hesi health assessment test bank

Correct Answer: D

Rationale: The correct answer is D: A high-fat meal. After gastric resection, high-fat meals are likely to cause rapid gastric emptying due to the delayed gastric emptying effect of fats. Fats take longer to digest compared to other nutrients, leading to slower emptying of the stomach contents. This can result in rapid emptying of the stomach post-resection. A: A high-protein meal does not necessarily cause rapid gastric emptying as proteins are digested at a moderate pace. B: A large meal regardless of nutrient content may lead to slower gastric emptying due to the increased volume. C: A high-carbohydrate meal can promote quicker gastric emptying, but it is not as likely to cause rapid emptying as high-fat meals post-gastric resection.

Correct Answer: A

Rationale: The correct first step is to administer pain relief (Choice A) because addressing the client's pain is a top priority to ensure their comfort and well-being. Pain management is crucial post-surgery to prevent complications and aid in recovery. Monitoring vital signs (Choice B) is important but should follow pain relief to ensure the client's stability. Assessing the wound (Choice C) is necessary but not the immediate priority when the client is in acute pain. Applying a warm compress (Choice D) may provide temporary relief but does not address the underlying cause of the pain. Therefore, administering pain relief is the most appropriate initial action to alleviate the client's discomfort and start the healing process effectively.

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: B

Rationale: The correct answer is B: Provide cooling measures. When caring for a client with hyperthermia, the nurse's priority is to lower the body temperature to prevent further complications. Providing cooling measures such as removing excess clothing, using fans, applying cool compresses, and encouraging hydration helps to reduce the body temperature effectively. Administering antipyretics (A and D) may be considered in some cases, but cooling measures are more immediate and effective. Administering corticosteroids (C) is not indicated in the treatment of hyperthermia. Cooling measures directly target the elevated body temperature, making it the top priority in managing hyperthermia.

Correct Answer: D

Rationale: The correct answer is D: Objective. During a physical assessment, the nurse gathers data through observation and measurement, such as vital signs and physical appearance, which are objective and measurable. This type of data is based on facts rather than opinions or interpretations, making it reliable for assessing the client's health status. Patient-centered data (A) refers to information focused on the client's perspective, subjective data (B) is based on the client's symptoms or feelings, and unconfirmed data (C) lacks validation or evidence, making them unreliable for making clinical decisions.