HESI CAT Exam

Correct Answer: D

Rationale: Observing for signs of depression is crucial in this patient's plan of care as depression can impact his overall recovery and management post-surgery. Depression is common in individuals struggling with weight management, diabetes mellitus, and hypertension. Monitoring for urinary incontinence (Choice A) is not the priority in this case as the patient is undergoing gastroplasty for weight management, not a urinary issue. Applying sequential compression stockings (Choice B) is important for preventing deep vein thrombosis in immobile patients but is not the priority in this scenario. Providing a wide variety of meal choices (Choice C) is not the most crucial intervention at this stage, as post-gastroplasty dietary restrictions are essential for successful weight management.

Correct Answer: C

Rationale: The correct answer is C: Low serum calcium. Hand spasms and paresthesia are indicative of potential hypocalcemia, which is characterized by low serum calcium levels. Elevated serum calcium (Choice A) is not consistent with the symptoms described. Low serum magnesium (Choice B) and elevated serum potassium (Choice D) are not typically associated with hand spasms and paresthesia.

Correct Answer: B

Rationale: Frequent reorientation is crucial for clients with neurological impairments from osmotic demyelination to prevent confusion and assist with orientation. It helps maintain a proper sense of time, place, and person, reducing disorientation. Patching one eye (Choice A) is not a priority intervention for osmotic demyelination and does not address the immediate need for reorientation. Range of motion exercises (Choice C) may be important for overall care, but reorientation takes precedence due to its impact on neurological functioning. Evaluating swallow (Choice D) is not the primary intervention needed for osmotic demyelination; it is essential but not the first priority.

Correct Answer: A

Rationale: The most important question for the nurse to ask in this situation is whether the client knows the person who raped her. This question is crucial for assessing additional safety concerns, providing appropriate support, and determining the need for forensic evidence collection. Choices B, C, and D are not as critical in the immediate assessment and response to a rape victim. Asking about bathing, the safety of her home, or reporting to the police may be important but are secondary to identifying the perpetrator for safety and legal reasons.

Correct Answer: D

Rationale: The correct answer is D because an illiterate client may require additional support to ensure they fully comprehend the information provided in the informed consent process. It is crucial to confirm that the client truly understands the nature of the procedure, its risks, and benefits. While it is important to assess pain control (choice A), a client's previous medication administration does not directly impact their ability to understand the consent process. Choice B, a 15-year-old primigravida who has been self-supporting, may legally provide informed consent depending on the jurisdiction and circumstances, so this situation may not require further exploration. Choice C, explaining a procedure by a different specialist, does not necessarily require additional exploration before witnessing the client's consent.