HESI RN Adult Health (D444)

Correct Answer:

D. Oatmeal, banana, and herbal tea

Explanation

For a client with diarrhea, the diet should be bland, low in fat, and easy to digest. Bananas are part of the BRAT diet (bananas, rice, applesauce, toast), which helps bulk stools. Oatmeal provides soluble fiber, which absorbs excess fluid and improves stool consistency. Herbal tea avoids caffeine, which can worsen diarrhea. This selection is gentle on the digestive tract and supports recovery.

Why Other Options Are Wrong

A. Buttered whole wheat toast and coffee

Coffee contains caffeine, which stimulates the gastrointestinal tract and increases fluid loss. Butter adds unnecessary fat, which can worsen diarrhea.

B. Sausage, poached eggs, and milk

Sausage is high in fat and may irritate the GI tract. Eggs can be tolerated in moderation, but the high-fat meal combined with milk (which may worsen diarrhea if lactose intolerance develops) is not recommended.

C. Granola, strawberries, and tea

Granola is high in insoluble fiber, which increases stool bulk and worsens diarrhea. Strawberries contain seeds that can further irritate the bowel. Regular tea contains caffeine, which is not recommended.

Correct Answer:

C. Imbalanced Nutrition: less than body requirements

Explanation

The most immediate, life-threatening complication of anorexia nervosa is severe malnutrition, which can result in electrolyte imbalances, cardiac arrhythmias, multi-organ failure, and death. Therefore, the priority nursing problem is Imbalanced Nutrition: less than body requirements. Restoring adequate nutrition and stabilizing the client’s physical health must occur before addressing psychological, family, or compliance issues.

Why Other Options Are Wrong

A. Disturbed Body Image

This is an important psychological issue in anorexia nervosa but is not the immediate life-threatening priority. It is addressed after stabilization of nutrition and physical health.

B. Interrupted Family Processes

Family dynamics often contribute to and are affected by anorexia nervosa, but this is not as critical as correcting malnutrition to preserve life.

D. Noncompliance with treatment regimen

Noncompliance can hinder recovery, but it is not the first priority. The nurse must first intervene to correct nutritional deficits before focusing on adherence.

Correct Answer D. Reduce the client's pain

Explanation:

In hospice care, the primary focus is comfort and quality of life. For a client experiencing severe pain, the nurse’s priority is prompt pain relief. Concerns about long-term consequences like addiction are not relevant at the end-of-life stage. The goal is to alleviate suffering and maintain dignity through effective pain management.

Why Other Options Are Incorrect:

A. Prevent addiction

Addiction is not a primary concern in hospice care because the focus is on comfort and symptom control, not long-term dependency risks.

B. Determine why the medication is needed

In hospice care, severe pain reported by the client is reason enough for medication without unnecessary questioning or delay.

C. Provide alternative comfort measures

While nonpharmacologic measures can complement treatment, they should not replace rapid pharmacologic intervention for severe pain.

Correct Answer:

A. Assess urine and stool for occult blood

Explanation

A platelet count of 25,000/mm³ places the client at high risk for spontaneous bleeding. The most important nursing intervention is to monitor for bleeding, which may be internal and subtle, such as occult blood in urine or stool. Early detection allows timely intervention to prevent life-threatening hemorrhage.

Why Other Options Are Wrong

B. Obtain client's temperature every 4 hours

This is important for infection monitoring in neutropenia, but the immediate priority with thrombocytopenia this severe is bleeding risk.

C. Monitor for signs of activity intolerance

Activity intolerance is expected with leukemia and chemotherapy, but it is not life-threatening compared to the risk of hemorrhage from severe thrombocytopenia.

D. Require visitors to wear respiratory masks

Masking visitors is an infection-control measure useful for neutropenic precautions, not thrombocytopenia. The client’s greatest danger here is bleeding, not infection.

Correct Answer:

A. Just before arterial blood gasses are drawn peripherally

Explanation

The Allen’s test is performed to assess the adequacy of collateral circulation in the hand before puncturing the radial artery for arterial blood gas (ABG) sampling or for inserting a radial arterial line. The test ensures that if the radial artery is damaged or occluded, the ulnar artery can provide sufficient blood flow to the hand. This step is essential to prevent ischemic complications.

Why Other Options Are Wrong

B. Prior to attempting a cardiac output calculation

Cardiac output measurement is not related to peripheral arterial circulation in the hand and does not require an Allen’s test.

C. To assess for presence of a deep vein thrombus in the leg

Deep vein thrombosis (DVT) is evaluated with Doppler ultrasound, Homan’s sign (not recommended anymore), or venography, not with an Allen’s test.

D. When pulmonary artery pressures are obtained

Pulmonary artery pressure monitoring involves a Swan-Ganz catheter and does not require assessment of collateral circulation in the hand.

Correct Answer:

B. Ask the client about his expected goals for this hospitalization

Explanation

Palliative care focuses on improving quality of life and aligning treatments with the patient’s goals, values, and preferences. Radiation therapy can be a valid palliative intervention, often prescribed to relieve symptoms such as pain, bleeding, or obstruction. The nurse should first clarify the client’s understanding and expectations for hospitalization, ensuring that the care plan supports the client’s specific goals. This therapeutic approach empowers the client while maintaining a holistic, patient-centered perspective.

