hesi health assessment test bank 2023

Questions 84

ATI RN

ATI RN Test Bank

hesi health assessment test bank 2023 Questions

Question 1 of 5

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which of the following statements reflects the nurse's best course of action?

Correct Answer: A

Rationale: The correct answer is A because memory loss after a fall can be indicative of a more serious issue like a head injury or neurological problem. A complete mental health examination by the nurse can help assess the extent of memory loss, identify potential causes, and determine appropriate interventions. Referring to a psychometrician (choice B) may not address the immediate health concern. Integrating the mental health examination into history taking and physical examination (choice C) is important but may not be as thorough as a complete mental health examination by a professional. Reassuring the wife that memory loss is normal (choice D) may lead to overlooking a potentially serious health issue.

Question 2 of 5

A 45-year-old man arrives at the clinic and tells the nurse that he has been experiencing severe chest pain. Upon assessment, the nurse notes that his pain radiates to his left arm. The nurse's priority action would be:

Correct Answer: B

Rationale: The correct answer is B: Assess vital signs and oxygen saturation levels. This is the priority action because the patient's symptoms suggest a possible cardiac event. Assessing vital signs and oxygen saturation levels can provide crucial information on the patient's condition and help determine the urgency of the situation. Administering pain medication (choice A) should not be done before assessing the patient's vital signs. Having the patient walk around (choice C) could worsen the situation if it is indeed a cardiac event. Ordering an EKG (choice D) is important but should come after assessing vital signs to guide further evaluation and treatment.

Question 3 of 5

What should be the first step in managing a client with suspected spinal cord injury?

Correct Answer: A

Rationale: The correct first step is to immobilize the spine (A) in a suspected spinal cord injury to prevent further damage. This helps to stabilize the spine and prevent any potential movement that could worsen the injury. Providing pain relief (B) should come after immobilization. Assessing for signs of spinal shock (C) is important but comes after immobilization. Placing the client in a supine position (D) can be part of immobilization but is not the first step.

Question 4 of 5

Which areas are most important to address for a client in Buck's traction?

Correct Answer: C

Rationale: Step 1: Nutrition is important for healing and energy. Step 2: Elimination is crucial for bowel and bladder function. Step 3: Comfort ensures the client's well-being. Step 4: Safety prevents complications. Step 5: ROM exercises can prevent muscle atrophy. Step 6: Transportation and isotonic exercises are not immediate priorities.

Question 5 of 5

A nurse is caring for a 70-year-old patient with a history of congestive heart failure. The nurse should monitor the patient for which of the following?

Correct Answer: A

Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.

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