hesi health assessment test bank 2023

Correct Answer: A

Rationale: The most appropriate nursing diagnosis for a client with advanced Parkinson's disease and gait issues is "A: Impaired Physical Mobility." This diagnosis accurately reflects the client's limited ability to move due to the disease's impact on coordination and muscle control. Impaired Physical Mobility addresses the specific issue of gait problems commonly seen in Parkinson's patients. Choice B, "Impaired Role Performance," does not directly address the physical limitations caused by the disease. Choice C, "Ineffective Role Performance," focuses more on the client's inability to fulfill societal roles rather than the physical aspect of gait issues. Choice D, "Powerlessness," does not capture the primary concern of impaired movement and mobility in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Bleeding. Warfarin is an anticoagulant medication that works by inhibiting blood clotting factors. Monitoring for signs of bleeding is crucial as warfarin increases the risk of bleeding events. Signs of bleeding may include easy bruising, nosebleeds, blood in urine or stool. Hypertension (B), hyperglycemia (C), and hypokalemia (D) are not direct effects of warfarin. Monitoring for these conditions may be important for other medications or conditions, but they are not the primary concern when a patient is prescribed warfarin.

Correct Answer: A

Rationale: The correct answer is A. Older adults may have a longer story to tell due to their wealth of life experiences. This can include medical history, family background, and personal stories that may impact their health. It is important for the nurse to gather all relevant information to provide appropriate care. Choice B is incorrect because not all older adults are lonely, and the reason for a longer interview is not solely based on the need for social interaction. Choice C is incorrect because while some older adults may experience cognitive decline, it is not a blanket statement that all older adults lose mental abilities. Choice D is incorrect because hearing loss is not a universal issue among older adults, and assuming so can lead to ageist stereotypes.

Correct Answer: A

Rationale: The correct answer is A: Administer pain medication. This is the most appropriate nursing intervention because severe pain post-surgery requires immediate relief to ensure the client's comfort and aid in recovery. Pain medication helps manage pain effectively, improving the client's overall well-being and promoting healing. Monitoring vital signs (choice B) is important but secondary to pain relief in this scenario. Administering IV fluids (choice C) may be necessary for hydration but does not directly address the pain. Administering corticosteroids (choice D) is not typically indicated for severe pain post-surgery.

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.