HESI RN
HESI RN Nursing Leadership and Management Exam 5
1. The client with DM is being taught about the signs of hyperglycemia. Which symptom should the nurse include?
- A. Excessive thirst
- B. Sweating
- C. Shaking
- D. Hunger
Correct answer: A
Rationale: Excessive thirst, also known as polydipsia, is a hallmark symptom of hyperglycemia. When blood glucose levels are high, the body tries to eliminate the excess glucose through urine, leading to increased urination and subsequent thirst. Sweating, shaking, and hunger are more commonly associated with hypoglycemia, not hyperglycemia. Sweating can occur when blood sugar levels drop too low, shaking is a sign of hypoglycemia, and hunger is often a result of low blood sugar levels triggering the body to seek fuel.
2. A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?
- A. Accept and document the client's wish to refrain from bathing.
- B. Offer to give the client a bed bath, avoiding the perineal area.
- C. Obtain written brochures about menstruation to give to the client.
- D. Teach the importance of personal hygiene during menstruation to the client.
Correct answer: D
Rationale: The priority for the nurse is to educate the client on the importance of personal hygiene during menstruation. Although it's crucial to respect the client's beliefs, providing education ensures the client receives accurate information to make informed decisions about her hygiene practices. By offering teaching first, the nurse can address any misconceptions or concerns the client may have while promoting optimal hygiene practices for overall well-being. Choice A should not be the first action as it does not address the client's potential misinformation about hygiene. Choice B is not ideal as it only offers a temporary solution without addressing the underlying issue. Choice C is not the priority as the immediate concern is the client's personal hygiene practices.
3. When caring for an immobile client, what nursing diagnosis has the highest priority?
- A. Risk for fluid volume deficit.
- B. Impaired gas exchange.
- C. Risk for impaired skin integrity.
- D. Altered tissue perfusion.
Correct answer: B
Rationale: When caring for an immobile client, the nursing diagnosis with the highest priority is impaired gas exchange. This is because impaired gas exchange implies difficulty with breathing, which is essential for sustaining life. Adequate oxygenation is crucial for all bodily functions, and any impairment in gas exchange can lead to serious complications, making it the priority nursing diagnosis to address in an immobile client. Choices A, C, and D are important considerations as well when caring for an immobile client, but they are secondary to impaired gas exchange. Risk for fluid volume deficit may occur due to immobility, but ensuring proper gas exchange takes precedence as it directly impacts the client's immediate survival. Risk for impaired skin integrity is a concern in immobile clients but does not pose an immediate threat to life like impaired gas exchange. Altered tissue perfusion is also critical but is usually a consequence of impaired gas exchange, reinforcing the priority of addressing gas exchange first.
4. A public health nurse is developing a campaign to promote breast cancer screening. Which population should be the primary target of this campaign?
- A. women aged 20-30
- B. women aged 30-40
- C. women aged 40-50
- D. women aged 50-60
Correct answer: C
Rationale: The correct answer is women aged 40-50. This age group is at an increased risk for breast cancer and should be the primary target for screening campaigns. Women in this age range are more likely to benefit from regular screening as early detection can lead to better outcomes. Choices A, B, and D are incorrect because women aged 20-30 are generally not recommended for routine screening due to their lower risk, women aged 30-40 have a moderate risk but are not the primary target group, and women aged 50-60 should still be screened but targeting the 40-50 age group is more crucial for early detection and intervention.
5. A client with stage 4 lung cancer receiving in-home hospice care expresses concerns about pain while the nurse is arranging for discharge. What action should the nurse take?
- A. Explain the potential respiratory issues associated with morphine use.
- B. Educate the family on assessing the effectiveness of analgesics.
- C. Suggest requesting a patient-controlled analgesic (PCA) pump from the healthcare provider.
- D. Provide the client with a schedule for around-the-clock prescribed analgesic use.
Correct answer: D
Rationale: In managing pain for a client with stage 4 lung cancer in hospice care, providing a schedule for around-the-clock prescribed analgesic use is essential. This approach ensures continuous pain control and helps prevent breakthrough pain. By having a consistent dosing schedule, the client can maintain a more stable level of pain relief, enhancing their comfort and quality of life during this critical time.