HESI RN Adult Health (D444)

Correct Answer C. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month

Explanation:

PCP is a common opportunistic infection in clients with AIDS, and recurrence is likely without ongoing prophylaxis. After treatment for an acute episode with IV pentamidine, monthly prophylactic doses of IV or aerosolized pentamidine are required to reduce the risk of recurrence. This maintenance therapy is essential for long-term infection control in immunocompromised patients.

Why Other Options Are Incorrect:

A. AZT therapy must be stopped when IV aerosol pentamidine is being used

Pentamidine therapy does not require discontinuation of antiretroviral drugs like AZT. These medications can be used concurrently to manage both HIV and opportunistic infections.

B. IV pentamidine will be given until oral pentamidine can be tolerated

Pentamidine is not given orally because it is poorly absorbed through the gastrointestinal tract; prophylaxis is administered via aerosol or IV route.

D. IV pentamidine may offer protection to other AIDS-related conditions such as Kaposi's sarcoma

Pentamidine is specifically effective against Pneumocystis jirovecii. It does not provide protection against malignancies such as Kaposi’s sarcoma or other opportunistic infections unrelated to PCP.

Correct Answer C. Give as ordered

Explanation:

Insulin glargine is a long-acting basal insulin that provides steady blood glucose control over 24 hours and does not peak like short-acting insulins. It is typically continued even when the patient is NPO to maintain basal insulin needs and prevent hyperglycemia or diabetic ketoacidosis. Since it is not tied to meal intake, it should be given as prescribed unless otherwise directed by the provider.

Why Other Options Are Incorrect:

A. Give half the dose

Adjusting the dose without provider orders is inappropriate and can cause inadequate glucose control.

B. Hold and notify the provider

Holding basal insulin unnecessarily can result in dangerous hyperglycemia and ketosis, especially in type 1 diabetes.

D. Change to regular insulin

Switching insulin types requires a provider’s order, and regular insulin has a different onset, peak, and duration, making it unsuitable as a substitute for basal coverage without specific instructions.

Correct Answer C. Monitor for signs of bleeding

Explanation:

Clients with chronic kidney disease (CKD) who are on hemodialysis have an increased risk of bleeding due to uremia-induced platelet dysfunction and the use of anticoagulants during dialysis. Monitoring for signs such as bruising, petechiae, prolonged bleeding from needle sites, or gastrointestinal bleeding is a critical safety intervention. Early recognition of bleeding complications helps prevent severe blood loss and related morbidity.

Why Other Options Are Incorrect:

A. Plan meals that include dark leafy vegetables:

Dark leafy vegetables are high in potassium, which can be dangerous for CKD patients because their kidneys cannot effectively excrete excess potassium, increasing the risk of life-threatening hyperkalemia. Potassium-rich foods must be restricted, not encouraged.

B. Use adult briefs to prevent skin breakdown:

This patient is anuric (no urine production), so using adult briefs is unnecessary and could actually promote skin irritation rather than prevent breakdown. Skin protection measures should be individualized and not automatically involve briefs.

D. Record strict urinary output:

Since the patient is anuric, urinary output measurement is not relevant. Instead, fluid management and monitoring for fluid overload (weight gain, edema, shortness of breath) are more appropriate for care planning.

Correct Answer:

A, B, D

Explanation of Correct Answers

A. Avoid prolonged standing or sitting

Prolonged immobility increases venous pressure and worsens blood pooling in the legs. Clients should be encouraged to move frequently to enhance venous return and reduce swelling.

B. Continue wearing compression stockings

Compression stockings are essential for improving venous return, preventing swelling, and minimizing complications of venous insufficiency. Clients should wear them as prescribed.

D. Use recliner for long periods of sitting

When extended sitting cannot be avoided, a recliner is preferable because it allows the legs to be elevated. Elevating the legs reduces venous pooling, promotes better circulation, and helps manage symptoms.

Why Other Options Are Wrong

C. Cross legs at knee but not at ankle

Crossing the legs in any position impedes venous return and should be avoided completely.

E. Maintain the bed flat while sleeping

The bed should not remain flat, as this does not support venous return. Elevating the legs during rest or sleep helps decrease venous pressure and improve circulation.

Correct Answer:

A. Place a bedside commode next to bed, B. Measure neurological vital signs every 4 hours, D. Encourage family to participate in the client's care

Explanation of Correct Answers

A. Place a bedside commode next to bed

Mobility is often impaired following a stroke, and a bedside commode helps reduce fall risk, promotes independence, and preserves dignity.

B. Measure neurological vital signs every 4 hours

Even after the acute phase, ongoing neurological checks are necessary to monitor for complications, such as increased intracranial pressure or recurrent stroke. This remains a key nursing responsibility.

D. Encourage family to participate in the client's care

Family participation enhances emotional support, promotes recovery, and helps prepare caregivers to assist with long-term rehabilitation after discharge.

