HESI

A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. Which diet can the nurse expect will be prescribed for this client based upon the assessment? No protein Moderate protein High protein Strict protein restriction

Moderate protein (Because the liver is unable to detoxify ammonia to urea and the client is experiencing impending hepatic encephalopathy coma, protein intake should be moderate.)

Which hormone overproduction is associated with carpel tunnel syndrome in clients? Growth hormone Antidiuretic hormone Parathyroid hormone Aldosterone hormone

Overproduction of growth hormone is associated with carpel tunnel syndrome Antidiuretic hormone overproduction can result in syndrome of inappropriate antidiuretic hormone Overproduction of parathyroid hormone results in hyperparathyroidism

Which cells does the nurse identify as producing thyrocalcitonin hormone? Islet cells Adrenal cells Pituitary cells Parafollicular cells

Parafollicular cells

A nurse reviews the laboratory results of a client with acute pancreatitis. Which test is most significant in determining the client's response to treatment? Platelet count Amylase level Red blood cell count Erythrocyte sedimentation rate

amylase level rationale: in PTs with acute pancreatitis, the amylase level is elevated up to 3x baseline

What does the presence of ketones in the urine of a client with renal dysfunction indicate? Cystitis Heart failure Urinary calculi Anorexia nervosa

anorexia body produces ketones as an alternate source of fuel for muscles and organs in people w/ anorexia

Which structure lies inside and parallel to the sclera? Lens Choroid Conjunctiva Ciliary processes

choroid

A nurse is caring for a client with Addison disease. Which dietary instruction should the nurse teach the client to follow? Add extra salt to food Consume high-potassium foods Omit protein foods at each meal Restrict the daily intake of fluids to 1 L

add extra salt to food rationale: PTs with Addisons are prone to developing hyponatremia

The nurse is teaching a nursing student about the use of magnetic resonance imaging (MRIs). Which statement of the nursing student indicates effective learning? "Clients with claustrophobia can have an MRI." "Clients who are allergic to iodine should not have an MRI." "Clients with pacemakers can have an MRI." "Clients with surgical clips can go through an MRI."

"Clients with claustrophobia can have an MRI." (MRIs do not involve the use of iodine or iodized products, so any clients allergic to iodine can still undergo the procedure.)

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma? 6 9 12 15

6 score of 8 or below indicates coma

During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A. Prepare the client for a pericardial tap. B. Administer intravenous furosemide (Lasix). C. Assist the client to cough and breathe deeply. D. Instruct the client to restrict oral fluid intake.

A. Prepare the client for a pericardial tap. (PT is exhibiting symptoms of a cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in CO tx is pericardial tap)

Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)? A. Provide a room that can be kept warm. B. Make sure that the room can be kept dark. C. Keep the client close to the nursing unit. D. Select a room that is visible from the nurses' desk.

A. Provide a room that can be kept warm. (Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma.)

Which nursing action would be most effective in reducing complications in an older client who has decreased cell division in the epidermal layer of the skin? Advising the client to prevent skin trauma Advising the client to protect open areas Assessing for excessive dryness or moisture Handling the client carefully to reduce skin friction Advising the client to change positions every 2 hours

Advising the client to prevent skin trauma Advising the client to protect open areas

Which hormone synthesis does the nurse state is inhibited by hypokalemia? Aldosterone Somatostatin Norepinephrine Androstenedione

Aldosterone Hypokalemia inhibits synthesis of aldosterone hormone. Somatostatin inhibits the synthesis of insulin. Norepinephrine also inhibits the synthesis of insulin

On the first day after a right pneumonectomy, a client suddenly sits straight up in bed. The client's respirations are labored, and a crowing sound is audible. The client's skin is pale, cool, and moist. Which action is priority? The client's skin is pale, cool, and moist. Which action is priority? Notify the primary healthcare provider Check the chest tube for patency Inspect the incision for bleeding Auscultate the left lung

Auscultate the left lung (A mediastinal shift with airway obstruction may occur because pressure builds up on the operative side, causing the trachea to deviate toward the nonoperative side; assessment of the airway takes priority.)

