HESI CAT Exam Test Bank

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An adolescent male client is admitted to the hospital. Based on Erikson's theory of psychosocial development, which nursing intervention best assists this adolescent's adjustment to his hospital stay?

  • A. Invite him to participate in the evening group activity
  • B. Schedule frequent private phone calls to his parents
  • C. Provide access to a variety of video games in his room
  • D. Encourage him to learn his way around the hospital
Correct Answer: A

Rationale: Inviting the adolescent to participate in group activities aligns with Erikson's theory of psychosocial development, specifically the stage of developing social relationships. By engaging in group activities, the adolescent can interact with peers, fostering social skills and aiding in adjustment to the hospital environment.

Choice B is incorrect as excessive reliance on phone calls to parents may hinder the adolescent's autonomy and independence, which are crucial aspects of Erikson's theory for this age group. Choice C, providing access to video games, while potentially offering entertainment, does not directly address the need for social interaction and relationship-building. Choice D, encouraging the adolescent to learn his way around the hospital, is important for familiarity but may not directly address the need for social interaction and adjustment in the hospital setting.

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A female client is admitted for a diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet?

  • A. Understands the importance of timing insulin administration 30 minutes before eating
  • B. Frequently includes fruits and vegetables in meals and snacks
  • C. Has access to someone who can assist with meal preparation and monitoring
  • D. Demonstrates willingness to consistently follow the prescribed diet
Correct Answer: D

Rationale: The most crucial characteristic for successful adherence to a diabetic diet is the client's willingness to consistently follow the prescribed diet plan. Option A, understanding insulin timing, is important for treatment but not directly related to dietary adherence. Option B, consuming fruits and vegetables, is a healthy practice but does not ensure adherence to a specific diabetic diet. Option C, having assistance with meal preparation, is beneficial but not as essential as the client's personal commitment to adhering to the diet consistently.

A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

  • A. Check the visual difficulties
  • B. Note the most recent hemoglobin level
  • C. Assess for hand and joint pain
  • D. Observe rhythm on telemetry monitor
Correct Answer: D

Rationale: The correct answer is to observe the rhythm on the telemetry monitor. Decreased magnesium levels can lead to cardiac issues, such as arrhythmias. Monitoring the heart rhythm is crucial in this situation. Checking visual difficulties (choice A) is not directly related to the potential cardiac effects of low magnesium levels. Noting the hemoglobin level (choice B) and assessing for hand and joint pain (choice C) are not the priority when dealing with low magnesium levels and possible cardiac complications.

A client collapses while showering and is found by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next?

  • A. Follow the prompts of the AED
  • B. Apply the AED pads to the client's chest
  • C. Wipe the client's chest dry
  • D. Move the client from the bathroom
Correct Answer: B

Rationale: Applying the AED pads is the immediate next step after obtaining the AED in a cardiac arrest situation. Placing the pads correctly on the client's chest is crucial for the AED to analyze the heart rhythm accurately and deliver a shock if needed. Following the prompts of the AED comes after the pads are in place. Wiping the client's chest dry or moving the client from the bathroom are not priorities at this critical moment and may delay life-saving interventions.

Which entry in the client record best reflects significant data on a male client who is admitted with complaints of chest pain?

  • A. Nurse will check client q1h for the presence of chest pain
  • B. Client has a nervous, tense personality and is likely to overreact
  • C. Client states he will notify the nurse if chest pain returns
  • D. Client understands how to use the call button and the telephone
Correct Answer: C

Rationale: The correct answer is C because documenting the client's statement about notifying the nurse if chest pain returns provides direct, relevant information about their condition. This entry indicates the client's awareness of their symptoms and their willingness to seek assistance, which is crucial in managing chest pain. Choice A is incorrect because it focuses on the nurse's actions rather than the client's condition. Choice B is irrelevant as it discusses the client's personality rather than their current health issue. Choice D, though related to communication, does not directly address the client's chest pain complaint.

During discharge teaching, the nurse discusses the parameters for weight monitoring with a client recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

  • A. Weigh at the same time every day
  • B. Report weight gain of 2 pounds (0.9kg) in 24 hours
  • C. Maintain a daily weight record
  • D. Limit dietary salt intake
Correct Answer: B

Rationale: The correct answer is B. Reporting a weight gain of 2 pounds in 24 hours is crucial for detecting fluid retention or worsening heart failure. This rapid weight gain indicates possible fluid overload, which can be a sign of worsening HF. Option A is not as critical as the timing of weighing can vary. Option C is important for tracking trends but does not emphasize the significance of a sudden weight gain. Option D is relevant for managing HF but does not address the immediate need for reporting rapid weight gain.

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