the nurse is caring for a 75 year old client in congestive heart failure which finding suggests that digitalis levels should be reviewed
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Nursing Elites

HESI LPN

Community Health HESI Test Bank 2023

1. The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

Correct answer: A

Rationale: Extreme fatigue can be a sign of digitalis toxicity, especially in older adults, and warrants a review of the client's medication levels and potential adjustment. Increased appetite, intense itching, and constipation are not typically associated with digitalis toxicity and do not directly indicate a need for a review of digitalis levels.

2. A client is suspected of being poisoned and presents with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth. The nurse should consider these findings consistent with which potential bioterrorism agent?

Correct answer: B

Rationale: The correct answer is B: botulism toxin. Botulism toxin is associated with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth, which are consistent with the client's presentation. Ricin (Choice A) typically presents with gastrointestinal symptoms. Sulfur mustard (Choice C) is a blistering agent causing skin, eye, and respiratory issues. Yersinia pestis (Choice D) is associated with the bubonic plague, presenting with fever, malaise, and buboes.

3. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?

Correct answer: A

Rationale: The correct answer is A: 'Double the birth weight.' Infants typically double their birth weight by 6 months of age. This is a common milestone in healthy infant growth and development. Choice B is incorrect because tripling the birth weight would be excessive and not in line with normal growth patterns. Choice C, 'Gain 6 ounces each week,' is not accurate as infant growth is not linear each week. Choice D, 'Add 2 pounds each month,' is also incorrect as this rate of growth would be too rapid and unrealistic for healthy infant development.

4. Which of the following BEST describes the strategies to address the nutrition problems of Filipinos related to non-communicable diseases?

Correct answer: B

Rationale: While considering food preferences of family members is important in promoting adherence to a healthy diet, the best strategies to address nutrition problems related to non-communicable diseases should focus on evidence-based approaches like aiming for an ideal body weight, building healthy nutrition-related practices, and choosing food wisely to improve overall health outcomes.

5. A client with acute pancreatitis is experiencing severe abdominal pain. The nurse should implement which of the following interventions?

Correct answer: B

Rationale: The correct intervention for a client with acute pancreatitis experiencing severe abdominal pain is to administer opioid analgesics. Opioids are effective in managing the severe pain associated with acute pancreatitis. Encouraging oral intake may exacerbate the symptoms and is contraindicated due to the need for bowel rest. Applying a heating pad to the abdomen can worsen inflammation and should be avoided. Placing the client in a supine position may not provide relief and could potentially lead to increased discomfort.

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