a client with a diagnosis of hypertension is being assessewhich symptom would be most concerning
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HESI Practice Test for Fundamentals

1. A client with a diagnosis of hypertension is being assessed. Which symptom would be most concerning?

Correct answer: D

Rationale: Chest pain in a client with hypertension is the most concerning symptom as it may indicate a myocardial infarction or other serious cardiac event related to hypertension. Immediate intervention is required to address potential life-threatening conditions. Headache, blurred vision, and dizziness are common symptoms associated with hypertension but are not typically indicative of an acute cardiac event requiring urgent attention.

2. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?

Correct answer: C

Rationale: The nurse should reassure the mother that the child's behavior is normal for their age and situation.

3. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct answer: B

Rationale: After reviewing the expected outcomes in the plan of care, the nurse should obtain current client data to compare with these outcomes. This step is crucial in determining the effectiveness of the care provided. Choice A is incorrect because determining the realism of expected outcomes comes after assessing current client data. Choice C is incorrect as modifying nursing interventions should be based on the data comparison rather than done immediately after reviewing expected outcomes. Choice D is also incorrect as reviewing professional standards of care is important but not the immediate next step in evaluating care effectiveness.

4. A client is drawing up and mixing insulin under the observation of a nurse. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?

Correct answer: B

Rationale: The correct answer is B because the ability to demonstrate the appropriate technique shows that the client has acquired the psychomotor skills needed for insulin preparation. Merely discussing, stating an understanding, or writing the steps does not confirm that the client can physically perform the task correctly. Being able to demonstrate indicates practical application and mastery of the skill. Choice A is incorrect because discussing the technique does not necessarily mean the client can physically perform it. Choice C is incorrect as stating an understanding does not guarantee the client's ability to perform the task. Choice D is incorrect because writing the steps does not assess the client's physical execution of the technique.

5. During an assessment, a nurse is evaluating the breath sounds of an adult client diagnosed with pneumonia. Which of the following actions should the nurse take?

Correct answer: A

Rationale: When assessing breath sounds in a client with pneumonia, the nurse should follow a systematic pattern from side-to-side moving down the client’s chest. This approach ensures a comprehensive evaluation of breath sounds across different lung fields. Asking the client to breathe in deeply through their nose (Choice B) is not necessary for assessing breath sounds. Instructing the client to sit upright with their head slightly tilted backward (Choice C) is not directly related to assessing breath sounds and may not be required. Placing the diaphragm of the stethoscope on the client’s chest (Choice D) is not the correct technique for auscultating breath sounds, as the diaphragm should be used for this purpose.

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