The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home.

B A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad B. Broiled fish, green beans, and an apple C. Pork chops, macaroni and cheese, and grapes D. Avocado salad, milk, and angel food cake

B Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet

A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A. Immediately after feeding B. Just prior to tube feeding C. Continuous inflation is required D. Inflation is not required

B. Just prior to tube feeding (The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system.)

During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose levels. D. Evaluate the client's oxygen saturation and breath sounds.

C. Monitor the client's serum potassium and blood glucose levels. PTs with tumor lysis syndrome have hyperkalemia and need insulin to reduce the serum K+ level

A client with an obstruction of the pancreatic ducts has been diagnosed with acute pancreatitis. The client's physical condition continues to deteriorate despite supportive care, and a subtotal pancreatectomy is performed. The nurse should monitor the client for what postoperative complication? Constipation Cholecystitis Paralytic ileus Respiratory distress

Paralytic ileus (A paralytic ileus may occur because of the surgical manipulation of the gastrointestinal tract.)

A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5." Which intervention should the nurse implement? A. Give the medication as prescribed to decrease the client's pain. B. Call the anesthesia provider for a different medication for pain. C. Use nonpharmacologic techniques before giving the medication. D. Reassess the pain level in 30 minutes and medicate if it remains elevated.

Call the anesthesia provider for a different medication for pain. rationale: morphine is a histamine-releasing opioid and should be avoided in PTs with asthma

A client is admitted to the hospital for surgery for a laparoscopic cholecystectomy. To monitor the flow of bile to the gastrointestinal tract, what symptom should the nurse assess? Color of the stool Presence of peristalsis Bleeding at the operative site Presence of cholesterol intolerance

Color of the stool (As edema of the common bile duct subsides, bile flows to the duodenum and gives stool its characteristic brown color. Peristalsis may affect the consistency of the stool but not the color.)

An exploratory laparotomy is performed on a client with melena, and gastric cancer is discovered. A partial gastrectomy is performed, and a jejunostomy tube is surgically implanted. A nasogastric tube to suction is in place. What should the nurse expect regarding the client's nasogastric tube drainage during the first 24 hours after surgery? Minimal to no drainage Contains some blood and clots Contains large amounts of frank blood Similar to coffee grounds in color and consistency

Contains some blood and clots (Coffee ground material results from blood that has been digested by the gastric acid; gastric bleeding with a nasogastric tube in place will be red because gastric acids will not have time to act on the blood.)

Which type of drug-induced hormonal imbalance is likely to be observed in the client undergoing treatment with demeclocycline? Acromegaly Diabetes mellitus Diabetes insipidus Cushing's syndrome

DI rationale: interferes with response of kidneys to ADH

Which drug can cause diabetes insipidus? Cabergoline Metyrapone Demeclocycline Aminoglutethimide

Demeclocyline

A nurse is assessing the skin of a client with a cortisol deficiency. Which integumentary assessment finding will most likely be observed in this client? Dry skin Ulcerated skin Generalized edema Diminished axillary hair

Diminished axillary hair (Clients with cortisol deficiencies will have diminished axillary and pubic hair. Dry skin is associated with hypothyroidism. Ulcerated skin is a sign of peripheral neuropathy and peripheral vascular disease. Generalized edema is seen in clients with hypothyroidism)

A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? Question the client about the confusion. Change the method of oxygen delivery. Percuss and vibrate the client's chest wall. Discontinue or decrease the oxygen flow rate.

Discontinue or decrease the oxygen flow rate. (With emphysema, it is believed that the respiratory center no longer responds to elevated carbon dioxide as the stimulus to breathe but rather to lowered oxygen levels; therefore, the oxygen being delivered must be lowered to supply enough for oxygenation without being so elevated that it negates the stimulus to breathe.)

