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

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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. You assisted the midwife in formulating the objectives of the plan of care for Barangay Mabulaklak. Which of the following is a well-stated objective?

Correct answer: D

Rationale: A specific, measurable objective like reducing the number of underweight children by 10% is well-stated. This objective is clear, quantifiable, and time-bound, making it easier to track progress and evaluate the effectiveness of the plan. Choices A, B, and C are not as well-stated as they lack specificity, measurability, and a quantifiable target.

3. The home health nursing director is conducting an educational program for registered nurses and practical nurses about Medicare reimbursement. To obtain payment for Medicare services, what must be included in the client's record?

Correct answer: B

Rationale: The correct answer is B: Documentation of skilled care services is required for Medicare reimbursement. Medicare reimbursement is based on the provision of skilled care services, not on prescriptions or preventative healthcare services. Including a copy of the client's health history and social security card is not a requirement for Medicare reimbursement.

4. A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of 'suppression'?

Correct answer: B

Rationale: The correct answer is B because the statement "I'd rather not talk about it right now" indicates that the client is consciously choosing to avoid discussing the distressing issue, which aligns with the mechanism of suppression. Choice A does not involve active avoidance but rather memory loss, which is not suppression. Choice C involves blaming others, which is a defense mechanism known as projection. Choice D involves expressing emotions rather than avoiding them, which does not align with suppression.

5. Which of the following is designed to help clients reduce the risk of illness and maintain the maximum level of function?

Correct answer: D

Rationale: The correct answer is 'D: health promotion.' Health promotion strategies are aimed at helping individuals reduce the risk of illness and maintain their maximum level of function by emphasizing preventive measures, healthy behaviors, and lifestyle choices. Illness prevention (choice A) focuses on specific actions to avoid illness but may not necessarily address overall function. Crisis intervention (choice B) refers to immediate assistance during emergencies rather than long-term prevention. Rehabilitation (choice C) involves restoring function after illness or injury rather than primarily focusing on preventive measures and maintaining maximum function.

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