hesi health assessment test bank 2023

Correct Answer: B

Rationale: The correct answer is B: Jaundice. Yellowish brown skin coloration along with pink coloration of the hard and soft palate is indicative of jaundice, a condition characterized by elevated levels of bilirubin in the blood. Bilirubin causes a yellowish discoloration of the skin but does not affect the color of the mucous membranes like the hard and soft palate. Pallor (A) refers to paleness of the skin due to decreased blood flow or anemia, not relevant in this case. Cyanosis (C) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, which is not consistent with the presented findings. Iron deficiency (D) may lead to pallor, but it does not cause yellowish brown skin coloration like jaundice.

Correct Answer: A

Rationale: The correct answer is A: Functional status. Including functional status in the history is essential as it provides information about the client's ability to perform activities of daily living. This information is crucial for assessing the client's overall health and well-being. Functional status helps the nurse understand the impact of health issues on the client's daily life and helps in planning appropriate care interventions. B: Data focusing on the client complaint is too narrow and may not provide a comprehensive understanding of the client's health status. C: A focused assessment of the client complaint may overlook other important aspects of the client's health that could impact their overall well-being. D: Family history for the past three generations is not typically included in a detailed history-taking process and may not be directly relevant to the client's current health status.

Correct Answer: A

Rationale: The correct answer is A: Chest pain. A symptom is a subjective indication of a condition experienced by the patient. Chest pain is a subjective sensation that a patient reports, making it a symptom. Clammy skin, serum potassium level, and temperature are all objective signs or measurements, not subjective experiences reported by the patient. Symptoms are what the patient feels or experiences, while signs are objective findings that can be measured or observed by healthcare providers.

Correct Answer: A

Rationale: The correct first step in managing a client with acute renal failure is to administer IV fluids (Choice A). This is crucial to ensure adequate hydration and maintain renal perfusion. By administering IV fluids, you can help improve kidney function and prevent further damage. Monitoring urine output (Choice B) is important but comes after addressing the fluid balance with IV fluids. Performing a CT scan (Choice C) is not typically the initial step in managing acute renal failure as it does not directly impact the patient's immediate condition. Administering diuretics (Choice D) can worsen the condition by further reducing kidney function, so it is not the recommended first step.

Correct Answer: B

Rationale: The correct answer is B: Use a bath blanket for warmth and privacy. This is important when making an occupied bed to ensure the comfort and dignity of the patient. The bath blanket provides warmth and privacy during the bed-making process, maintaining the patient's comfort and respecting their privacy. Keeping the bed in a low position (choice A) is important for safety but not directly related to the patient's comfort during bed-making. Constantly raising side rails (choice C) is unnecessary and may cause discomfort to the patient. Moving back and forth between sides (choice D) is not essential for making an occupied bed and may disrupt the process.