A client is admitted with a tentative diagnosis of pneumonia. On admission the client is not in respiratory distress, but later develops chest pain and a fever of 103° F (39.4° C). A productive cough produces rust-colored sputum. How should the nurse interpret these findings? Onset of pulmonary edema Expected course of pneumonia Presence of a pulmonary embolus Insidious onset of tuberculosis (TB)

Expected course of pneumonia (Chest pain, fever, productive cough, and rust-colored sputum are cardinal signs of pneumonia. Chest pain results from excessive coughing; fever, increased sputum, and rust-colored sputum result from the infectious process)

A client has a tentative diagnosis of Cushing syndrome. What physical symptoms will the client exhibit? Fever and tachycardia Lethargy and constipation Hypertension and moon face Hyperactivity and exophthalmos

HTN and moon face Increased glucocorticoids cause sodium and water retention, hypertension, and fat deposition, resulting in a moon face.

The client with emphysema complains of increased shortness of breath and becomes anxious. The healthcare provider prescribes oxygen at 1 L/min via nasal cannula. The nurse understands that this prescription is appropriate for what reason? High concentrations of oxygen cause alveoli to rupture. High concentrations of oxygen eliminate the respiratory drive. The client does not need any more than 1 L/min. The oxygen at 1 L/min should be enough to diminish the anxiety.

High concentrations of oxygen eliminate the respiratory drive. (Clients with emphysema are used to low levels of oxygen and high levels of carbon dioxide. Oxygen is the stimulus for breathing for these clients instead of the natural breathing stimulus. Too much oxygen will knock out the stimulus to breathe.)

A nurse who is caring for a client after head and neck surgery is concerned with the client's anger and depressive episodes about the effects of surgery. Which action indicates the client is reaching acceptance?Smiling and becoming more extroverted Performing self-care of the tracheal stoma Ambulating in the hall and sitting in the lounge Allowing a family member to participate in care

Performing self-care of the tracheal stoma (best indicator of acceptance is participating in self care)

A client is admitted to the hospital with a history of cancer of the liver and jaundice. In relation to the jaundice, the nurse expects the client to report the presence of what symptom? Pruritus Diarrhea Blurred vision Bleeding gums

Pruritus (Itching associated with jaundice is believed to be caused by accumulating bile salts in the skin)

Which hormone is released from the pancreas? Oxytocin Prolactin Calcitonin Somatostatin

Somatostatin rationale: produced by pancreas and inhibits release of insulin and glucagon

Which explanation should the nurse consider when formulating a response to a client's inquiry about intussusception of the bowel? Kinking of the bowel onto itself A band of connective tissue compressing the bowel Telescoping of a proximal loop of bowel into a distal loop A protrusion of an organ or part of an organ through the wall that contains it

Telescoping of a proximal loop of bowel into a distal loop

A client with oat-cell lung cancer is scheduled for a mediastinoscopy and biopsy. What should the nurse include in the client's education? Chest tubes will be in place after the procedure. The procedure will visualize the mainstem bronchus. Some pleural fluid will be removed during the procedure. The procedure is an endoscopic examination of lymph nodes.

The procedure is an endoscopic examination of lymph nodes (A mediastinoscopy is an endoscopic examination of mediastinal lymph nodes through a small suprasternal incision)

After reviewing the client's laboratory reports, the physician concludes that the client has primary hypofunction of the adrenal gland. Which clinical manifestation is likely to be observed in that client? Edema at extremities Uneven patches of pigment loss Reddish-purple stretch marks on the abdomen "Buffalo hump" between shoulders on the back

Uneven patches of pigment loss rationale: vitiligo is caused by hypofunction of the adrenal gland. Straie and buffalo hump is from excessive adrenocortical secretions

