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: 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 because reinforcing good habits, such as healthy eating and exercise, is essential for promoting health and preventing disease. This involves educating patients on proper self-care practices. Providing medical diagnosis (B) is not a nursing role, as it falls under the domain of medical professionals. Maintaining optimal functioning (C) is important but not specific to promoting health. Prescribing treatment (D) is beyond the scope of nursing practice, as only advanced practice nurses have prescriptive authority.

Correct Answer: C

Rationale: The correct answer is C: Chocolate. Chocolate is known to trigger heartburn in individuals with GERD due to its high fat content and caffeine. Fat relaxes the lower esophageal sphincter, allowing stomach acid to flow back up the esophagus, leading to heartburn. Caffeine can also relax the sphincter and trigger acid reflux. Lettuce (A) and eggs (B) are generally well-tolerated and do not commonly trigger heartburn. Butterscotch (D) may be high in fat and sugar, but it is less likely to cause heartburn compared to chocolate.

Correct Answer: A

Rationale: The correct answer is A: Administer warm IV fluids. This is because in severe hypothermia, the body's core temperature drops dangerously low, leading to decreased circulation and potential organ failure. Administering warm IV fluids helps to gradually raise the core temperature and prevent further complications. Choice B (Warming the client with a heating pad) can cause rewarming shock and skin burns. Choice C (Placing the client in a supine position) is not directly related to treating hypothermia. Choice D (Administering analgesics) is not the priority in treating severe hypothermia.