HESI Review Adult Health 1

The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laënnec's cirrhosis. Which question related to the client's history would be most important to ask?

"Do you abuse alcohol?"

The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis?

"I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

The nurse teaches the parent of a child diagnosed with bacterial conjunctivitis about measures to prevent transmission of the infection. Which statement by the parent indicates a need for further teaching?

"It is all right to share towels and washcloths as long as they are bleached after use."

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise?

"The best time for me to exercise is mid- to late afternoon."

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder?

A sedentary 65-year-old woman who smokes cigarettes

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding would the nurse expect to observe?

A red, dull, thick, and immobile tympanic membrane

The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which would the nurse expect to note on assessment of the client?

A rounded "moonlike" appearance to the face

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved?

A urine output that is pale yellow

The nurse is developing a teaching plan for a client with viral hepatitis. The nurse would plan to include which information in the teaching session?

Activity would be limited to prevent fatigue.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA?

Anorexia

The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse would instruct the client to take which measure?

Apply an emollient lotion to the skin to enhance softening.

A client is experiencing anxiety about being hospitalized. What therapeutic communication techniques would the nurse use while interacting with the client? Select all that apply.

Ask the client to identify how they feel., Help the client identify the cause of the anxiety., Observe for expressions of helplessness and hopelessness

A client with Ménière's disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo?

Avoid sudden head movements.

The nurse is developing a plan of care for a client who is scheduled for a thyroidectomy. The nurse focuses on psychosocial needs, knowing that which is likely to occur in the client?

Body image changes

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?

Cardiovascular disease

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding would the nurse expect to note?

Changes in mental status

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus?

Clear mentation

The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding would the nurse expect to note in this client?

Dry skin

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care would the nurse include? Select all that apply.

Ensure adequate oxygenation., Provide assistance to prevent falls., Monitor medication administration of diuretics, Prevent complications during potassium administration.

Which essential role does the nurse play in the health care team with multiple primary health care providers and specialists?

Facilitates communication among the team

The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The primary health care provider (PHCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment finding by the nurse is the most important and would be reported to the PHCP immediately?

Hematemesis

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed?

Heparin

The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific sign of this complication would be included on the list?

Increased thirst

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which prescriptions would the nurse anticipate receiving? Select all that apply.

Initiate an infusion of 3% NaCl., Restrict fluids to 800 mL over 24 hours., Administer a vasopressin antagonist as prescribed.

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated prescription?

Intravenous infusion of normal saline

The nurse is caring for a teenage client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?

Leukocytosis with a shift to the left

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply.

Nocturia, Incontinence, Enlarged prostate

A client who does not speak English arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?

Page an interpreter from the hospital's interpreter services.

The nurse is caring for a client after an above-the-knee amputation. The nurse assesses the residual limb and expects to note which finding?

Pink color to the skin flap

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information?

Place a clock and calendar in the client's room.

A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that they have a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention would the nurse anticipate to be prescribed initially for the client?

Regular insulin via the intravenous (IV) route

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action?

Resume full activity level.

The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of Addisonian crisis. The nurse would assess the client for which manifestation that would be associated with this crisis?

Severe abdominal pain

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose would be taken if which symptom or symptoms develop? Select all that apply.

Shakiness, Palpitations, Light-headedness

The nurse is creating a plan of care for a client in skin traction. The nurse would monitor for which priority finding in this client?

Signs of skin breakdown

A client who is admitted with emAphysema is having difficulty breathing. In which position should the nurse place the client?

Sitting upright and forward with both arms supported on an over the bed table

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?

Speak at a normal volume.

The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action would the nurse take?

Speak at normal tone and pitch, slowly and clearly.

A registered nurse (RN) has instructed an assistive personnel (AP) to administer soap suds enemas until clear to a client. The AP reports that three enemas have been administered and the client is still passing brown, liquid stool. What would the RN instruct the AP to do?

Stop administering the enemas until the primary health care provider (PHCP) is notified.

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction would the nurse include in the teaching plan?

Take a blood glucose test before exercising.

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101° F (38.3° C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse?

Temperature

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse's response to the client's question is based on which correct understanding of TB transmission?

The disease is transmitted by droplet nuclei.

The nurse is preparing to provide preoperative teaching to a non-English-speaking client and the client's family. Which nursing action would be most effective for teaching the client?

The nurse secures the assistance of a professional interpreter to communicate with the client.

The charge nurse is assessing the nurse's knowledge about the use of an interpreter. Which statement made by the nurse requires a need for further teaching?

The use of an interpreter does not need to occur until the client requests one

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?

Thick, yellow drainage from the pin sites

The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication the nurse would employ? Select all that apply

Timing, Volume, Voice tone, Ability to share thoughts and feelings

A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?

Tinnitus

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?

Urine specific gravity of 1.032

The nurse is preparing to teach a client with a new colostomy about how to perform a colostomy irrigation. Which information would the nurse include in the teaching plan?

Use 500 to 1000 mL of warm tap water.