ATI RN
hesi health assessment test bank 2023 Questions
Question 1 of 9
A nurse is teaching a patient with heart failure about managing their condition. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C: "I can stop taking my medication if I feel fine." This statement indicates a misunderstanding of the importance of medication adherence in managing heart failure. Here's the rationale: 1. Patients with heart failure often require lifelong medication to control symptoms and prevent complications. 2. Stopping medication abruptly can lead to worsening of heart failure symptoms and potential health risks. 3. Monitoring for symptoms is essential, but it does not replace the need for consistent medication use. Other choices are incorrect because: A is correct as daily medication adherence is crucial. B is correct as reducing sodium intake helps manage fluid retention in heart failure. D is correct as daily weight monitoring helps detect fluid retention early.
Question 2 of 9
The nurse is caring for a client moving toward illness and premature death. How would the nurse know this?
Correct Answer: B
Rationale: The correct answer is B. When a client is moving towards illness and premature death, signs and symptoms typically start to manifest. These can include physical changes, abnormal lab results, or new onset of health issues. This serves as a direct indication of the client's deteriorating health status. Choices A, C, and D are incorrect because stopping wellness-promoting activities (A) could simply be due to lack of motivation, starting to exercise (C) may not necessarily indicate illness progression, and verbalizing anxiety over medication costs (D) is not a direct indicator of impending illness and premature death.
Question 3 of 9
What are the types of nursing assessments? (Select one that doesn't apply)
Correct Answer: C
Rationale: The correct answer is C: Mental. Nursing assessments typically include physical, focused, and emergency assessments. Mental assessments are more commonly associated with psychiatric nursing rather than general nursing assessments. Mental assessments focus on assessing a patient's mental status, emotions, and cognitive functions, which are not typically part of routine nursing assessments. Therefore, mental assessments do not fall under the types of assessments typically performed by general nurses.
Question 4 of 9
Which technique is most effective for assessing the patient's abdominal organ size?
Correct Answer: B
Rationale: The correct answer is B: Palpation. Palpation is the most effective technique for assessing the patient's abdominal organ size as it allows the healthcare provider to feel and evaluate the size, texture, and consistency of the abdominal organs through touch. This hands-on approach provides valuable information about any abnormalities or tenderness in the organs. Inspection (choice A) involves looking at the abdomen for any visible signs but does not provide information on organ size. Percussion (choice C) involves tapping on the abdomen to assess the density of underlying structures, not specifically organ size. Auscultation (choice D) involves listening to sounds within the abdomen and does not directly assess organ size. Palpation is the preferred method for accurately assessing abdominal organ size due to its tactile nature.
Question 5 of 9
What should be the nurse's first action when a client develops symptoms of anaphylaxis?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. This is the first action because epinephrine is the primary treatment for anaphylaxis, a severe allergic reaction that can be life-threatening. It works quickly to reverse the symptoms by constricting blood vessels and opening airways. Administering epinephrine promptly can prevent progression to severe complications such as respiratory distress or cardiovascular collapse. Placing the client in a supine position and administering oxygen (B) may be necessary but should not delay the administration of epinephrine. Administering fluids (C) may help maintain blood pressure but is not the priority in the acute phase of anaphylaxis. Antihistamines (D) are not effective for treating the severe symptoms of anaphylaxis and should not be the first-line treatment.
Question 6 of 9
What should the nurse do when a client develops severe shortness of breath after surgery?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. This is the priority intervention to address severe shortness of breath, ensuring the client receives adequate oxygenation. Administering oxygen helps improve oxygen saturation levels and supports respiratory function. Encouraging deep breathing (B) may exacerbate the client's distress. Elevating the head of the bed (C) can help improve breathing but does not address the immediate need for oxygen. Administering antibiotics (D) is not indicated for shortness of breath unless there is an underlying infection causing it.
Question 7 of 9
The nurse would plan to use the Nipissing District Developmental Screen with a child who is:
Correct Answer: A
Rationale: The correct answer is A (3 years old) because the Nipissing District Developmental Screen is specifically designed for children aged 1 month to 6 years to assess their developmental milestones. It focuses on various areas of development appropriate for this age group, such as motor skills, language, social interaction, and cognitive abilities. Using this tool with a 3-year-old child allows for early identification of potential developmental delays or concerns. Incorrect choices: B (16 years old) - The Nipissing District Developmental Screen is not intended for children above 6 years old. C (8 years old with a developmental delay) - The tool is primarily for early screening, not for children already identified with developmental delays. D (Having difficulty with gross motor skills) - While this child may benefit from assessment, the Nipissing Screen is a comprehensive tool for overall development, not just specific skill deficits.
Question 8 of 9
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.
Question 9 of 9
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.