a male client tells the nurse i am so stressed because i am expected to achieve excellence in everything my job my marriage and my children must be pe
Logo

Nursing Elites

HESI RN

HESI RN CAT Exit Exam 1

1. A male client tells the nurse, 'I am so stressed because I am expected to achieve excellence in everything. My job, my marriage, and my children must be perfect!' Which coping response should the nurse recognize that the client is using?

Correct answer: C

Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where the client justifies their stress and need for perfection by creating logical explanations or excuses. In this case, the client is rationalizing their stress by believing that everything in their life must be perfect. Repression (choice A) involves unconsciously blocking out thoughts or feelings. Sublimation (choice B) is redirecting unacceptable impulses into socially acceptable activities. Displacement (choice D) involves transferring emotions from one target to another.

2. The nurse is caring for a client who has a chest tube in place following a pneumothorax. The nurse notes that there is continuous bubbling in the water seal chamber of the chest tube drainage system. What action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when observing continuous bubbling in the water seal chamber of the chest tube drainage system is to notify the healthcare provider. Continuous bubbling indicates a possible air leak, and the healthcare provider needs to be informed to assess the situation and take appropriate actions. Checking for kinks in the tubing (Choice A) may be done initially but is not the priority when continuous bubbling is present. Replacing the chest tube drainage system (Choice C) and reinforcing the chest tube dressing (Choice D) are not immediate actions needed in response to continuous bubbling in the water seal chamber.

3. The nurse is preparing a client for discharge who has a prescription for enoxaparin (Lovenox) self-administration. What information is most important for the nurse to provide the client about this medication?

Correct answer: A

Rationale: Teaching the client about self-administration techniques for subcutaneous injection is crucial for safe and effective use of enoxaparin. Option A is the correct answer as it directly addresses the client's need to know how to properly administer the medication. Options B, C, and D are important aspects of care but are not the most critical information needed for the client's self-administration of enoxaparin.

4. The nurse is evaluating the health status of an older client. Which finding is most important for the nurse to report to the healthcare provider?

Correct answer: C

Rationale: Pain in the lower back is a significant finding in an older client as it can indicate underlying issues such as kidney problems, spinal issues, or even aortic aneurysm. These conditions can be serious and require prompt medical attention. Decreased urine output (choice A) could indicate dehydration or kidney issues but is not as urgent as lower back pain. Loss of appetite (choice B) may be concerning but is not as critical as the potential life-threatening conditions associated with lower back pain. A persistent cough (choice D) is important to assess but is generally not as urgent as the potential serious implications of lower back pain in an older client.

5. A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?

Correct answer: B

Rationale: In this situation, the nurse should prioritize the safety of the client. Taking the client to a room for supervision by staff is crucial to ensure immediate safety and further assessment of the client's condition. While cleaning and assessing the client's wrists are important, ensuring ongoing safety and monitoring by staff is the priority. Calling the healthcare provider at this moment may cause delays in providing immediate assistance. Finding supplies to put a dressing on the client's wrists can wait until the client is in a safe environment. Therefore, option B is the best course of action to address the client's safety needs promptly.

Similar Questions

Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?
A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement?
When preparing an educational program for adolescents about the risks of multiple sexual partners, which information is most important to include?
The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?
Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses