HESI Health Assessment Questions With Complete Solutions 2024

HESI Health Assessment Questions With Complete Solutions 2024 What is gamma globulin and when is it used? - answerGamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. So the antigen is neutralized by the antibodies gamma globulin supplies. Used when a pt is exposed to Hep A A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. 1 Pain history, including location, intensity, and quality of pain 2 Client's purposeful body movement in arranging the papers on the bedside table 3 Pain pattern, including precipitating and alleviating factors 4 Vital signs, such as increased blood pressure and heart rate 5 The client's family statement about increases in pain with ambulation - answer1 & 3 Why not others?? Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience, and therefore the nurse has to ask the client directly instead of accepting the statement of the family members. Pressure Ulcers and stages - answerstage I pressure ulcer- an area of persistent redness with no break in skin integrity. stage II pressure ulcer-partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater stage III pressure ulcer- full-thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed. stage IV- full thickness tissue loss with exposed bone, tendon, muscle, bone (slough or eschar may be present within wound bed) unstageable- contains necrotic tissue, necrotic tissue must be removed before the wound can be staged. While assessing a client's skin, a nurse notices that the skin is dry. What is the probable etiology of the condition? Select all that apply. - answerThe use of hard soap and frequent bathing may result in dry skin. A skin allergy may result in skin rashes, but not dry skin. Using tanning pills and petroleum products may result in skin cancer. The community nurse is assessing an elderly client who lives alone at home. the client refrains from physical activity for fear of falling when walking. Which interventions by the nurse are most beneficial to promote a healthy lifestyle? - answerEncourage the client to wear nonskid shoes. Suggest that the client use an assistive device. Help the client rearrange furniture in the house. Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply. 1 Nursing diagnoses involve the client when possible. 2 Nursing diagnoses are based on results of diagnostic tests and procedures. 3 Nursing diagnoses are the identification of a disease condition in the client. 4 Nursing diagnoses involve the sorting of health problems within the nursing domain. 5 Nursing diagnoses involve clinical judgment about the client's response to health problems. - answerNursing diagnoses involve (client participation) the client when possible. Nursing diagnoses involve the sorting of health problems within the nursing domain. Nursing diagnoses involve clinical judgment about the client's response to health problems. WRONG ANSWER: Nursing diagnoses are based on results of diagnostic tests and procedures. WRONG ANSWER: Nursing diagnoses are the identification of a disease condition in the client. A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply. 1 Radial pulse: 70 2 Temperature: 37 °C 3 Respiratory rate: 14 4 Blood pressure: 110/70 5 Oxygen saturation: 96% - answer3,4,5 Why not 1&2? The radial pulse indicates a positive outcome of the therapy if the client has a history of heart disease. A body temperature reading of 36.8 °C is considered normal and not a sign of COPD. Which client is at an increased risk for right-sided heart failure? Client A: R Jugular Venous Pressure: 2.5 cm L Jugular Venous Pressure: 3.0 cm Client B: RJVP = 2.0 LJVP = 1.5 Client C: RJVP = 1.5 LJVP = 1.0 - answerClient A Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of right-sided heart failure. Client A has both right and left jugular venous pressure above 2.5 cm. Therefore this client is at risk for right-sided heart failure. why not B/C: One-sided pressure elevation is caused by obstruction, as observed in clients B, C Right sided heart failure risk - answerBilateral pressures higher than 2.5 cm are considered elevated and are a sign of right-sided heart failure. Client A has both right and left jugular venous pressure above 2.5 cm. Therefore this client is at risk for right-sided heart failure. One-sided pressure elevation is caused by obstruction, as observed in clients B, C, and D. in clients B,C, D the right jugular venous pressure is .5 cm high than the left jugular venous pressure The community nurse is assessing an elderly client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which interventions by the nurse are most beneficial to promote a healthy lifestyle? Select all that apply. 1 Instruct the client to apply bed side rails. 2 Encourage the client to wear nonskid shoes. 3 Suggest that the client use an assistive device. 4 Ask the client to install hand rails in the bathroom. 5 Help the client rearrange furniture in the house. - answer2,3,5 Why not 1,4? The bed side rails p