a 20 year old female client with a noticeable body odor has refused to shower for the last 3 days she states i have been told that it is harmful to ba
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Nursing Elites

HESI RN

HESI Fundamentals Practice Exam

1. A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?

Correct answer: D

Rationale: The priority for the nurse is to educate the client on the importance of personal hygiene during menstruation. Although it's crucial to respect the client's beliefs, providing education ensures the client receives accurate information to make informed decisions about her hygiene practices. By offering teaching first, the nurse can address any misconceptions or concerns the client may have while promoting optimal hygiene practices for overall well-being. Choice A should not be the first action as it does not address the client's potential misinformation about hygiene. Choice B is not ideal as it only offers a temporary solution without addressing the underlying issue. Choice C is not the priority as the immediate concern is the client's personal hygiene practices.

2. A male client with unstable angina needs a cardiac catheterization. The healthcare provider explains the risks and benefits of the procedure and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take?

Correct answer: D

Rationale: The nurse should ask the healthcare provider to return and provide further explanation to the client. The healthcare provider is the one who can address the risks and benefits of the procedure in detail, ensuring the client receives accurate information before providing consent.

3. The caregiver learns the use of a gait belt from the nurse for a woman with right-sided weakness. The caregiver demonstrates the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly?

Correct answer: B

Rationale: The correct answer is B. Standing on the weak side of the client and holding the gait belt from the back provides better security and support during ambulation, reducing the risk of falls. This positioning allows the caregiver to offer stability and assistance without interfering with the client's movement, ensuring safe ambulation for the client with right-sided weakness. Choices A, C, and D are incorrect because they do not provide the optimal support and security needed for a client with right-sided weakness. Standing on the weak side and holding the gait belt from the back is the most effective way to assist the client while minimizing the risk of falls.

4. The father of an 11-year-old client reports to the nurse that the client has been 'wetting the bed' since the passing of his mother and is concerned. Which action is most important for the nurse to take?

Correct answer: C

Rationale: Bedwetting after trauma, such as losing a parent, is common in children. The nurse should inform the father that it is crucial to let the son know that bedwetting is a normal response to trauma. Reassurance and understanding are essential in addressing the child's emotional needs during this difficult time. Choice A is incorrect as it focuses on puberty rather than trauma as the underlying cause. Choice B is incorrect as it provides inaccurate information about nocturnal emissions and developmental delay. Choice D is premature as the first step should be to provide education and support before considering a referral to a psychologist.

5. The daughter of an older woman who became depressed following the death of her husband asks, 'My mother was always well-adjusted until my father died. Will she tend to be sick from now on?' Which response is best for the nurse to provide?

Correct answer: B

Rationale: The successful resolution of a developmental crisis in the later years involves acceptance and adaptation, and the daughter should be reassured that recovery is likely.

Similar Questions

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After an adult had an indwelling catheter removed, the nurse catheterizes them as ordered and obtains 200 cc of urine. What is the best interpretation of this finding?
A client has a nursing diagnosis of 'spiritual distress.' What intervention is best for the nurse to implement when caring for this client?
What is the most important action for the nurse to take when caring for a client with a spinal cord injury experiencing autonomic dysreflexia?

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