Why Other Options Are Wrong

A. Notify the radiation department to withhold the treatments for now

The nurse should not unilaterally cancel or delay prescribed therapy. Without first understanding the client’s goals and discussing them with the provider, withholding treatment could inappropriately interfere with care that might improve comfort.

C. Determine if the client wishes to cancel further radiation treatments

This approach presumes that radiation is inconsistent with palliative care. However, radiation may still meet palliative goals, such as pain relief. The first priority is to explore the client’s goals before presenting treatment options.

D. Explain that palliative care measures can be provided at home

While true, this does not address the client’s current hospitalization. The immediate responsibility is to clarify goals of care in the hospital, not to redirect the discussion toward home-based options.

Correct Answer:

A. Remain non-judgmental and assure the client of confidentiality

Explanation

When discussing sexually transmitted infections, the nurse’s priority is to establish trust and provide a safe environment for honest communication. Remaining non-judgmental and assuring confidentiality encourages the client to share sensitive information openly, which is essential for proper counseling, education, and treatment planning. This therapeutic approach promotes effective nurse-client communication and adherence to care.

Why Other Options Are Wrong

B. Provide counseling that most contraceptives protect against infection

This is inaccurate. While condoms can reduce transmission of some STIs, many contraceptives (like oral pills, IUDs, or implants) do not protect against infections. Providing false information could harm the client.

C. Clarify that all STIs are transmitted through sexual intercourse

Not all STIs are exclusively spread by intercourse; some can spread through blood (HIV, hepatitis B), perinatal transmission, or skin-to-skin contact (genital herpes, HPV). This statement is misleading.

D. Inform the client that complications will not result from reinfection

This is incorrect. Reinfection or repeated outbreaks of herpes can increase complications, such as more severe lesions, increased transmission risk, and neonatal herpes if the client becomes pregnant.

Correct Answer:

D. Ensure that the client is assigned to a room close to the nurses' station.

Explanation

Older adults with dementia often experience “sundowning,” where confusion, agitation, and restlessness worsen in the evening. The most important nursing intervention is to prioritize safety, as these clients are at risk for wandering, falls, or harm. Assigning the client to a room near the nurses' station ensures frequent observation, quicker response to needs, and better monitoring of behaviors. This proactive measure minimizes risk while still supporting therapeutic management.

Why Other Options Are Wrong

A. Ask family members to remain with the client in the evenings from 1700 to 2100

Family presence can provide comfort and reduce agitation, but it is not a consistently reliable intervention because family members may not always be available. Safety monitoring by nursing staff remains the priority.

B. Administer a prescribed PRN benzodiazepine at the onset of a confused state

Medication is not the first-line intervention because sedatives increase the risk of falls, confusion, and dependence in older adults. Nonpharmacologic measures and safety precautions are preferred before resorting to PRN drugs.

C. Postpone administration of nighttime medications until after 2300

Delaying medications does not address the underlying safety risk posed by evening confusion. In fact, it may disrupt treatment schedules and could worsen agitation if therapeutic medications are missed at the appropriate time.

Correct Answer: B. Capillary refill

Capillary refill is an important indicator of peripheral perfusion and hydration status. A delayed refill time suggests poor circulation due to intravascular fluid deficit. It is a quick, reliable, and noninvasive method to assess the severity of dehydration and guides the nurse in determining if the child is compensating or deteriorating.

Correct Answer: C. Temperature

Temperature must be monitored because fever contributes to increased insensible water loss through sweating and tachypnea. In children with dehydration, fever can quickly worsen fluid deficit, and tracking it helps the nurse adjust fluid replacement needs appropriately.

Correct Answer: D. Blood pressure

Blood pressure is a late but critical sign in pediatric dehydration assessment. Hypotension indicates severe volume depletion and progression toward decompensated shock. Because children often maintain normal blood pressure until late stages, monitoring it carefully is essential to identify advanced dehydration and circulatory compromise.

Correct Answer: E. Mucous membrane moisture and urine output

Moisture of oral mucous membranes and urine output are direct markers of hydration. Dry mucosa, absence of tears, and oliguria reflect significant fluid loss. These findings give the nurse concrete evidence of hydration status and are key components of focused dehydration assessment.

Correct Answer: H. Heart rate

Tachycardia is an early compensatory response to hypovolemia in children. It often appears before hypotension and signals worsening dehydration. Monitoring heart rate trends provides crucial information about the child’s volume status and the effectiveness of rehydration therapy.

Why Other Options Are Wrong

A. Level of consciousness

Although changes in alertness can occur with severe dehydration and shock, it is not the most specific or early indicator compared with perfusion and hydration measures such as heart rate and mucous membranes

F. Pupil size and reactiveness

This is used to assess neurologic function, not hydration status. It does not provide useful information about fluid deficit or volume replacement.

G. Skin turgor

Skin turgor can be unreliable in infants and young children due to elasticity differences, fever, and nutritional status. It may supplement assessment but is less accurate than capillary refill, mucous membranes, and urine output.