hesi health assessment test bank

Correct Answer: C

Rationale: The correct answer is C: perimenopause. Perimenopause is the transitional phase leading to menopause, characterized by irregular menstrual cycles. Climacteric refers to the period of reproductive senescence, not just irregular menses. Menopause is the cessation of menstruation for 12 consecutive months. Postmenopause is the period after menopause, not characterized by irregular menses. Assessing for symptoms of perimenopause in a woman with irregular menses over the past six months is important to understand the hormonal changes and potential menopausal symptoms she may be experiencing.

Correct Answer: A

Rationale: Correct Answer: A - Administer antiemetics Rationale: The priority nursing action for a client vomiting post-surgery is to administer antiemetics to control nausea and vomiting, preventing complications like dehydration and electrolyte imbalance. Antiemetics help the client feel more comfortable and promote recovery. Administering fluids (choices B and C) is important, but addressing the vomiting itself takes precedence. Pain relief (choice D) is essential, but not the priority in this case.

Correct Answer: A

Rationale: The correct answer is A because assessing capillary refill indicates adequate blood flow, warm toes suggest good circulation, and no discomfort indicates proper alignment and fit of the cast. Choice B is incorrect as posterior tibial pulses are not directly related to cast assessment. Choice C is incorrect as moist skin and pain threshold are not specific to cast assessment. Choice D is incorrect as discomfort of the metacarpals is not a comprehensive assessment of a cast.

Correct Answer: A

Rationale: The correct answer is A: Creatinine. Creatinine is a waste product produced by muscles and excreted by the kidneys. An elevated creatinine level indicates impaired kidney function, making it a key indicator for early detection of renal failure. Blood urea nitrogen (BUN) can also be elevated in renal failure, but creatinine is a more specific and sensitive marker. Sodium and potassium levels are not directly related to renal failure detection.

Correct Answer: A

Rationale: The correct answer is A: Place the client on their side. This is the first nursing action for a client who develops a seizure to prevent aspiration and maintain an open airway. Placing the client on their side helps to keep their airway clear and prevents them from choking on saliva or vomit. Choice B, loosening clothing, is important but not the first priority. Choice C, placing the client in a Trendelenburg position, is not recommended as it may increase intracranial pressure. Choice D, placing the client in a sitting position, can increase the risk of injury during a seizure.