HESI 799 RN Exit Exam Capstone

Correct Answer: B

Rationale: Fixed, dilated pupils are a sign of increased intracranial pressure or brain injury, indicating a potentially serious neurological condition. Flaccid paralysis, although concerning, may not always indicate immediate life-threatening issues. Diminished spinal reflexes and reduced sensory responses are important neurological assessments but are not as acutely concerning as fixed, dilated pupils in this context.

Correct Answer: C

Rationale: The most important instruction for the nurse to provide to a client scheduled for a colonoscopy and prescribed a bowel preparation is to take the entire bowel preparation as directed. Completing the entire bowel preparation as prescribed is crucial to ensure the colon is properly cleansed for the colonoscopy. Incomplete bowel prep can interfere with the visualization of the colon, leading to inaccurate results. Choices A, B, and D are important but not as crucial as ensuring the complete intake of the bowel preparation for an effective procedure.

Correct Answer: B

Rationale: The correct action for the nurse to take first when a client with Alzheimer's disease is becoming increasingly confused is to monitor the client's vital signs (Choice B). Increased confusion in Alzheimer's disease patients may indicate underlying issues like infection, dehydration, or medication side effects. Monitoring vital signs is crucial in identifying any potential causes of the confusion. Choices A, C, and D are not the priority in this situation. Reorienting the client to time and place (Choice A) can be helpful but is not the first priority. Providing calming activities (Choice C) and consulting with the healthcare provider about medication adjustments (Choice D) may be necessary but should come after assessing the client's vital signs to rule out immediate physical causes of confusion.

Correct Answer: B

Rationale: Offering frequent snacks of foods the client enjoys is the most appropriate action to enhance the nutritional intake of a client with Alzheimer's disease. This approach helps to ensure that the client receives an adequate amount of nutrients throughout the day, especially when larger meals might be challenging for individuals with Alzheimer's. Encouraging large meals in one sitting (Choice A) may overwhelm the client and lead to decreased food intake. While foods high in fiber (Choice C) are beneficial for digestion, the primary focus should be on providing foods the client enjoys to increase intake. Discouraging eating late at night (Choice D) is not directly related to enhancing nutritional intake in this scenario.

Correct Answer: D

Rationale: The correct answer is D: 'It reduces gastrointestinal upset.' Levodopa/carbidopa can cause nausea and other gastrointestinal side effects. Taking the medication with food can help reduce these side effects and improve the client's comfort. Choices A, B, and C are incorrect because taking the medication with food does not primarily enhance effectiveness, improve absorption, or prevent orthostatic hypotension. The main reason for advising to take the medication with meals is to minimize gastrointestinal upset.