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. After a thyroidectomy, which vital sign is the most important for the nurse to monitor closely?

Correct answer: B

Rationale: The correct answer is B: Assess for signs of hypocalcemia. After a thyroidectomy, monitoring for hypocalcemia is crucial because damage to the parathyroid glands during surgery can result in low calcium levels, which may cause life-threatening complications. Monitoring respiratory rate and rhythm (choice A) is important but not the most critical in this situation. Monitoring for elevated body temperature (choice C) is less of a priority post-thyroidectomy. Checking blood pressure every 30 minutes (choice D) is not as vital as monitoring for hypocalcemia in this context.

3. A client with type 2 diabetes mellitus arrives at the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation?

Correct answer: B

Rationale: Numb fingertips may suggest neuropathy, a common complication of diabetes that may indicate a worsening condition. Episodes of weakness and palpitations, combined with neuropathy symptoms, could also suggest hypoglycemia or poor glycemic control, requiring further investigation. The other choices are less likely to be directly related to the client's current symptoms. While a history of hypertension is a common comorbidity in clients with diabetes, it may not directly explain the reported weakness and palpitations. Reduced deep tendon reflexes are more indicative of certain neurological conditions rather than acute emerging situations related to the client's current symptoms. An elevated fasting blood glucose level is expected in a client with type 2 diabetes and may not be the primary indicator of an emerging situation in this context.

4. A client is experiencing shortness of breath and wheezing. What is the nurse's first action?

Correct answer: A

Rationale: Administering a bronchodilator is the priority intervention to open the airways and relieve wheezing and shortness of breath. Bronchodilators work quickly to dilate the airways, making it easier for the client to breathe. Checking oxygen saturation is important but can be done after initiating bronchodilator therapy. Encouraging pursed-lip breathing and elevating the head of the bed can help improve breathing patterns but should follow the administration of the bronchodilator.

5. A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?

Correct answer: C

Rationale: An elevated temperature may indicate infection and should be treated immediately in a client with heart failure.

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