Why the Other Options Are Wrong

C. Suction oral cavity every 4 hours

Suctioning should only be performed as needed. Routine suctioning increases the risk of trauma and infection and is not appropriate in rehabilitation unless secretions are excessive.

E. Play classical music in room while client is resting

Music therapy may provide comfort, but it is not a standard, evidence-based intervention in stroke rehabilitation plans. It may be used as an adjunct, not a primary nursing priority.

Correct Answer D. Infection

Explanation:

In older adults, the typical symptoms of hyperglycemia—such as polyuria, polydipsia, and unexplained weight loss—may be absent or less noticeable due to age-related changes in renal function, thirst perception, and metabolism. Instead, infections (especially urinary tract infections, skin infections, and pneumonia) are often the most prominent presenting symptom. Hyperglycemia impairs immune function, making older adults more susceptible to infections, which may be the first or only sign prompting evaluation.

Why Other Options Are Incorrect:

A. Polyuria

While increased urination is a classic symptom of hyperglycemia, older adults may not develop obvious polyuria because of decreased kidney concentrating ability and possible concurrent conditions such as urinary incontinence, which can mask this sign.

B. Polydipsia

Older adults often have a decreased thirst mechanism, so even with significant hyperglycemia and fluid loss, they may not report excessive thirst. This makes polydipsia a less reliable indicator of hyperglycemia in this population.

C. Weight loss

Although weight loss can occur in uncontrolled hyperglycemia, it tends to be a more gradual symptom and may be overlooked in older adults, especially if they have multiple comorbidities or are already underweight. It is less likely to be the initial presenting concern compared to infection

Correct Answer A. Notify the health care provider about the client's symptoms

Explanation:

The client’s presentation—severe abdominal pain, faintness, thready rapid pulse—suggests possible postoperative complications such as hemorrhage or hypovolemic shock rather than uncontrolled pain alone. These symptoms indicate a potentially life-threatening condition requiring immediate evaluation and intervention. The nurse’s priority is to recognize these warning signs, stop routine actions, and notify the health care provider promptly. Timely communication can lead to rapid diagnostic and life-saving measures, including fluid resuscitation, blood transfusion, or emergency surgery. Addressing the underlying cause is more important than providing additional pain medication at this stage.

Why the Other Options Are Incorrect:

B. Explain to the client that it is too early to have an injection for pain

Simply telling the client it is too early for pain medication delays addressing a potentially life-threatening cause of the symptoms. This response neglects the urgent assessment and intervention required in this situation.

C. Reposition the client for greater comfort and turn on the television as a distraction

Nonpharmacological comfort measures are not appropriate when the client’s symptoms suggest shock. Delaying emergency assessment and treatment could cause rapid deterioration.

D. Prepare the injection to administer it to the client early because of the severe pain

Giving pain medication without addressing the cause of faintness and a thready rapid pulse can mask symptoms and delay diagnosis of serious complications like hemorrhage. It does not address the underlying problem and could worsen hypotension if present.  

Correct Answer:

D. Risk for self-directed violence as evidenced by feelings of hopelessness

Explanation

The priority nursing problem is the client’s risk for self-directed violence. The client is expressing classic depressive symptoms (anhedonia, worthlessness, weight loss, and loss of appetite), but feelings of worthlessness and hopelessness place her at high risk for suicide. According to Maslow’s hierarchy and the nursing process, client safety and survival must come before all other problems. This means suicide risk assessment and safety interventions are the first priority.

Why Other Options Are Wrong

A. Anxiety as evidenced by abdominal complaints secondary to depression

Although anxiety may be present, it is not life-threatening. The client’s risk of self-harm outweighs the need to address anxiety first.

B. Imbalanced nutrition as evidenced by 25 pound (11 kg) weight loss in four months

Weight loss is a concern, but it does not take priority over immediate threats to life, such as suicide risk. Nutritional needs can be addressed after ensuring safety.

C. Chronic low self-esteem as evidenced by feelings of worthlessness

Feelings of worthlessness are concerning and linked to depression, but the possibility of self-harm requires more urgent intervention than addressing self-esteem.

Correct Answer C. The client smokes one to two packs of cigarettes per day.

Explanation:

Cigarette smoking is the most significant and preventable risk factor for the development of COPD. Long-term exposure to tobacco smoke damages the cilia, causes chronic airway inflammation, and leads to structural changes in the lungs such as emphysema and chronic bronchitis. The risk increases with the number of cigarettes smoked per day and the duration of smoking history. Smoking cessation is the most effective intervention for slowing COPD progression.

Why Other Options Are Incorrect:

A. The client's father was diagnosed with COPD in his 50s

While genetic factors (such as alpha-1 antitrypsin deficiency) can predispose individuals to COPD, they are far less common than smoking-related causes.

B. A close family member contracted tuberculosis last year

Tuberculosis can cause lung scarring, but it is not a leading cause of COPD.

D. The client has been 40 pounds overweight for 15 years

Obesity can contribute to respiratory difficulty but is not a direct cause of COPD.