hesi health assessment test bank 2023

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.

Correct Answer: B

Rationale: The correct answer is B. When a patient with severe injuries is brought to the emergency department, the nurse should prioritize performing a physical examination and initiating lifesaving measures while asking history questions simultaneously. This approach allows for immediate assessment and intervention to address any life-threatening conditions. Gathering history information while performing the examination ensures that critical details are not missed and helps in making timely decisions. Choosing option A could delay lifesaving interventions, while option C is not a priority during the initial assessment of a critically injured patient. Option D is incorrect as it prioritizes lifesaving measures over obtaining important history information during the initial assessment.

Correct Answer: D

Rationale: The correct response is D because it encourages the mother to provide specific information about the toddler's behavior indicating pain. This helps the nurse assess the severity and nature of the earache accurately. Options A and C are dismissive and may overlook a potential health issue. Option B suggests immediate action without gathering information first, which may not be necessary.

Correct Answer: B

Rationale: The correct answer is B: Administering oxygen as prescribed. Oxygen therapy is a critical intervention in pneumonia to improve oxygenation and prevent hypoxia. Priority is given to interventions that address the immediate physiological needs of the patient. Encouraging fluid intake (A) is important but not as urgent as oxygen therapy. Encouraging ambulation (C) can be beneficial for overall health but may not be suitable for a patient with pneumonia. Providing pain medication (D) is important for comfort but is not the priority in this case.

Correct Answer: C

Rationale: The correct answer is C because using the inhaler every time the patient feels short of breath, even without a flare-up, is not the recommended practice for managing COPD. Inhalers should be used as prescribed by the healthcare provider or only during exacerbations. Here's the rationale: 1. Using the inhaler excessively can lead to overuse of medication and potential side effects. 2. It is important for patients to differentiate between regular management and acute exacerbations. 3. Monitoring oxygen levels (choice D) is essential for COPD management. 4. Quitting smoking (choice A) and deep breathing exercises (choice B) are positive self-management strategies for COPD.