a female client reports that her hair is becoming coarse and breaking off that the outer part of her eyebrows have disappeared and that her eyes are p
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Nursing Elites

HESI RN

HESI RN Exit Exam Capstone

1. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows has disappeared, and that her eyes are puffy. What follow-up question is best for the nurse to ask?

Correct answer: D

Rationale: The correct answer is D. Cold intolerance, fatigue, and other changes may indicate hypothyroidism, which could explain the hair and eyebrow loss, and puffy eyes. Choices A, B, and C are less relevant in this context and do not directly address the symptoms presented by the client.

2. A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse?

Correct answer: D

Rationale: The correct answer is D. In acute pancreatitis, abdominal pain typically worsens after eating due to the stimulation of the pancreas to release enzymes that irritate the inflamed tissues. Pain relief when lying supine is uncommon and usually exacerbates discomfort. While nausea and vomiting are common symptoms, they are not as indicative of changes in pain intensity. Pain radiating to the back is characteristic but does not specifically relate to exacerbation post-eating.

3. A 78-year-old client with diabetes is being taught how to care for his feet. Which statement by the client indicates a need for further education?

Correct answer: A

Rationale: The correct answer is A. Soaking feet daily can lead to excessive moisture, which can increase the risk of skin breakdown or infection in diabetic clients. Choices B, C, and D are all correct statements for foot care in diabetic clients. Using a mirror for daily foot checks helps in early detection of any issues, applying lotion while avoiding the area between the toes helps keep the skin moisturized without creating a risk for fungal infections, and wearing properly fitting shoes is important to prevent pressure points and potential injuries.

4. A client presents with a suspected infection and has a fever of 102°F. What is the nurse's immediate priority?

Correct answer: B

Rationale: The immediate priority for a client with a suspected infection and fever is to take a blood culture before administering antibiotics. This step is crucial to identify the causative organism and ensure appropriate treatment. Administering antipyretics or encouraging fluid intake are important but should come after obtaining the blood culture to avoid interfering with test results. Monitoring vital signs, although essential, is not the immediate priority compared to identifying the infectious agent.

5. During an assessment of a client with congestive heart failure, the nurse is most likely to hear which of the following upon auscultation of the heart?

Correct answer: A

Rationale: Correct Answer: An S3 ventricular gallop is an abnormal heart sound commonly heard in clients with congestive heart failure. This sound is indicative of fluid overload or volume expansion in the ventricles, which is often present in heart failure. <br> Incorrect Answers: <br> B: An apical click is not typically associated with congestive heart failure. <br> C: A systolic murmur may be heard in various cardiac conditions but is not specific to congestive heart failure. <br> D: A split S2 refers to a normal heart sound caused by the closure of the aortic and pulmonic valves at slightly different times during inspiration, not directly related to congestive heart failure.

Similar Questions

A client is admitted to the emergency department after a motor vehicle accident. The client has a Glasgow Coma Scale (GCS) score of 10. What does this score indicate?
The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?
A client with a history of atrial fibrillation is prescribed warfarin. What is the nurse's priority teaching?
A client with pneumonia is receiving oxygen therapy. What assessment finding requires immediate intervention?
A client with a urinary tract infection (UTI) is prescribed ciprofloxacin. What client teaching is essential?

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