Community Health HESI Test Bank 2023

Correct Answer: C

Rationale: In this municipality, the nursing health care plan should primarily focus on health promotion and disease prevention. This approach addresses the underlying causes of health problems, promotes overall well-being, and helps prevent illnesses before they occur. While rehabilitative and curative services are important, health promotion and disease prevention are crucial for fostering a healthier community in the long term. Therefore, choices A, B, and D are not the best options as they do not prioritize preventing health issues at the root cause.

Correct Answer: B

Rationale: The correct action for the nurse to take when encountering a boggy uterus and vaginal bleeding after delivery is to massage the fundus. Massaging the fundus helps the uterus contract, which can reduce vaginal bleeding. Checking vital signs may be important but addressing the uterine atony and bleeding takes precedence. Offering a bedpan or checking for perineal lacerations are not the immediate actions needed to manage postpartum hemorrhage.

Correct Answer: A

Rationale: The correct answer is A: Insufficient oxygenation of the cardiac muscle. Myocardial infarction pain is primarily caused by inadequate oxygen reaching the heart muscle, leading to ischemia and tissue damage. Choices B, C, and D are incorrect because circulatory overload, left ventricular overload, and electrolyte imbalance are not the primary causes of chest pain in myocardial infarction. Circulatory overload may lead to other symptoms like edema, left ventricular overload can result in heart failure symptoms, and electrolyte imbalance may present with various manifestations, but none of these directly cause the characteristic chest pain associated with an MI.

Correct Answer: D

Rationale: The correct answer is D because a 30-month-old should have developed the skill to drink from a regular cup by this age. Drinking from a sip cup at this stage may indicate a delay in development. Choices A, B, and C are not as concerning as they can be within the range of normal development. A 13-month-old not walking yet, a 20-month-old using 2 and 3 word sentences, and a 24-month-old crying during examination are all behaviors that can fall within the spectrum of typical development for their respective ages.

Correct Answer: C

Rationale: The correct answer is C: Gingival hyperplasia. Phenytoin can cause gingival hyperplasia, characterized by an overgrowth of gum tissue. It is important for the nurse to monitor the client for this side effect as it can lead to oral health issues. Choices A, B, and D are incorrect. Phenytoin does not typically cause hypertension, hyperglycemia, or hypokalemia as common side effects.