the nurse is completing a neurological assessment on a client with a closed head injury the glasgow coma scale gcs score was 13 on admission it is now
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HESI CAT Exam Quizlet

1. The nurse is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. What is the priority nursing intervention based on the client’s current GCS?

Correct answer: A

Rationale: A significant drop in GCS indicates a severe decline in neurological status, necessitating immediate communication with the healthcare provider. Notifying the healthcare provider allows for prompt evaluation and intervention to address the worsening condition. Choice B is incorrect because preparing the family for imminent death is premature and not supported by the information provided. Choice C is incorrect as the frequency of monitoring should be increased to every 15 minutes rather than every hour due to the significant drop in GCS. Choice D is incorrect because initiating CPR is not indicated based solely on a decreased GCS score.

2. The client is assessing a client who was recently diagnosed with heart failure and is on a low-sodium diet. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C. Some salt substitutes can be high in potassium, which may not be suitable for clients with heart failure. Option A is correct as using lemon juice and herbs for flavoring is a good low-sodium alternative. Option B is also correct as canned soups and frozen dinners are typically high in sodium content. Option D is correct as checking food labels for sodium content is an essential part of managing a low-sodium diet. Therefore, the client's statement about using salt substitutes needs correction as it can introduce high levels of potassium, which may not be recommended for individuals with heart failure.

3. A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse’s station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

Correct answer: C

Rationale: The correct answer is C: 'Ineffective coping related to denial.' The client's behavior of wanting to go home and feeling much better shortly after a myocardial infarction indicates denial of the severity of his condition. This denial can lead to ineffective coping mechanisms, hindering his recovery and treatment. Choices A, B, and D are incorrect because the client's behavior is not primarily driven by anxiety about the treatment plan, deficient knowledge of lifestyle changes, or decisional conflict due to stress, but rather by denial and ineffective coping mechanisms.

4. A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/hour?

Correct answer: D

Rationale: The infusion rate is calculated based on the concentration of lidocaine and the prescribed rate of infusion. First, convert lidocaine's weight to milligrams (2 grams = 2000 mg). Then, use the formula: (Total volume in ml * dose in mg) / 60 minutes. For this case, (500 ml * 2000 mg) / 60 minutes = 45 ml/hour. Therefore, the correct answer is D. Choices A, B, and C are incorrect as they do not reflect the accurate calculation based on the provided concentration and infusion rate.

5. A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Correct answer: B

Rationale: Evaluating the newly hired UAP’s competency by observing them deliver care is the most effective intervention to ensure they can provide safe and effective care. This approach directly assesses the UAP's actual performance and allows for immediate feedback. Option A, asking the most experienced UAP to partner with the newly hired one, may not guarantee that the new UAP is competent. Option C, reviewing the UAP’s skills checklist and experience with the hiring person, does not provide a direct assessment of the UAP's current abilities. Option D, assigning the new UAP to less complex cases, does not address the need to evaluate their competency directly.

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