hesi health assessment test bank

Questions 47

ATI RN

ATI RN Test Bank

hesi health assessment test bank Questions

Question 1 of 5

Which intervention should the nurse implement for a client with hypothermia?

Correct Answer: B

Rationale: The correct answer is B, removing the client from the cold environment. This is because hypothermia occurs when the body loses heat faster than it can produce it, and being in a cold environment exacerbates this process. By removing the client from the cold environment, the nurse helps stop further heat loss. Warming the client slowly (A) can be detrimental as rapid rewarming can lead to complications. Providing a warm environment (C) and applying warm blankets (D) are important interventions but should come after removing the client from the cold environment to prevent further heat loss.

Question 2 of 5

What symptoms should a nurse assess for in a woman experiencing irregular menses over the past six months?

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.

Question 3 of 5

What assessment should the nurse perform when a client is wearing a cast?

Correct Answer: A

Rationale: The correct answer is A because capillary refill, warm toes, and no discomfort indicate good circulation and nerve function under the cast. This assessment helps detect any complications like impaired circulation or nerve damage. Posterior tibial pulses and moisture are not directly related to cast assessment. Pain threshold is subjective and does not provide objective information. Discomfort of the metacarpals is specific and not a comprehensive assessment.

Question 4 of 5

Why might breast implants interfere with mammography?

Correct Answer: D

Rationale: The correct answer is D because breast implants can hinder mammography by obscuring the view of breast tissue, making it difficult to detect abnormalities like masses. This is due to the implants blocking the x-ray machine's view. Choice A is incorrect as discomfort is not the primary reason for interference. Choice B is incorrect as breast implants are not a contraindication to mammography but can complicate the process. Choice C is incorrect as implants are designed to be secure and are not likely to be dislodged during a mammogram.

Question 5 of 5

A middle-aged woman reports irregular menses for six months. The nurse should assess for symptoms of:

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.

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