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HESI FUNDAMENTALS TEST 2021 GRADED A

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HESI FUNDAMENTALS TEST 2021 GRADED A>Fundamentals Hesi 1. The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance... of a quad cane. Which assessment finding has the greatest implications for this client's care? • The husband, who is the caregiver, begins to weep when the nurseasks how he is doing. • The client tells the nurse that she does not have much of an appetite today. • The nurse notes that there are numerous scatter rugs throughout the house. Correct • The client's pulse rate is 10 beats higher than it was at the last visit one week ago. Scatter rugs (C) pose a safety hazard because the client can trip on them when ambulating, so this finding has the greatest significance in planning this client's care. Psychological support of the caregiver (A) is a less acute need than that of client safety. The nurse needs to obtain more information about (B), but this is not a safety issue. (D) is not a significant increase, and additional assessment might provide information about the reason for the increase (anxiety, exercise, etc.). 2. The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? • Temperature increases from 98.8° to 99.0° F. • Pulse rate decreases from 78 to 52 beats/min. Correct • Respiratory rate increases from 16 to 24 breaths/min. • Blood pressure increases from 110/84 to 118/88 mm/Hg. Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure. [Show More]

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