HESI RN Adult Health (D444)

Correct Answer:

C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client

Explanation

Droplet precautions, such as those used for influenza, require a standard surgical mask, not a particulate filter mask (N95 respirator). An N95 respirator is required for airborne precautions (e.g., tuberculosis, measles, varicella). Since the client has flu-like symptoms and is on droplet precautions, a standard face mask provides adequate protection. The UAP can safely provide care with droplet-appropriate PPE.

Why Other Options Are Wrong

A. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client

This is unnecessary because droplet precautions do not require an N95 respirator.

B. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care

This is misleading because a particulate filter mask is not needed for droplet precautions. The standard mask is sufficient for all care.

D. Before changing assignments, determine which staff members have fitted particulate filter masks

This implies that only staff with respirators can provide care, which is incorrect. Droplet precautions do not require particulate filter masks.

Correct Answer C. Knee and hip joint pain

Explanation:

Long-term corticosteroid use after a kidney transplant can lead to avascular necrosis (osteonecrosis) of large joints such as the knees and hips. This condition results from compromised blood flow to bone tissue, causing pain and potential joint collapse. Early recognition of new or worsening joint pain is important so treatment can be initiated promptly to preserve joint function and mobility.

Why Other Options Are Incorrect:

A. Postural hypotension

This is more commonly associated with adrenal insufficiency or dehydration, not with the adverse effects of corticosteroid therapy in transplant patients.

B. Recurrent tachycardia

Tachycardia may result from infection, anemia, or fluid imbalance, but it is not a typical adverse effect of corticosteroid use.

D. Hypoglycemia

Corticosteroids tend to raise blood glucose levels, leading to hyperglycemia rather than hypoglycemia, especially in transplant patients who require high doses.

Correct Answer D. Immediate passive short-term immunity

Explanation:

Tetanus immune globulin provides passive immunity by supplying ready-made antibodies against the tetanus toxin. This protection is immediate but short-term, lasting only a few weeks to months, because the body is not producing its own antibodies. It is used when rapid protection is needed, such as after a high-risk injury in someone with unknown or incomplete immunization history.

Why Other Options Are Incorrect:

A. Lifelong passive immunity

Passive immunity is always temporary; antibodies will degrade over time. It never provides lifelong protection.

B. Long-lasting active protection

Active protection occurs when the body produces its own antibodies after vaccination or illness, which tetanus immune globulin does not stimulate.

C. Stimulation of antibody production

This describes active immunity from a tetanus toxoid vaccine, not immune globulin. Immune globulin only transfers existing antibodies; it does not trigger production of new ones.

Correct Answer:

D. Somnambulism

Explanation

Ramelteon is a melatonin receptor agonist used for insomnia related to sleep-onset difficulties. Common side effects include mild sedation, dizziness, or changes in sleep patterns. However, somnambulism (sleepwalking) is a severe adverse effect that poses safety risks to the client and requires prompt reporting to the healthcare provider. Monitoring and intervention are necessary because of the potential for injury during episodes of sleepwalking.

Why Other Options Are Wrong

A. Dizziness reported after initial dose

Dizziness is a common, usually mild, side effect of ramelteon. It does not require immediate reporting unless it worsens or leads to falls.

B. A change in the sleep-wake cycle

This is expected, as ramelteon alters circadian rhythm regulation to promote sleep. It is a therapeutic effect rather than a dangerous side effect.

C. Mild sedation

Sedation is the desired pharmacologic action of ramelteon, not a complication. It indicates the medication is working as intended.

Correct Answer C. Antibodies are made after an antigen is injected into the body.

Explanation of Correct Answer:

Artificial active immunity occurs when an antigen—such as a weakened, killed, or inactivated microorganism—is deliberately introduced into the body through immunization. The immune system recognizes the antigen as foreign and responds by producing antibodies and memory cells. This process trains the immune system to recognize and fight the pathogen in the future, providing long-term protection.

