HESI Level 1 Practice Exam

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Which assessment finding has the greatest implications for an elderly female client who had a stroke and can ambulate with a quad cane?

The husband, who is the caregiver, begins to weep when the nurse asks 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.

The presence of numerous scatter rugs throughout the house poses a significant safety risk for an elderly client who has had a stroke and is using a quad cane to ambulate. Scatter rugs can easily slip or move, which could lead to falls, especially for someone who may already have balance or mobility issues as a result of the stroke. Falls in the elderly can result in serious injuries, including fractures or head trauma, which may further complicate the client’s recovery and overall health.

In contrast, while the emotional state of the caregiver, the client’s reduced appetite, and slight changes in pulse rate are important aspects of holistic care—none of these findings indicate an immediate and significant risk to the client's safety. Monitoring emotional wellbeing and physical health are certainly important, but they do not carry the same direct implications for the client's physical safety as the assessment of the home environment does. Thus, the assessment of the scatter rugs is the most critical finding in this scenario.

The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

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