hesi health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Administer diuretics. Diuretics help reduce fluid overload in CHF by increasing urine output and decreasing the workload on the heart. This intervention addresses the underlying issue of fluid retention, a common problem in CHF. Monitoring vital signs (B) is important but does not directly target the primary problem of fluid overload. Monitoring respiratory rate (C) is essential in CHF, but administering diuretics takes precedence in managing fluid balance. Monitoring for arrhythmias (D) is important, but not the most crucial intervention in the management of CHF.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. The nurse should first assess the client's chest pain, then administer nitroglycerin if indicated for suspected cardiac origin. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can alleviate chest pain associated with angina or myocardial infarction. Administering morphine or aspirin should come after nitroglycerin if needed. Performing an ECG is important but should not delay immediate treatment with nitroglycerin for chest pain of cardiac origin.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the most appropriate intervention for a client with a suspected spinal cord injury to prevent further damage. Immobilization helps stabilize the spine and reduce the risk of spinal cord compression or injury. Administering pain relief (B) or IV fluids (C) should only be done after proper spinal immobilization to avoid exacerbating the injury. Placing the client in a supine position (D) can be beneficial if done carefully after spine immobilization, but immobilizing the spine takes precedence to prevent any potential movement that could worsen the injury.

Correct Answer: A

Rationale: The correct answer is A: Administer antiepileptics. Administering antiepileptics is the priority nursing action for a client with a history of seizures to prevent seizure recurrence. Antiepileptics help control and manage seizure activity effectively. Monitoring vital signs (B) and placing the client in a lateral position (C) are important actions during a seizure but are not the priority over administering antiepileptics. Providing seizure precautions (D) is also important but does not directly address the immediate need of administering antiepileptics to prevent a seizure.

Correct Answer: C

Rationale: The correct answer is C: perimenopause. Perimenopause is the transitional period before menopause when a woman's body begins to produce less estrogen. This can lead to irregular menstrual cycles and other symptoms such as hot flashes, night sweats, and mood changes. Assessing for symptoms of perimenopause in a woman reporting irregular menses for six months is appropriate as it aligns with the timing and characteristics of this phase. Explanation for incorrect choices: A: Climacteric refers to the period of menopausal transition and is not specific to the symptoms mentioned in the scenario. B: Menopause is the cessation of menstrual periods for 12 consecutive months and is not typically associated with irregular menses. D: Postmenopause is the period after menopause has been established for at least 12 months and irregular menses would not be expected during this phase.