In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?

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Community Health HESI Practice Exam Questions

Question 1 of 5

In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

The nurse is planning care for a client with increased intracranial pressure. The best position for this client is

Correct Answer: C

Rationale: The correct answer is C, Semi-Fowler's. This position helps to reduce intracranial pressure by promoting venous drainage from the head while maintaining adequate oxygenation. Option A, Trendelenburg position, is incorrect as it involves placing the patient with the head lower than the body, which can increase intracranial pressure. Option B, Prone position, is also incorrect as it involves lying on the stomach, which can further elevate intracranial pressure. Option D, Side-lying with head flat, does not provide the same benefits as the Semi-Fowler's position in terms of promoting venous drainage and maintaining oxygenation in a client with increased intracranial pressure.

Question 4 of 5

You are teaching a client about the patient-controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?

Correct Answer: B

Rationale: PCA allows patients to self-administer pain medication within prescribed limits, without the need to call the nurse before taking an additional dose. Choice B suggests a misunderstanding of how PCA works, as the patient should be educated that they can self-administer doses within the safety parameters set by the healthcare provider. Choices A, C, and D demonstrate proper understanding of PCA, hence are not indicative of needing further teaching.

Question 5 of 5

A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago. To confirm the presence or absence of an infection, it is most important for all family members to have a

Correct Answer: D

Rationale: The PPD (purified protein derivative) intradermal test is the standard screening method for detecting tuberculosis infection. It helps identify individuals who have been infected with Mycobacterium tuberculosis. A chest x-ray (Choice A) is used to assess the extent of active disease, not for screening purposes. Blood culture (Choice B) is not typically used for tuberculosis screening. Sputum culture (Choice C) is used to confirm active tuberculosis in symptomatic individuals, not for initial screening purposes.

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