HESI RN
HESI Fundamentals Quizlet Questions
Question 1 of 5
During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?
Correct Answer: D
Rationale: In assessing cranial nerve function, specifically cranial nerve II (optic nerve), the correct answer is D) The client can read a Snellen chart from 20 feet away. This finding indicates intact visual acuity, which is directly related to the function of cranial nerve II. Option A) The client can hear a whisper from 1 to 2 feet away, pertains to cranial nerve VIII (vestibulocochlear nerve), responsible for hearing and balance. Option B) The client can identify an object by touch, refers to cranial nerve V (trigeminal nerve), involved in facial sensation and chewing. Option C) The client can shrug the shoulders against resistance, relates to cranial nerve XI (accessory nerve), responsible for neck and shoulder movements. In an educational context, understanding cranial nerve function is crucial for nurses to perform comprehensive assessments and detect neurological abnormalities. Knowing the specific functions of each cranial nerve aids in accurately identifying issues and providing appropriate care to patients. It is essential for nurses to be able to differentiate assessment findings related to various cranial nerves to ensure effective patient care and outcomes.
Question 2 of 5
A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?
Correct Answer: B
Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Increasing fluid intake (A), avoiding potassium (C), and increasing protein intake (D) are not appropriate dietary instructions for heart failure management.
Question 3 of 5
A client is admitted with a diagnosis of acute pancreatitis. Which assessment finding is most indicative of this diagnosis?
Correct Answer: A
Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. Abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis but are less specific and may be seen in various other gastrointestinal conditions.
Question 4 of 5
A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?
Correct Answer: C
Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A), oxygen saturation of 92% (B), and respiratory rate of 24 (D) are not as immediately concerning as they may still fall within acceptable ranges for a client with COPD.
Question 5 of 5
The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?
Correct Answer: B
Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management.