HESI RN Adult Health (D444)

Correct Answer:

B. Cervical spine stiffness

Explanation

Cervical spine stiffness, when paired with confusion, is a red-flag neurological symptom that can indicate meningeal irritation. In a client with diabetes, this could suggest central nervous system infection such as meningitis, which requires immediate recognition and urgent intervention. Confusion alone can have many causes, but when combined with neck stiffness, it signals a serious complication beyond metabolic issues, warranting rapid evaluation and treatment.

Why Other Options Are Wrong

A. Blood pressure 130/80 mm Hg

This is a normal reading for an adult and does not indicate a complication. It would not explain the episodes of confusion.

C. Dark yellow urine

This finding may indicate mild dehydration but is not a direct cause of acute confusion and does not represent a serious complication in this scenario.

D. Excessive perspiration

While sweating can indicate hypoglycemia in diabetes, it is not present in this option’s scenario. Cervical spine stiffness carries a higher risk for a life-threatening complication compared to perspiration alone.

Correct Answer:

D. An 11-year-old with a headache, nausea, and projectile vomiting

Explanation

Projectile vomiting following a head injury is a red flag for increased intracranial pressure (ICP). This can rapidly become life-threatening if not addressed immediately. The child requires urgent intervention to prevent brain herniation or further neurologic deterioration.

Why Other Options Are Wrong

A. A 12-year-old reporting neck, arm, and lower back discomfort

This child may have a musculoskeletal injury or possible spinal involvement, which requires evaluation, but the presentation is stable and not immediately life-threatening compared to signs of increased ICP.

B. An 8-year-old with a full leg air splint for a possible broken tibia

The splint suggests stabilization is already in place. This is a serious but not emergent condition compared to neurologic compromise.

C. A 6-year-old with multiple superficial lacerations of all extremities

Although painful and requiring wound care, superficial lacerations are not immediately life-threatening.

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:

D. Increasing confusion of the client

Explanation

In SBAR communication, the Situation comes first — the most urgent, immediate concern about the client’s condition. In this case, the client’s increasing confusion is the priority to report first, since it represents an acute change in mental status that may indicate worsening heart failure, hypoxia, infection, or medication side effects. Clear, concise communication of the urgent problem ensures rapid provider attention.

Why Other Options Are Wrong

A. Currently prescribed medications

Medication history belongs in the Background portion of SBAR, not the opening statement.

B. Fall at home as reason for admission

The fall is part of the Background, providing context, but it is not the immediate issue to address first.

C. Client's healthcare power of attorney

This is important information for planning care but is not urgent clinical data. It belongs in Background or when discussing legal/decision-making matters.

Correct Answer:

C. Experiences facial swelling after eating crab

Explanation

Facial swelling after eating crab suggests a possible shellfish allergy. This is critically important before angioplasty because the contrast dye used in cardiac catheterization is iodine-based and may trigger severe allergic reactions in clients with shellfish or iodine allergies. Exploring this report ensures appropriate premedication or an alternative diagnostic approach is used to prevent anaphylaxis.

Why Other Options Are Wrong

A. Drank a glass of water in the past 2 hours

Drinking a small amount of water before a procedure is generally not a major concern. Fasting status is important, but this is not the most urgent risk compared to an allergy to contrast dye.

B. Reports left chest wall pain prior to admission

Chest pain is significant, but the procedure is being performed to address cardiac issues. Previous pain history does not delay the angioplasty preparation as much as a potential life-threatening allergic reaction would.

D. Verbalizes a fear of being in a confined space

Claustrophobia should be acknowledged and managed with reassurance or medication if necessary, but it does not present the same immediate, life-threatening risk as an allergy to contrast dye.

Correct Answer C. High levels of carbon dioxide have accumulated in the blood

Explanation:

Respiratory acidosis occurs when the lungs cannot adequately remove carbon dioxide (CO₂), leading to hypercapnia. CO₂ combines with water to form carbonic acid, lowering blood pH. This is commonly caused by hypoventilation from conditions like COPD, severe asthma, or respiratory muscle weakness. The accumulation of CO₂ in the blood is the primary mechanism behind respiratory acidosis.

Why Other Options Are Incorrect:

A. Hyperventilation is eliminating carbon dioxide rapidly:

This describes respiratory alkalosis, not acidosis. Rapid CO₂ elimination increases blood pH, which is the opposite of the problem in respiratory acidosis.

B. Blood oxygen levels are stimulating the respiratory rate:

While hypoxemia can stimulate breathing, respiratory acidosis is primarily related to CO₂ retention, not oxygen levels directly. Low oxygen may be present, but it is not the cause of acidosis.

D. Carbon dioxide is converted in the kidneys for elimination:

The kidneys do not convert CO₂ for elimination. They compensate for acidosis by retaining bicarbonate and excreting hydrogen ions, but this is a secondary response, not the primary pathophysiological cause.

Correct Answer:

D. Administer an IV analgesic

Explanation

The client is showing classic signs of severe, uncontrolled postoperative pain: tachycardia, tachypnea, hypertension, pallor, and verbal complaint of intense abdominal pain. The most important nursing intervention is to administer an IV analgesic as prescribed to manage pain effectively. Untreated acute pain can lead to complications such as increased cardiac workload, impaired ventilation, and delayed healing. Because the client has a functioning IV (as evidenced by IV fluids or medications already being administered postoperatively), the priority is to relieve pain immediately.

Why Other Options Are Wrong

A. Provide pillow for splinting

This may offer minor comfort but is insufficient for severe pain control.

B. Assess the IV site for patency

IV patency is a prerequisite, but in the context of immediate postoperative care, IV access is already assumed functional. The priority is to deliver analgesia, not reassess IV patency.

C. Place in a high Fowler position

Positioning may improve comfort but does not address the urgent need for pain relief.

E. None

Intervention is absolutely required; leaving the client untreated would worsen distress and risk complications.

Correct Answer:

D. A tuna fish sandwich with chips and ice cream

Explanation

Protein is essential for wound healing as it promotes collagen formation, tissue repair, and immune support. Tuna fish is a high-quality protein source that makes option D the best choice. While chips and ice cream are not nutrient-dense, the inclusion of tuna provides a sufficient protein contribution to aid recovery.

Why Other Options Are Wrong

A. A salad with three kinds of lettuce and fruit

This option is rich in vitamins and fiber but provides very little protein, making it inadequate for promoting wound healing.

B. Vegetable soup, crackers, and milk

While milk provides some protein, the overall meal is still too low in protein to support optimal wound healing compared to tuna fish.

C. A peanut butter sandwich with soda and cookies

Peanut butter contains some protein, but this meal is dominated by refined carbohydrates and sugar, making it insufficient to meet increased protein needs.

Correct Answer:

C. Average client scores improved on specific risk factor knowledge tests

Explanation

Primary prevention focuses on preventing disease before it occurs through education, risk-reduction strategies, and health promotion. Improved client knowledge of risk factors and preventive practices—demonstrated by higher test scores—shows that the program successfully reduced the likelihood of new sexually transmitted disease (STD) cases.

Why Other Options Are Wrong

A. New screening protocols were developed, validated, and implemented

This is part of secondary prevention, which focuses on early detection of disease through screening.

B. Clients who incurred disease complications promptly received rehabilitation

This reflects tertiary prevention, which addresses limiting disability and restoring function after disease complications occur.

D. More than half at risk clients were diagnosed early in the disease process

Early diagnosis is also secondary prevention, not primary prevention. The goal of primary prevention is to stop infection before it develops.