HESI Fundamentals

Correct Answer: Talk to the client and attempt to find out why the client is crying.

Explanation:

The first step the nurse should take in this situation is to establish communication with the client. Crying behind a locked bathroom door may indicate emotional distress or a need for support. By talking to the client, the nurse can assess the situation and determine if there is an immediate need for intervention, whether it be emotional support, addressing a safety concern, or simply providing reassurance. Listening and understanding the client's concerns are essential steps in offering effective care and preventing further escalation of the situation.

Why the other options are incorrect:

Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client: While it is important to have support, it is the nurse's responsibility to assess the situation and communicate with the client directly. Delegating this to a UAP could delay the nurse's ability to provide immediate care and comfort to the client. The nurse should be the one to initially intervene and assess the situation.

 Sit quietly in the client's room until the client leaves the bathroom: While sitting quietly might seem like a non-confrontational approach, it does not address the client's emotional distress or provide the immediate support the client may need. Sitting silently could also increase the client's sense of isolation or distress if they feel neglected.

 Allow the client to cry alone and leave the client in the bathroom: Leaving the client alone without offering support can increase feelings of isolation and abandonment, which is not conducive to the client’s emotional or psychological well-being. The nurse should not leave the client in distress without attempting to provide reassurance or assess the situation.

Summary:

The best approach is for the nurse to talk to the client and attempt to understand why they are crying. This direct communication helps address the client's emotional distress and enables the nurse to provide the appropriate support or intervention. Ignoring or leaving the client alone can worsen their emotional state, and delegating the task to a UAP would delay the necessary intervention by the nurse.

Correct Answer: Closed-ended questions

Explanation:

Closed-ended questions are the most efficient technique for obtaining specific information about a client’s signs and symptoms during the admission interview. These questions typically require a yes, no, or short factual answer, which helps the nurse collect precise and focused information quickly. For example, asking, "Do you have chest pain?" or "When did the pain start?" provides clear, concise details that help identify the nature, onset, and severity of symptoms. This is particularly useful in time-sensitive situations where efficiency is crucial.

Why the Other Options Are Incorrect:

 Restatement of responses:

While restating a client’s responses can be helpful to ensure clarity and understanding, it is not the most efficient way to gather new information. This technique focuses on confirming or clarifying what the client has already said rather than eliciting additional details about their health problem.

Open-ended questions:

Although open-ended questions encourage clients to share their experiences in detail, they are time-consuming and may result in broad, unfocused answers. For example, asking, "Can you describe how you are feeling?" might generate a long narrative that is less efficient when specific details about symptoms are needed quickly.

Problem-seeking responses:

This term is not a standard interviewing technique in nursing. It may refer to exploring a client’s concerns but is vague and does not emphasize the structured, efficient approach provided by closed-ended questions.

Summary:

The correct answer is Closed-ended questions because they allow the nurse to quickly gather specific and relevant information about the signs and symptoms of a client’s primary health problem. This method is efficient and ensures the nurse obtains clear, focused responses to guide care planning and intervention.

Correct Answer: The nurse who transferred the client to the chair when the fall occurred.

Explanation:

In a malpractice case, the nurse directly responsible for the client during the time of the injury is at the greatest risk for legal liability. If a fall occurs during a transfer, the nurse performing the transfer is responsible for ensuring safety and using proper techniques. Failure to follow standard procedures or provide adequate support may lead to injury and legal consequences for negligence. This is the correct answer because malpractice involves failure to meet the standard of care. Since the client fell during a transfer, the nurse performing the transfer is most directly responsible for ensuring safe handling and monitoring the client's condition. If improper technique or negligence occurred, this nurse is at the highest legal risk.

Why the Other Options Are Incorrect:

A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes:

While poor documentation may contribute to liability, this nurse was not present at the time of the fall. Inaccurate charting can weaken a legal defense, but it does not directly cause the injury and is less likely to result in malpractice compared to the nurse actively involved.

The nurse assigned to care for the client who was at lunch at the time of the fall:

This nurse is not directly responsible because they were not present during the fall. If the nurse properly delegated care while on break, the liability falls to the individual performing direct care (in this case, the nurse performing the transfer).

The charge nurse who completed rounds 30 minutes before the fall occurred:

The charge nurse has a supervisory role but is not directly involved in client handling. Completing rounds 30 minutes before the incident does not make this nurse liable if the fall happened under the care of another responsible nurse.

Summary:

The nurse performing the transfer is at the greatest risk for a malpractice judgment because they had direct responsibility during the time of the fall. Legal liability primarily focuses on the nurse responsible for the client’s safety during care activities, particularly when injury occurs during direct intervention like a transfer.

Correct Answer: Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.

