HESI RN
Community Health HESI
1. During a home health visit, the nurse notices that an older male client with type 2 diabetes mellitus is wearing loose cloth slippers. The client reports that he cannot comfortably wear other shoes because his toenails get in the way. The nurse inspects the client's feet and finds long thick nails that curl down under some of the toes. Which action should the nurse take?
- A. demonstrate proper foot care to the client and family
- B. have a home health aide assist the client with hygiene weekly
- C. schedule an appointment for the client with a podiatrist
- D. trim the client's toenails gradually over several visits
Correct answer: C
Rationale: Scheduling an appointment with a podiatrist is the most appropriate action in this scenario. For a client with long thick nails that curl under the toes, professional foot care by a podiatrist is necessary to prevent complications, especially in a client with diabetes mellitus. Demonstrating proper foot care (choice A) may not address the immediate need for nail trimming. Having a home health aide assist with hygiene weekly (choice B) may not be sufficient for managing the client's toenail issue effectively. Trimming the client's toenails gradually over several visits (choice D) should be performed by a professional like a podiatrist to avoid potential complications.
2. A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse document as health risk factors for the client? (Select all that apply)
- A. age
- B. school dropout
- C. drug addiction
- D. All of the above
Correct answer: D
Rationale: All these factors - age, school dropout, drug addiction - are significant health risk factors for the client. Being young, a high school dropout, and struggling with drug addiction can lead to various complications during pregnancy, such as poor prenatal outcomes and social challenges. These factors can impact the client's overall health and well-being, highlighting the importance of addressing them during prenatal care.
3. A client with a history of coronary artery disease is admitted with chest pain. Which finding requires immediate intervention?
- A. Heart rate of 90 beats per minute.
- B. Blood pressure of 130/80 mm Hg.
- C. Respiratory rate of 20 breaths per minute.
- D. Chest pain radiating to the left arm.
Correct answer: D
Rationale: The correct answer is D. Chest pain radiating to the left arm can be a sign of myocardial infarction (heart attack) and requires immediate intervention. This symptom is known as a classic presentation of a heart attack and warrants urgent medical attention to prevent further cardiac damage. Choices A, B, and C are not directly indicative of an acute cardiac event and may not require immediate intervention in this scenario. While heart rate, blood pressure, and respiratory rate are important vital signs to monitor, they do not specifically indicate the urgency associated with chest pain radiating to the left arm in a patient with a history of coronary artery disease.
4. A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, 'Why do you have to wear a gown and mask when you are in my room?' How should the nurse respond?
- A. To protect myself from your germs.
- B. To protect you because you can get an infection very easily.
- C. Until your white blood cell count increases.
- D. To keep others from getting your infection.
Correct answer: B
Rationale: Reverse isolation precautions protect the client from exposure to microorganisms from others.
5. A client with a history of hypertension is admitted with a blood pressure of 180/110 mm Hg. Which medication should the nurse prepare to administer?
- A. Atenolol (Tenormin)
- B. Nifedipine (Procardia)
- C. Hydrochlorothiazide (Microzide)
- D. Clonidine (Catapres)
Correct answer: D
Rationale: In this scenario of severe hypertension (180/110 mm Hg), the nurse should prepare to administer Clonidine (Catapres), which is an antihypertensive medication commonly used to rapidly lower blood pressure in acute situations. Atenolol and Nifedipine are also antihypertensive medications, but Clonidine is more appropriate for immediate blood pressure reduction in this critical situation. Hydrochlorothiazide is a diuretic often used for long-term management of hypertension, not for rapid lowering of severely elevated blood pressure.
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