the need for immediate intervention. Beginning cardiopulmonary resuscitation or preparing for immediate defibrillation without first assessing the airway, breathing, and circulation could delay potentially life-saving interventions. Notifying the 'Code' team and healthcare provider should come after ensuring the client's immediate needs are addressed.

2. Iwa, two years old, was brought to the health center because of diarrhea for 4 days. Assessment revealed that Iwa has under-nutrition. Which of the following actions will you take?

Correct answer: A

Rationale: In the case of a child with under-nutrition and diarrhea, advising the mother to give milk and juices between meals at home is the appropriate action. This helps address the nutritional needs of the child while also providing hydration. Option B, giving nutritious food available at home, may not be sufficient in addressing immediate needs such as dehydration. Option C, referring to the hospital, may be necessary in severe cases but is not the first-line action. Option D, providing ORS solution, is important but does not directly address the under-nutrition concern.

3. What influences health status?

Correct answer: D

Rationale: Health status is influenced by a combination of lifestyle choices, community resources, health technology like diagnostic machines, and environmental conditions. Each of these factors plays a role in determining an individual's overall health. Choice A is correct as lifestyle choices (such as diet, exercise, and smoking habits) and access to community resources (like healthcare facilities, support groups, and recreational spaces) are important determinants of health. Choice B is correct as the availability of health technology, including diagnostic machines, can impact early detection and treatment of health conditions. Choice C is correct as exposure to toxic environmental conditions (such as pollution, contaminated water, or hazardous waste) can have adverse effects on health. Therefore, the correct answer is D because all of these factors collectively influence health status.

4. Which of these statements by the nurse is incorrect to use to reinforce information about cancers to a group of young adults?

Correct answer: A

Rationale: The corrected statement in choice A emphasizes limiting red meat for the prevention of stomach cancer, which is more accurate than avoiding all meats. By focusing on red meat specifically, it provides clearer guidance to young adults. Choice B is not the correct answer as it provides accurate information about prostate cancer being the most common cancer in American men and its impact on sexuality and life quality. Choice C is also a valid statement, correctly highlighting colorectal cancer as the second-leading cause of cancer-related deaths in the United States. Choice D provides accurate information about lung cancer being the leading cause of cancer deaths in the United States and emphasizes its preventability among cancers, making it a valid statement for reinforcing information about cancers to young adults.

5. When caring for a child with Reye's Syndrome, which action should the nurse give the highest priority?

Correct answer: C

Rationale: Assessing the level of consciousness is crucial when caring for a child with Reye's Syndrome. Changes in neurological status can indicate deterioration of the condition, necessitating immediate medical attention. Monitoring intake and output is important but not the highest priority compared to assessing the child's level of consciousness. Providing good skin care and assisting with range of motion are also important aspects of care but take a lower priority than assessing the child's neurological status in this critical condition.

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