Explanation:

When a client experiences difficulty falling asleep and becomes irritable or restless, it is important to understand and address factors that may contribute to their sleep disturbances. One key factor is the client’s usual bedtime routine. Establishing a familiar routine can promote relaxation and help the client feel more comfortable, which can improve sleep quality. The nurse should ask the client about their typical pre-sleep activities (such as reading, listening to music, or relaxation techniques) and attempt to replicate these routines as much as possible, while considering safety precautions based on the client’s condition. This approach respects the client's individual needs and preferences, fostering a sense of normalcy and promoting better sleep.

Why the other options are incorrect:

Instruct the UAP not to wake the client under any circumstances during the night: This action may be well-intentioned, but it is not the most appropriate for improving the client’s sleep. Some assessments or interventions may still need to be conducted (such as checking vital signs or administering medications). It is essential to balance the client's rest with necessary care needs. Avoiding interruptions completely may compromise the client's health or safety.

Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8 hours: While a "Do Not Disturb" sign may reduce unnecessary interruptions, this option does not fully address the cause of the client’s sleep difficulties. Changing the frequency of assessments from every 4 hours to every 8 hours could delay important care, especially in a hospital setting where frequent monitoring is often necessary. Simply reducing assessments may compromise the client's well-being, especially if they are at risk for other conditions that require monitoring.

Encourage the client to avoid pain medication during the day, which might increase daytime napping: This suggestion may be counterproductive, as pain management is important for overall comfort and can actually improve sleep if managed appropriately. Avoiding pain medication during the day could lead to discomfort, increasing restlessness and irritability at night. Instead, ensuring that the client receives appropriate pain relief, possibly through non-pharmacological interventions at night, is more likely to improve sleep without affecting daytime napping.

Summary:

The best action is to understand the client’s usual bedtime routine and incorporate these familiar practices into the plan of care. This approach helps create a more comfortable and relaxed environment, promoting better sleep quality while ensuring safety.

Correct Answer: Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.

Rationale:

If the nurse is unable to distinguish the first sound (systolic pressure) when taking a blood pressure reading, the most appropriate action is to completely deflate the cuff and wait 30 to 60 seconds before attempting to take the reading again. This allows blood flow to return to normal and prevents inaccurate readings due to venous congestion or prolonged cuff inflation. Repeating the measurement too quickly can lead to false readings (either too high or too low) due to vessel compression.

Why the other options are incorrect:

 Deflate the cuff completely and immediately reattempt the reading

Immediately reattempting the reading does not allow time for blood flow to return to the arm. This can lead to an inaccurate reading because the vessels are still compressed from the initial measurement, potentially giving a false high reading.

Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading

Leaving the cuff inflated for such a long time restricts blood flow and can cause pain, tissue damage, and an inaccurate measurement. The cuff should only be inflated long enough to obtain a reading, and extended inflation can produce venous pooling and a false reading.

Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen

Visualizing the needle oscillations on the sphygmomanometer is not a reliable method to determine systolic blood pressure. Blood pressure should always be based on Korotkoff sounds (the audible tapping sounds heard through a stethoscope). Documenting an unreliable measurement could lead to inaccurate treatment decisions.

Summary:

If the nurse cannot clearly identify the first Korotkoff sound, the best action is to deflate the cuff to zero, wait 30 to 60 seconds, and retry. This allows the arterial circulation to recover, reducing the risk of inaccurate readings and ensuring a more precise blood pressure measurement. Other actions either cause inaccurate results or pose a risk to the client’s comfort and safety.

Correct Answer: Give an around-the-clock schedule for administration of analgesics.

Explanation:

In hospice care, the primary goal is to provide comfort and symptom management rather than attempting to cure the underlying disease. For clients experiencing increasing pain, it is best to administer analgesics on a regular, around-the-clock schedule rather than waiting for the client to request pain relief. This approach helps to maintain consistent pain control, prevents pain escalation, and improves the client’s quality of life. Consistent pain management is especially important in hospice settings to alleviate physical suffering and enhance emotional well-being during end-of-life care.

Why the Other Options Are Incorrect:

Administer analgesic medication as needed when the pain is severe:

This is incorrect because waiting until the pain becomes severe can cause unnecessary suffering and make pain more difficult to control. Pain that is allowed to escalate may require higher doses of medication to relieve it. Consistent, scheduled pain management provides better relief and prevents the pain from becoming unmanageable.

Provide medication to keep the client sedated and unaware of stimuli:

This is inappropriate because the goal of hospice care is to ensure comfort while allowing the client to remain as alert and engaged as desired. While sedation may sometimes be appropriate for refractory pain (pain that does not respond to standard treatments), the routine goal is to balance pain relief with maintaining the best possible quality of life. Over-sedating a client could impair their ability to interact with loved ones and participate in meaningful activities.

Offer a medication-free period so that the client can do daily activities:

This is incorrect because unrelieved pain may limit the client’s ability to engage in daily activities. Scheduled pain relief helps clients remain comfortable and may actually improve their ability to perform activities and interact with loved ones. Withholding medication can lead to unnecessary discomfort and increased suffering.