Which diagnostic test is performed under general anesthesia to detect non-Hodgkin lymphoma and requires the client to sign an informed consent form? A thoracentesis A bronchoscopy A mediastinoscopy Computed tomography (CT)

a mediastinoscopy

Which hormone does the nurse state is formed from cholesterol? Insulin Cortisol Prolactin Growth hormone

cortisol

While assessing a client during a routine examination, a nurse in the clinic identifies signs and symptoms of hyperthyroidism. Which signs are characteristic of hyperthyroidism? Diaphoresis Weight loss Constipation Protruding eyes Cold intolerance

diaphoresis weight loss protruding eyes diarrhea

A nurse is providing postoperative care for a client one hour after an adrenalectomy. Maintenance steroid therapy has not begun yet. The nurse should monitor the client for which complication? Hypotension Hyperglycemia Sodium retention Potassium excretion

hypotension hypotension occurs until the hormone level is controlled by replacement therapy

What information should the nurse include in a discharge teaching plan for a client who recently had a laryngectomy? Limit the daily intake of fluids. Keep the stoma covered with a scarf. Only humidified air should be breathed. Mucus plugs can be removed with cotton-tipped swabs.

keep the stoma covered with a scarf (prevents particles of dirt and insects from entering)

What does the nurse state as the etiological factor of nephrogenic diabetes insipidus (DI)? Meningitis Lithium therapy Graves' disease Sulfonamide therapy

lithium therapy

The nurse is observing an unlicensed assistive personnel (UAP) performing morning care for a bedridden client with Huntington disease. Which care measure is most important for the nurse to supervise? A. Oral care B. Bathing C. Foot care D. Catheter care

oral care PTs w/ Huntingtons have problems w/ motor skills such as swallowing and are at high risk for aspiration

Which hormones are secreted by the posterior pituitary gland? Oxytocin Prolactin Corticotropin Antidiuretic hormone Melanocyte-stimulating hormone

oxytocin, ADH everything else is anterior pituitary gland

The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L (5.4 mmol/L). What would the nurse expect to see on the ECG tracing monitor? Abnormal P waves and depressed T waves Peaked T waves and widened QRS complexes Abnormal Q waves and prolonged ST segments Peaked P waves and an increased number of T waves

peaked T waves and wide QRS

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder? Ham sandwich with cheese, whole milk, and potato chips Penne pasta, spinach, banana, and decaffeinated iced tea Baked lasagna with sausage, salad, and milkshake Hamburger, french fries, and cola

penne pasta, spinach, banana, decaf iced tea rationale: PT w/ cirrhosis and ascites needs moderate-low fat and low sodium

Which condition results in elevated serum adrenocorticotropic hormone (ACTH) and urine cortisol levels? Diabetes insipidus Adrenal Cushing's syndrome Pituitary Cushing's syndrome Syndrome of inappropriate antidiuretic hormone

pituitary cushing's syndrome rationale: in pituitary cushing's syndrome, urine cortisol and serum ACTH are raised. Adrenal cushing's is caused by chronic steroid use so the PT will have increased urine cortisol and decreased ACTH

Which diagnostic test would the nurse consider to be the gold standard for diagnosis of pulmonary embolism? Pulmonary angiography Helical computed tomography (CT) Ventilation-perfusion (V/Q) scans Computed tomography pulmonary angiography (CT-PA)

pulmonary angiography

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis? Turkey salad, french fries, sherbet Cottage cheese, mixed fruit salad, milkshake Salad, sliced chicken sandwich, gelatin dessert Cheeseburger, tortilla chips, chocolate pudding

salad, sliced chicken sandwich, gelatin dessert rationale: diet should be high in carbs with moderate protein and fat content

Before a client has a cardiac catheterization, an electrocardiogram (ECG) is performed, and hypokalemia is suspected. The nurse expects that the diagnosis will be confirmed by which diagnostic test? Complete blood count Serum potassium level X-ray film of long bones Blood cultures times three

serum potassium level rationale: hypokalemia is suspected when T wave on EKG is depressed or flattened

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? Fever and chest pain Positive Homans sign Loss of sensation in the operative leg Tachycardia and petechiae over the chest

tachycardia and petechiae over chest rationale: tachy occurs bc of impaired gas exchange, petechiae are caused by occlusion of small vessels w/in skin