hesi health assessment test bank 2023

Correct Answer: C

Rationale: The correct answer is C because it reflects empathy by acknowledging the mother's feelings without judgment or personal bias. The nurse shows understanding and compassion by recognizing the difficulty of the situation. Incorrect answer A lacks empathy as it simply restates the mother's feeling without demonstrating understanding. Answer B also lacks empathy as it focuses on the boyfriend's actions rather than the mother's feelings. Answer D shows some empathy by acknowledging the difficulty but fails to address the mother's emotional state directly. In summary, answer C is correct because it shows empathy by acknowledging the mother's emotions and validating her experience without judgment or redirection.

Correct Answer: A

Rationale: The correct answer is A: Patient's age and mobility. Age and mobility are key factors in pressure ulcer development as elderly and immobile patients are at higher risk due to decreased circulation and pressure on skin. Family medical history (B) is not directly linked to pressure ulcers. Frequency of hospital visits (C) is not a determining factor, and patient's education level (D) does not directly impact pressure ulcer risk. In summary, assessing age and mobility helps identify high-risk patients for developing pressure ulcers.

Correct Answer: B

Rationale: The correct answer is B: ondansetron (Zofran). Ondansetron is a selective serotonin receptor antagonist that effectively targets the serotonin receptors in the chemoreceptor trigger zone to relieve nausea and vomiting. It is commonly used in chemotherapy-induced nausea and vomiting. A: Metoclopramide is a dopamine receptor antagonist and primarily used for gastrointestinal motility disorders, not specifically for nausea relief. C: Hydroxyzine is an antihistamine with sedative properties, primarily used for anxiety and itching, not specifically for nausea relief. D: Prochlorperazine is a dopamine receptor antagonist primarily used for treating psychotic disorders, not specifically for nausea relief. In summary, ondansetron is the correct choice as it targets serotonin receptors specifically for relieving nausea and vomiting, whereas the other options focus on different mechanisms of action.

Correct Answer: A

Rationale: The correct answer is A: Apply a sterile dressing. Firstly, cover the wound with a sterile occlusive dressing to prevent air from entering the pleural space, reducing the risk of tension pneumothorax. This also helps to prevent infection and further complications. Administering morphine (B) or nitroglycerin (D) is not the priority in this situation as managing the chest wound is crucial. Applying an airtight dressing (C) may lead to tension pneumothorax if not done properly. Therefore, the immediate action should be to apply a sterile dressing to stabilize the wound and prevent further complications.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.