hesi health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants help prevent the blood clot from getting larger and reduce the risk of it breaking loose and causing a pulmonary embolism. Other choices are incorrect because B: Monitoring vital signs alone does not treat the DVT, C: Providing bed rest can increase the risk of complications like pulmonary embolism, and D: Administering fibrinolytics is not the first-line treatment for DVT.

Correct Answer: D

Rationale: The correct answer is D: Encourage deep breathing. This is because encouraging deep breathing can help alleviate anxiety and promote relaxation, which can be beneficial in managing severe chest pain. Administering nitroglycerin (A) should only be done after assessing the client's condition and confirming it is safe to do so. Providing pain relief (B) may be necessary, but addressing the root cause of the pain should be the priority. Monitoring ECG (C) is important but should come after ensuring the client's immediate needs are addressed.

Correct Answer: A

Rationale: The correct answer is A: Vital signs. Assessing vital signs is crucial in a client presenting with symptoms of dehydration because it provides immediate information on the client's overall condition, including heart rate, blood pressure, respiratory rate, and temperature. Changes in vital signs can indicate the severity of dehydration and guide the nurse in determining the appropriate interventions. Summary: - B: Urine output is important in assessing dehydration but may not provide immediate information on the client's current condition compared to vital signs. - C: Skin turgor is a sign of dehydration but may not be the most accurate or immediate indicator compared to vital signs. - D: Skin color can also provide information on dehydration, but assessing vital signs gives a more comprehensive picture of the client's condition.

Correct Answer: D

Rationale: The correct answer is D: cirrhosis. Cirrhosis leads to impaired liver function, causing the liver to be unable to effectively metabolize ammonia, leading to high ammonia levels in the blood. Renal failure (choice A) is associated with high creatinine levels, not ammonia. Psoriasis (choice B) is a skin condition unrelated to ammonia levels. Lupus (choice C) is an autoimmune disease affecting various organs, not directly linked to high ammonia levels. In summary, cirrhosis is the only condition among the options that directly impacts liver function and can lead to high ammonia levels in the blood.

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.