HESI RN
Community Health HESI 2023 Quizlet
1. The healthcare provider is caring for a client with hypokalemia. Which assessment finding requires immediate intervention?
- A. Muscle weakness.
- B. Irregular heart rate.
- C. Increased urinary output.
- D. Decreased deep tendon reflexes.
Correct answer: D
Rationale: Decreased deep tendon reflexes are a critical finding in hypokalemia that indicates severe potassium deficiency affecting neuromuscular function. Immediate intervention is necessary to prevent life-threatening complications such as respiratory failure or cardiac arrhythmias. Muscle weakness, irregular heart rate, and increased urinary output are also associated with hypokalemia but do not pose the same level of urgency as decreased deep tendon reflexes.
2. The nurse is caring for a client with chronic renal failure who is receiving peritoneal dialysis. Which of the following findings should be reported immediately to the physician?
- A. Clear dialysate outflow.
- B. Increased blood pressure.
- C. Cloudy dialysate outflow.
- D. Decreased urine output.
Correct answer: C
Rationale: Cloudy dialysate outflow should be reported immediately to the physician. It is indicative of peritonitis, a severe infection of the peritoneal cavity and a serious complication of peritoneal dialysis. Prompt medical attention is crucial to prevent further complications or systemic infection. Clear dialysate outflow (Choice A) is a normal finding in peritoneal dialysis. Increased blood pressure (Choice B) and decreased urine output (Choice D) are common in clients with chronic renal failure and may not require immediate reporting unless they are significantly abnormal or accompanied by other concerning symptoms.
3. Which of the following is a common complication of immobility?
- A. Muscle hypertrophy.
- B. Pressure ulcers.
- C. Bone fractures.
- D. Joint stiffness.
Correct answer: B
Rationale: The correct answer is B, Pressure ulcers. Immobility can lead to pressure ulcers due to prolonged pressure on the skin, especially over bony prominences. Muscle hypertrophy (Choice A) is not a common complication of immobility; instead, muscle atrophy is more likely to occur due to disuse. Bone fractures (Choice C) can result from trauma but are not directly associated with immobility unless there is a fall or accident. Joint stiffness (Choice D) can develop due to lack of movement but is not as common or severe as pressure ulcers in cases of prolonged immobility.
4. A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
- A. Americans with Disabilities Act of 1990
- B. ANA Code of Ethics with Interpretative Statements
- C. ANA's Scope and Standards of Nursing Practice
- D. Patient's Bill of Rights of 1990
Correct answer: C
Rationale: The ANA's Scope and Standards of Nursing Practice are essential guidelines for nursing practice in various specialties, including mental health. The document outlines the expectations and responsibilities of nurses in providing high-quality care within their specific practice areas. In the context of opening a mental health services department, using the Scope and Standards specific to psychiatric–mental health nursing would ensure that the unit's nursing guidelines align with best practices and professional standards in mental health care. Choices A, B, and D are not focused on providing specific guidelines for nursing practice in a mental health services department, making them incorrect options.
5. A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed due to early morning stiffness. Which intervention should the nurse implement?
- A. Assign a UAP to assist the client with a warm shower early in the morning.
- B. Administer anti-inflammatory medication before the procedure.
- C. Encourage the client to perform range-of-motion exercises.
- D. Reschedule the procedure for later in the day.
Correct answer: A
Rationale: A warm shower can help alleviate stiffness, allowing the client to be more comfortable and mobile before the procedure. This intervention promotes increased comfort and mobility, which may help the client proceed with the procedure later in the day. Administering anti-inflammatory medication (Choice B) may be helpful but may take time to be effective, while range-of-motion exercises (Choice C) may be challenging for the client due to stiffness. Rescheduling the procedure (Choice D) does not address the immediate need to alleviate stiffness.