a client presents at a community based clinic with complaints of shortness of breath headache dizziness and nausea during the assessment the nurse lea
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Nursing Elites

HESI LPN

Community Health HESI Exam

1. A client presents at a community-based clinic with complaints of shortness of breath, headache, dizziness, and nausea. During the assessment, the nurse learns that the client is a migrant worker who often uses a gasoline-powered pressure washer to clean equipment and farm buildings. Which type of poisoning is the most likely etiology of this client's symptoms?

Correct answer: D

Rationale: The client's symptoms of shortness of breath, headache, dizziness, and nausea are indicative of carbon monoxide poisoning, which can result from exposure to gasoline-powered equipment like pressure washers. Asbestos (Choice A) exposure would typically present with respiratory issues and cancer but not the rapid onset of symptoms described. Silica dust (Choice B) exposure is associated with respiratory conditions like silicosis, not the multisystem symptoms in the scenario. Histoplasmosis (Choice C) is a fungal infection that primarily affects the lungs and is not related to the client's exposure to a gasoline-powered pressure washer.

2. A 6-month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to

Correct answer: C

Rationale: The correct answer is to check every few hours for the next day or 2 for swelling in the baby's feet. Swelling in the baby's feet could indicate compromised circulation due to the cast, and frequent checks are necessary to ensure that there are no complications. Choices A, B, and D are incorrect because rubbing the skin with a cotton swab, placing favorite items in the crib, and turning the baby with the abduction stabilizer bar do not address the potential issue of compromised circulation and swelling in the baby's feet.

3. A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?

Correct answer: D

Rationale: The correct answer is to listen to the client. Listening allows the nurse to establish therapeutic communication, understand the client's fears and concerns, provide emotional support, and help alleviate anxiety. Calling a chaplain (Choice A) may be appropriate if the client requests spiritual support but should not be the initial response. Denying the feelings (Choice B) is dismissive and can hinder trust and communication. Citing recovery statistics (Choice C) is irrelevant and does not address the client's immediate emotional needs.

4. Which of the following is a major focus of tertiary prevention?

Correct answer: C

Rationale: The correct answer is C, 'Reducing the impact of an ongoing illness.' Tertiary prevention aims to minimize the effects of a disease or condition that is already established. Choices A, 'Preventing the onset of disease,' and B, 'Early detection and treatment,' are aspects of primary and secondary prevention, respectively. Choice D, 'Health education,' is more related to promoting awareness and knowledge rather than specifically focusing on reducing the impact of an ongoing illness.

5. A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is

Correct answer: D

Rationale: Risk for aspiration is a priority concern following a seizure, especially when the child vomits, as there is a danger of aspirating the vomit into the lungs, leading to respiratory complications. The other options are not the priority in this situation. While infection risk and fluid volume deficit are important, ensuring the child's airway is clear and there is no risk of aspiration takes precedence. Altered family processes may be a concern but addressing the immediate physiological risk is the priority.

Similar Questions

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A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the 'evil eye.' The nurse should communicate to other personnel that the appropriate approach is to
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