HESI RN
HESI Nutrition Exam
1. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is
- A. Heart rate
- B. Pedal pulses
- C. Lung sounds
- D. Pupil responses
Correct answer: D
Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.
2. The census on the unit is 90 percent, and there are no private rooms available. An elderly client with influenza is admitted. Which of the following rooms would it be appropriate to assign this client?
- A. A double room with a client admitted for impetigo.
- B. A double room with another client with the same diagnosis.
- C. A four-bed room with three clients who have had orthopedic surgery.
- D. A double room with an elderly client with a diagnosis of chickenpox.
Correct answer: B
Rationale: When a private room is not an option, the best choice is to assign the elderly client with influenza to a double room with another client diagnosed with the same condition. This is ideal as droplet precautions would likely already be in place for the other client, reducing the risk of spreading the infection to other clients in the unit. Choice A is not appropriate as impetigo does not require the same precautions as influenza. Choice C is not ideal as orthopedic surgery does not involve respiratory precautions. Choice D is incorrect because chickenpox requires airborne precautions, which could pose a risk to the elderly client with influenza.
3. While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition?
- A. Tinea corporis
- B. Herpes zoster
- C. Psoriasis
- D. Drug reaction
Correct answer: C
Rationale: The correct answer is C, Psoriasis. Psoriasis commonly presents with well-circumscribed, silvery scales and plaques, typically found on extensor surfaces like elbows and knees. Tinea corporis (A) presents as a circular rash, herpes zoster (B) presents as a painful rash following a dermatomal pattern, and drug reactions (D) have variable presentations not specific to elbows and knees with silvery scales and plaques.
4. A client undergoing chemotherapy reports extreme fatigue. What should the nurse recommend to manage this symptom?
- A. Increase the dose of chemotherapy.
- B. Rest when needed and maintain a balanced diet.
- C. Perform light physical activity to reduce fatigue.
- D. Consider delaying the chemotherapy treatment.
Correct answer: B
Rationale: The correct recommendation for managing chemotherapy-induced fatigue is to advise the client to rest when needed and maintain a balanced diet. Increasing the dose of chemotherapy (Choice A) would exacerbate the fatigue and other side effects. While light physical activity (Choice C) can be beneficial, extreme fatigue may require more rest initially. Delaying chemotherapy treatment (Choice D) should only be considered after consultation with the healthcare provider, as timely treatment is usually crucial in cancer care.
5. What principle about patient-nurse communication should guide a nurse's fear of 'saying the wrong thing' to a patient?
- A. Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation.
- B. The patient is more interested in talking to you than listening to what you have to say and is not likely to be offended.
- C. Considering the patient's history, there is little chance that the comment will do any actual harm.
- D. Most people with a mental illness have by necessity developed a high tolerance for forgiveness.
Correct answer: A
Rationale: The correct principle guiding nurse-patient communication is that patients value genuine acceptance, respect, and concern. Choice A is the correct answer because showing genuine care and concern for the patient's situation fosters a positive and therapeutic relationship. Choice B is incorrect as effective communication involves active listening and responding appropriately, not assuming the patient is only interested in talking. Choice C is incorrect because a patient's history does not guarantee immunity to harm from inappropriate comments. Choice D is incorrect as it generalizes individuals with mental illness and forgiveness, which is not directly related to communication fears.