HESI RN
HESI Community Health
1. When documenting assessment data, which statement should the nurse record in the narrative nursing notes?
- A. Client appears anxious.
- B. Client's skin is warm and dry.
- C. S1 murmur auscultated in supine position.
- D. Client is resting quietly.
Correct answer: C
Rationale: The correct answer is C. When documenting assessment data in the narrative nursing notes, it is essential to include objective findings that are specific, clear, and descriptive. 'S1 murmur auscultated in supine position' provides a precise and objective assessment finding that can aid in accurately documenting the client's condition. Choices A, B, and D are more subjective statements that lack the specificity and clarity required for detailed documentation. 'Client appears anxious' and 'Client is resting quietly' are subjective observations, while 'Client's skin is warm and dry' is an objective finding but may not be as significant or relevant for comprehensive documentation as the auscultated murmur.
2. The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory result requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum potassium of 4.5 mEq/L.
- C. Serum osmolality of 280 mOsm/kg.
- D. Serum sodium of 130 mEq/L.
Correct answer: D
Rationale: The correct answer is D: Serum sodium of 130 mEq/L. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia. A serum sodium level of 130 mEq/L indicates severe hyponatremia, which can result in neurological symptoms, such as confusion, seizures, and coma. Therefore, immediate intervention is required to prevent further complications. Choice A, a serum sodium of 140 mEq/L, is within the normal range and does not require immediate intervention. Choice B, serum potassium of 4.5 mEq/L, is also within the normal range and is not directly related to SIADH. Choice C, serum osmolality of 280 mOsm/kg, is a measure of the concentration of solutes in the blood and may not be the most critical parameter to address in a client with SIADH and severe hyponatremia.
3. A community health nurse is addressing the issue of domestic violence in the community. Which intervention should be prioritized?
- A. Providing education on the signs of domestic violence
- B. Setting up a support group for survivors
- C. Partnering with local law enforcement to increase patrols
- D. Creating a confidential hotline for reporting abuse
Correct answer: D
Rationale: Creating a confidential hotline for reporting abuse is the most critical intervention when addressing domestic violence. A hotline offers a safe and confidential way for individuals experiencing abuse to report incidents, seek help, and access support services. This intervention prioritizes immediate safety and support for victims. Providing education on the signs of domestic violence (Choice A) is important for prevention but may not address the urgent needs of individuals currently experiencing abuse. Setting up a support group for survivors (Choice B) is valuable for emotional support but may not reach those who are not yet identified as survivors. Partnering with local law enforcement to increase patrols (Choice C) focuses more on the law enforcement response rather than providing a direct avenue for victims to seek help and support.
4. The nurse is developing a program to educate parents on the importance of childhood immunizations. Which topic should be prioritized?
- A. the benefits of immunizations
- B. the potential side effects of vaccines
- C. the immunization schedule
- D. ways to comfort children during vaccinations
Correct answer: A
Rationale: The correct answer is A: the benefits of immunizations. Emphasizing the benefits of immunizations helps parents understand the importance of vaccines in protecting their children from preventable diseases. This choice should be prioritized as it focuses on the positive outcomes of immunizations, which can motivate parents to vaccinate their children. Choices B, C, and D are not the top priority because while it's important to address potential side effects, the immunization schedule, and comforting children during vaccinations, the main focus should be on highlighting the benefits to encourage parents to make informed decisions regarding their child's immunizations.
5. A school nurse is providing education on the importance of physical activity to elementary school students. Which activity is most appropriate for this age group?
- A. a lecture on the benefits of exercise
- B. an interactive game that involves physical movement
- C. a worksheet about different types of physical activities
- D. a video presentation on famous athletes
Correct answer: B
Rationale: An interactive game that involves physical movement is the most appropriate activity for elementary school students when educating them on the importance of physical activity. This choice is preferred because it engages children directly in physical activity, making the learning experience fun, interactive, and memorable. Children at this age group learn best through hands-on experiences and active participation, which can be effectively facilitated through interactive games. Choices A, C, and D are less suitable for this age group as they do not actively involve children in physical movement or interactive learning experiences. A lecture may not be engaging enough for young children, a worksheet may not provide the required level of activity, and a video presentation may not offer the same level of direct engagement and participation as an interactive game.
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