Why the Other Options Are Incorrect:

A. Antibodies are passed from one person to another

This describes passive immunity, not active immunity. In passive immunity, the recipient gains antibodies without producing them, such as through breast milk or antibody injections.

B. Antibodies against an antigen are produced naturally in the body

This refers to natural active immunity, which occurs after direct exposure to a pathogen (e.g., getting sick from measles), not through deliberate injection.

D. Antibodies produced by one body or animal are transferred to another body or animal

This describes artificial passive immunity, such as giving antitoxins or immune globulin. The recipient gains immediate but temporary protection without producing their own antibodies.

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 Answers:

A. Anxiety

B. Palpitations

C. Weight loss

Explanation of Correct Answers:

A. Anxiety

Cocaine stimulates the central nervous system, increasing dopamine levels and leading to heightened alertness and energy. Overstimulation can produce anxiety, restlessness, and irritability, which are common in individuals with cocaine addiction.

B. Palpitations

Because cocaine causes cardiovascular stimulation by increasing heart rate and blood pressure, palpitations are a frequent symptom. The drug's vasoconstrictive effects can also increase the risk of arrhythmias and myocardial infarction.

C. Weight loss

Cocaine suppresses appetite by affecting the hypothalamus, leading to decreased food intake and eventual weight loss. Chronic users often show signs of malnutrition along with noticeable weight reduction.

Why the Other Options Are Incorrect:

D. Sedentary habits

Cocaine use generally increases energy and activity levels rather than causing sedentary behavior. Users may display hyperactivity, restlessness, or repetitive movements instead of inactivity.

E. Difficulties with speech

Speech difficulties are not a hallmark symptom of cocaine use. While extreme intoxication or neurological damage from long-term use can impair coordination, typical effects involve rapid, pressured speech rather than speech difficulty.

Correct Answer D. Encourage the client to keep taking the drug until seen by the health care provider.

Explanation:

A persistent, dry cough is a common side effect of ACE inhibitors due to increased bradykinin levels. While it is often not dangerous, it can be bothersome and may require switching to another medication (such as an ARB). The nurse should advise the client to continue the medication until evaluated by the health care provider to avoid uncontrolled hypertension or other complications.

Why Other Options Are Incorrect:

A. Advise the client to come to the clinic immediately for further assessment.

An immediate visit is not required unless there are signs of a serious reaction such as angioedema, shortness of breath, or swelling of the face and throat.

B. Instruct the client to discontinue use of the drug and to make an appointment at the clinic.

Stopping the drug abruptly without medical supervision can lead to uncontrolled blood pressure and potential cardiovascular complications.

C. Suggest that the client learn to accept the cough as a side effect to a necessary prescription.

While the cough is a known side effect, it may be intolerable for some clients, and there are alternative medications. Dismissing the symptom is not appropriate without considering other options.

Correct Answer:

D. Explain to mother that the finding is due to increased androgen

Explanation

In congenital adrenal hyperplasia (CAH) caused by 21-hydroxylase deficiency, the adrenal glands cannot produce sufficient cortisol and aldosterone. As a result, excess adrenal androgens are produced, leading to virilization of female genitalia, such as clitoral enlargement. The nurse should provide clear, supportive education to the mother, explaining that the finding is due to elevated androgen levels. This helps reduce parental anxiety and supports understanding of the condition.

Why Other Options Are Wrong

A. Review transcutaneous bilirubin levels with a bilirubinometer

Bilirubin measurement is used to assess for jaundice. Clitoral enlargement in CAH is unrelated to bilirubin metabolism and does not require this intervention.

B. Observe and palpate newborn's breast tissue for enlargement

Breast tissue enlargement may occur in newborns due to maternal hormones but has no connection to clitoral enlargement in CAH. This assessment does not address the current finding.

C. Assess for signs of fluid retention and bilateral pedal edema

Salt-wasting CAH is associated with dehydration, hyponatremia, and hyperkalemia, not fluid retention. Pedal edema is not expected and is not relevant to the finding of clitoral enlargement.