Health Assessment HESI Exam with Complete Solutions

The RN is caring for an older client who has been bedridden for 2 weeks. What assessment finding indicates that the client is developing a complication related to imobility? - ️️Stiffness in joints is an early sign of contractures and muscle atrophy related to inactivity and immobility. The RN is developing a plan of care for a client who is admitted for alcohol detoxification. Which goal should be most important for the RN to primarily focus the client's care? A. The client maintains optimal nutritional status. B. The client will remain alert and oriented. C. The client will remain free from injury. D. The client will remain alcohol free during hospitalization. - ️️The client is at highest risk for injury due to altered cognitive and sensory disturbances as well as tremors during withdrawal. Remaining free from injury (C) is the most important goal for the acute phase of alcohol withdrawal. (A, B, and D) are important goals to obtain during the client's stay but not the priority during the acute phase of withdrawal from alcohol. What action should the RN implement to complete an assessment for a client while using an interpreter? - ️️When completing an assessment, the RN should maintain eye contact with the client to gather additional information from the client's non-verbal cues.