ATI RN
hesi health assessment test bank 2023 Questions
Question 1 of 5
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. This is the priority intervention as it helps prevent complications such as blood clots and pneumonia, promotes circulation, and aids in faster recovery. Ambulation also helps maintain joint mobility and muscle strength. Administering pain medications (B) is important but not the priority. Providing wound care (C) and monitoring for infection (D) are important, but ambulation takes precedence in preventing complications.
Question 2 of 5
What is the most appropriate nursing diagnosis for a client with advanced Parkinson's disease and gait issues?
Correct Answer: A
Rationale: The most appropriate nursing diagnosis for a client with advanced Parkinson's disease and gait issues is "A: Impaired Physical Mobility." This diagnosis accurately reflects the client's limited ability to move due to the disease's impact on coordination and muscle control. Impaired Physical Mobility addresses the specific issue of gait problems commonly seen in Parkinson's patients. Choice B, "Impaired Role Performance," does not directly address the physical limitations caused by the disease. Choice C, "Ineffective Role Performance," focuses more on the client's inability to fulfill societal roles rather than the physical aspect of gait issues. Choice D, "Powerlessness," does not capture the primary concern of impaired movement and mobility in this scenario.
Question 3 of 5
Which of the following is an example of a symptom?
Correct Answer: A
Rationale: The correct answer is A: Chest pain. A symptom is a subjective indication of a condition experienced by the patient. Chest pain is a subjective sensation that a patient reports, making it a symptom. Clammy skin, serum potassium level, and temperature are all objective signs or measurements, not subjective experiences reported by the patient. Symptoms are what the patient feels or experiences, while signs are objective findings that can be measured or observed by healthcare providers.
Question 4 of 5
Which of the following should be assessed first in a client with a high fever?
Correct Answer: C
Rationale: The correct answer is C: Check for dehydration. When a client has a high fever, assessing for dehydration is crucial because fever can lead to increased fluid loss through sweating and increased respiratory rate. Dehydration can exacerbate the client's condition and needs to be addressed promptly. Monitoring respiratory rate (choice A) and pulse (choice D) are important assessments but do not address the immediate need to identify dehydration. Obtaining a blood sample (choice B) may be necessary at some point but is not the initial priority in a client with a high fever. Thus, checking for dehydration should be assessed first to ensure proper management of the client's condition.
Question 5 of 5
A nurse is caring for a patient with a history of diabetes and peripheral neuropathy. The nurse should educate the patient to prioritize which of the following?
Correct Answer: A
Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for patients with diabetes and peripheral neuropathy to prevent complications like infections and ulcers. By inspecting their feet daily, the patient can identify any injuries or abnormalities early and seek prompt medical attention. This proactive approach can help prevent serious consequences such as amputations. Summary of incorrect choices: B: Taking medications only when experiencing symptoms - This is not recommended as medications for diabetes and neuropathy are often prescribed to prevent complications and manage the conditions on a daily basis. C: Exercising to increase foot circulation - While exercise is beneficial, patients with peripheral neuropathy may have decreased sensation in their feet, increasing the risk of injury during exercise. D: Wearing tight-fitting shoes to avoid blisters - Tight-fitting shoes can cause pressure points and increase the risk of foot injuries, especially in patients with neuropathy.
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