BSN 246 HESI HEALTH ASSESSMENT EXAM
The registered nurse (RN) is developing the plan of care for a client who is
admitted for alcohol detoxification. Which goal should be most important for the
RN to primarily focus the client's care?
The client maintains optimal nutritional status.
The client will remain alert and oriented.
The client will remain free from injury.
The client will remain alcohol free during hospitalization.
The client will remain free from injury.
Rationale
The client is at highest risk for injury due to altered cognitive and sensory
disturbances as well as delirium tremors during withdrawal. Remaining free from
injury is the most important goal for the acute phase of alcohol withdrawal.
A client with progressive hearing loss appears distressed when the registered
nurse (RN) asks open-ended questions about the client's health history. Which
forms of communication should the RN use?Select all that apply
Face the client so the client can see the RN's mouth.
Increase one's speech volume when interacting with the client.
Repeat information to the client if misunderstood.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
Face the client so the client can see the RN's mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
The nurse palpates a weak pedal pulse in the client's right foot. Which
assessment findings should the RN document that are consistent with
diminished peripheral circulation?
(Select all that apply.)
Diminished hair on legs
Bruising on extremities
Skin cool to touch
Capillary refill less than 3 seconds
Darkened skin on extremities
Diminished hair on legs
Skin cool to touch
No on the Darkened skin on extremities - indicates hemosiderin staining caused by the
destruction of red blood cells and the release of the pigment heme within hemoglobin.
Occurs with peripheral vascular disease.
Rationale
Diminished hair on the legs and skin that is cool to touch are symptoms of
decreased arterial blood flow. The other options are not indicators for impaired
peripheral circulation.
A female client calls the clinic and talks with the registered nurse (RN) to inquire
about a possible reaction after taking amoxicillin for 5 days. She reports having
, vaginal discomfort, itching, and a white discharge. The RN should discuss which
action with the client?
Discontinue the antibiotic because original symptoms have subsided.
Continue taking medication until finished until the symptoms subside.
Consult with healthcare provider about another treatment for this effect.
Use an over-the-counter (OTC) vaginal wash to flush out the secretions.
**Think best intervention**
Consult with healthcare provider about another treatment for this effect.
Rationale
A superinfection with normal flora yeast may occur during antibiotic therapy. If
suspected, the new onset of findings should be reported to the healthcare
provider for another prescribed treatment to treat the superinfection.
The registered nurse (RN) is administering haloperidol 0.5 mg IM PRN to a client
for the first time. What side effects should the RN assess the client for during the
initial dose?
Bradykinesia.
Dystonia.
Somatization.
Akathisia.
Dystonia: a neurological movement disorder that causes involuntary muscle
contractions, resulting in abnormal postures, repetitive movements, and
sometimes pain
Think in terms of ADVERSE REACTION
Rationale
Dystonia can be a sudden adverse reaction to this psychotropic medication
which should be discontinued to resolve dystonia, and the healthcare provider
notified immediately.
A client who is uses ipratropium reports having nausea, blurred vision,
headaches, and insomnia after using the inhaler. Which action should the
registered nurse (RN) implement first?
Withhold medication and report symptoms and vital signs to healthcare provider.
Give PRN medication for nausea and vomiting and evaluate client in 30 minutes.
Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication is
scheduled.
Withhold medication and report symptoms and vital signs to healthcare provider.
**Again think beneficial to the patient overall as a primary concern
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of excessive use
of ipratropium, so withholding the medication until the healthcare provider is
notified should be initiated to maintain client safety.
While caring for a client who has esophageal varices, which nursing intervention
is most important for the registered nurse (RN) to implement?
Monitor infusing IV fluids and any replacement blood products.
Prepare for esophagogastroduodenoscopy (EGD).
Maintain the client on strict bedrest.
The registered nurse (RN) is developing the plan of care for a client who is
admitted for alcohol detoxification. Which goal should be most important for the
RN to primarily focus the client's care?
The client maintains optimal nutritional status.
The client will remain alert and oriented.
The client will remain free from injury.
The client will remain alcohol free during hospitalization.
The client will remain free from injury.
Rationale
The client is at highest risk for injury due to altered cognitive and sensory
disturbances as well as delirium tremors during withdrawal. Remaining free from
injury is the most important goal for the acute phase of alcohol withdrawal.
A client with progressive hearing loss appears distressed when the registered
nurse (RN) asks open-ended questions about the client's health history. Which
forms of communication should the RN use?Select all that apply
Face the client so the client can see the RN's mouth.
Increase one's speech volume when interacting with the client.
Repeat information to the client if misunderstood.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
Face the client so the client can see the RN's mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
The nurse palpates a weak pedal pulse in the client's right foot. Which
assessment findings should the RN document that are consistent with
diminished peripheral circulation?
(Select all that apply.)
Diminished hair on legs
Bruising on extremities
Skin cool to touch
Capillary refill less than 3 seconds
Darkened skin on extremities
Diminished hair on legs
Skin cool to touch
No on the Darkened skin on extremities - indicates hemosiderin staining caused by the
destruction of red blood cells and the release of the pigment heme within hemoglobin.
Occurs with peripheral vascular disease.
Rationale
Diminished hair on the legs and skin that is cool to touch are symptoms of
decreased arterial blood flow. The other options are not indicators for impaired
peripheral circulation.
A female client calls the clinic and talks with the registered nurse (RN) to inquire
about a possible reaction after taking amoxicillin for 5 days. She reports having
, vaginal discomfort, itching, and a white discharge. The RN should discuss which
action with the client?
Discontinue the antibiotic because original symptoms have subsided.
Continue taking medication until finished until the symptoms subside.
Consult with healthcare provider about another treatment for this effect.
Use an over-the-counter (OTC) vaginal wash to flush out the secretions.
**Think best intervention**
Consult with healthcare provider about another treatment for this effect.
Rationale
A superinfection with normal flora yeast may occur during antibiotic therapy. If
suspected, the new onset of findings should be reported to the healthcare
provider for another prescribed treatment to treat the superinfection.
The registered nurse (RN) is administering haloperidol 0.5 mg IM PRN to a client
for the first time. What side effects should the RN assess the client for during the
initial dose?
Bradykinesia.
Dystonia.
Somatization.
Akathisia.
Dystonia: a neurological movement disorder that causes involuntary muscle
contractions, resulting in abnormal postures, repetitive movements, and
sometimes pain
Think in terms of ADVERSE REACTION
Rationale
Dystonia can be a sudden adverse reaction to this psychotropic medication
which should be discontinued to resolve dystonia, and the healthcare provider
notified immediately.
A client who is uses ipratropium reports having nausea, blurred vision,
headaches, and insomnia after using the inhaler. Which action should the
registered nurse (RN) implement first?
Withhold medication and report symptoms and vital signs to healthcare provider.
Give PRN medication for nausea and vomiting and evaluate client in 30 minutes.
Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication is
scheduled.
Withhold medication and report symptoms and vital signs to healthcare provider.
**Again think beneficial to the patient overall as a primary concern
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of excessive use
of ipratropium, so withholding the medication until the healthcare provider is
notified should be initiated to maintain client safety.
While caring for a client who has esophageal varices, which nursing intervention
is most important for the registered nurse (RN) to implement?
Monitor infusing IV fluids and any replacement blood products.
Prepare for esophagogastroduodenoscopy (EGD).
Maintain the client on strict bedrest.
