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: 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.

Correct Answer: C

Rationale: The correct answer is C: Mental. Nursing assessments typically include physical, focused, and emergency assessments. Mental assessments are more commonly associated with psychiatric nursing rather than general nursing assessments. Mental assessments focus on assessing a patient's mental status, emotions, and cognitive functions, which are not typically part of routine nursing assessments. Therefore, mental assessments do not fall under the types of assessments typically performed by general nurses.

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: A

Rationale: The correct first action when a client develops a fever after surgery is to administer antipyretics (A). Fever post-surgery can indicate infection, and antipyretics help lower the body temperature. Administering pain medications (B) may mask the fever's underlying cause. Providing fluids (C) is essential but not the priority. Providing wound care (D) is important but comes after addressing the fever. Administering antipyretics promptly helps manage the fever and allows for further assessment and intervention if needed.