Summary:

The most appropriate action is to give analgesics on an around-the-clock schedule to maintain consistent pain relief and prevent pain from becoming severe. This approach aligns with hospice principles of comfort-focused care. The other options do not adequately address pain management or could contribute to increased suffering or decreased quality of life.

Correct Answer:  Inquire about the source and type of pain.

Explanation:

In African-American cultural expressions, the term "miseries" is often used to describe physical discomfort, particularly pain. This term may refer to various types of aches or pain (such as headaches, joint pain, or general body discomfort). Given the cultural context, the nurse should first inquire about the source, location, and nature of the pain to accurately assess the child’s condition and provide appropriate care. By exploring the type and intensity of pain, the nurse gathers essential information to guide further assessment and treatment planning.

Why the Other Options Are Incorrect:

 Examine the nose for congestion and discharge:

This is incorrect because "miseries" does not typically refer to nasal congestion or upper respiratory issues in this cultural context. While assessing for cold symptoms could be useful if the child describes such discomfort, it is not the most appropriate first step based on the grandmother’s statement.

 Take vital signs for temperature elevation:

Although fever can indicate illness, the term "miseries" is not specifically linked to elevated temperature in this cultural usage. Taking vital signs is always part of a comprehensive assessment, but it is not the first priority when trying to clarify a culturally specific symptom description.

Explore the abdominal area for distention:

While abdominal pain is a possible concern, "miseries" is a broad and nonspecific term. The nurse should not focus only on one area without first clarifying the exact location and nature of the discomfort through a focused pain assessment.

Summary:

The nurse should inquire about the source and type of pain because, in African-American cultural context, "miseries" often refers to physical pain or discomfort. This approach ensures a culturally sensitive and client-centered assessment. The other options focus on specific symptoms that are not directly indicated by the term "miseries" and should follow only after clarifying the nature of the child’s discomfort.

Correct Answer: Commend the client for selecting a high biologic value protein.

Explanation:

Clients with chronic renal failure (CRF) must carefully manage protein intake to reduce the workload on the kidneys. However, they still require adequate protein to maintain muscle mass and prevent malnutrition. High biologic value (HBV) proteins like eggs, meat, poultry, and dairy provide essential amino acids that the body cannot produce, making them the preferred protein source for clients with CRF. By choosing a scrambled egg, the client has made a nutritionally sound decision, and the nurse should reinforce this positive choice.

Why the Other Options Are Incorrect:

Remind the client that protein in the diet should be avoided:

This is incorrect because complete protein restriction is not appropriate for clients with CRF. While excessive protein can worsen kidney function, adequate intake of high-quality proteins is necessary to prevent muscle wasting and malnutrition.

Suggest that the client also select orange juice, to promote absorption:

This is not relevant in this context. Orange juice is not necessary to absorb protein. Additionally, citrus juices are high in potassium, which should be limited in CRF to avoid hyperkalemia, a potentially life-threatening condition.

 Encourage the client to attend classes on dietary management of CRF:

While education is important, this is not the immediate action. The client has already made a good dietary choice, and it is more appropriate to reinforce this behavior rather than suggesting additional education at this time.

Summary:

The correct response is to commend the client for choosing a high biologic value protein like scrambled eggs, which provides essential amino acids without excessive protein waste. Clients with CRF need to limit but not eliminate protein, and HBV proteins are the best option to meet their nutritional needs while protecting kidney function.

Correct Answer: Do not give the medication and document the reason.

Explanation:

Informed consent is a fundamental requirement for the administration of any medication, especially for minors. For an adolescent, the parent or legal guardian generally must provide consent before medications can be administered, unless the adolescent is emancipated or has the legal right to consent for themselves. In this situation, the nurse should not administer the medication until appropriate consent has been obtained from the parents or legal guardian. The nurse should document the reason for withholding the medication, ensuring that there is a clear record of the situation for future reference and legal purposes.

Why the other options are incorrect:

Review the chart for a signed consent for hospitalization: A signed consent for hospitalization is not the same as a consent for medication administration. Each form of treatment or intervention requires its own specific consent. If the parent or guardian has not signed a consent for the medication, this should be addressed before proceeding.

Get the health care provider's permission to give the medication: While the health care provider plays a role in prescribing the medication, they cannot override the legal requirement for obtaining parental consent for a minor unless specific exceptions apply (e.g., emergency situations, emancipated minors). The nurse must ensure that the consent is obtained from the parents or guardians.

 Complete an incident report and notify the parents: An incident report is typically used to document errors or unusual events. This situation involves a lack of parental consent, not an error or adverse event. The appropriate action is to withhold the medication and document why, but filing an incident report is not necessary in this case.

Summary:

The nurse should not administer the medication without parental consent for an adolescent client. The correct action is to document the reason for withholding the medication and ensure that the proper consent is obtained before proceeding.