bsn225 hesi exam prep 2

an older client with dementia of Alzheimer's type is residing in a nursing home when in bed. Client consistently is found sleeping in semi Fowler's position what area of the clients body does a nurse determine has the most risk for developing a pressure ulcer

sacrum

a client had surgery for perforated appendix with localized. peritonitis in which position should the nurse place the client

semi fowler

a nurse's preceptor for orientee that warranty is providing post-operative care to a client who recently returned from a laryngoscopy the orienteering mines a client not to eat or drink anything until instructed to do so how does the preceptor evaluate the suitability of the instructions given to the client by the orientee

appropriate oral intake after the procedure may result in aspiration

a nurse working in emergency department is concerned about recent increase in malpractice claims against the nurses what is the best way for the nurse to prevent being named in a lawsuit

attend professional development programs

which drug may cause photophobia as an adverse effect

clomiphene a fertility Rationale- Nifedipine- Maternal Fetal problems Aldenorate- cause dysphagia Indomethacib- may cause birth defects

what is the nurses primary consideration when caring for a client with rheumatoid arthritis

comfort

an Asian client arrives at the mental health clinic with symptoms of anxiety and panic while speaking with the client the nurse notes that the client makes very little eye contact what does this assessment data suggest

cultural variation

a client with a history of pulmonary embolus is to receive 3 mg of work there in Daily the client has blood drawn twice-weekly to a certain that the intentional normalized ratio stays within therapeutic range the nurse provides dietary teaching which foods like your by the client indicates that further teaching is necessary

spinach salad which contains high levels of vitamin K and acts as a catalyst in the liver for the production of blood clotting factors and

an executive busy at work receives a phone call from my friend relating bad news the executive makes a conscious effort to put this information out of his mind and continue to work at the task at hand the next day the executive remembers that the friend telephone but is unable to recall the message what defense mechanism does this Behavior represent

suppression

the nursing parts of a client with Raynaud's disease to stop smoking which primary goal is the nurse trying to achieve

to prevent peripheral vasoconstriction

a nurse is caring for hyperactive manic client who exhibits flight of ideas and is not eating what may be the reason why this client is not

too busy to take the time to eat

a nurse is evaluating a three year old child developmental progress the inability to perform which tasks indicates a nurse that there is a Bella pencil delay

using a spoon effectively

the nurse is providing discharge teaching to a 30 year old client who was hospitalized for exacerbation rheumatoid arthritis which statement by the client indicates a correct understanding of the treatment plant

when I exercise, I will reduce the number of repetitions when I have pain

what is the maximum recommended length for enema tube insertion in adolescents

10 cm

at what age does the anterior Fontanel of the skull close

12 to 18 months

which hormone influences kidney function

Aldosterone

a client is going for a magnetic resonament imaging what should the nurse a certain before taking the client to the procedure

All Metals such as jewelry and hair ornaments have been removed

a psychologist has been a client on a mental health unit for three days the client has questioned the authority of the treatment team advise other clients that their treatment plans are wrong and been deceptive & group therapy what is the most appropriate nursing intervention

accepting that the client is unable to control this behavior and setting appropriate limits

a pregnant woman asks the nurse when she may expect her baby to be born she tells the nurse said her last menstrual. Begins on April 14th according to not Jill's rules what is the current expected date of birth

January 21st naegeles rules talk to you later be subtract 3 months and add 7 days to the date of the last menstrual.

a nurse identifies that a client who had a myocardial infraction is struggling with an alteration in self concept the nurse intervenes to promote client autonomy which behavior by the client demonstrates an increase in client autonomy

active participation in providing self-care

what childhood problem has legal as well as emotional aspects and cannot be ignored

School phobia

which hormone does the nearest State fines to the receptor site on the surface of a Target

adrenaline water soluble hormones

how does the World Health Organization to find help

a state of complete physical mental and social well-being

a client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid

analgesic

what does the presence of ketones in the urine of a client with renal dysfunction indicate

anorexia nervosa

a nurse is providing discharge instructions about digoxin response should a nurse include as a reason for a client's withto without digoxin

blurred vision

which influenza vaccine is administered by way of intranasal route

flumist

which of these stages is followed by the society maintaining orientation according to kohlberg Theory

good boy nice girl orientation

a mother whose child has been killed in a school bus accident tells the nurse that her child was just getting over the chicken pox and did not want to go to school but she insisted that the child's go the mother cried bitterly and says that her child stuff is her fault the nurse understands that receiving a death of preventable most often will influence the grieving process in that it may do What

grow in intensity and duration

a four-year-old child is being prepared for a myringotomy in the Ambulatory Care Unit what is most important for the nurse to do when the child is called to the operating room

having a parent accompany the child to the operating two

what is most important for the nurse to do to assist a couple to cope with their feelings about the husband's terminal illness

helping a couple Express to each other their feelings about his terminal illness

a nurse is assessing a client with Cushing's syndrome which sign should the nurse expect the client to exhibit select all that apply

hirsutism round face buffalo hump

a female client who physically abused her nine-year-old son is undergoing treatment to help her control her behavior which statement indicates that the client has developed a safe coping method to help her deescalate

if I get angry at my son again I'm going to need a pillow in the bedroom to punch

which would the nurse claim is cardiovascular manifestation of alkalosis

increase digitalis toxicity

a client with alcoholism was admitted a few hours ago for pancreatitis for which symptoms should the nurse purpley monitor this client

irritability and tremors

how does the international classification of nursing practice help nurses deliver effective care to clients

it provides vocabulary to include nursing data and computerized Information Systems

a client who has subtotal thyroidectomy ask how hypothyroidism May develop when the problem was hyperthyroidism what should the nurse consider when formulating a response

less thyroid tissue is available to supply thyroid hormone after surgery

a client has a tentative diagnosis of Hodgkin's disease how does a nurse expect the diagnosis to be confirmed

lymph node biopsy

a nurse is caring for an infant who has just undergone myelomeningocele repair what should the nursing plan of care include

monitoring for cerebral spinal fluid leakage

hydrocephalus developing an infant who was born with meningomyelicele and a ventriculoperitoneal shunt is inserted What nursing intervention is most important in this infant care during the first 24 hours after surgery

monitoring for increased intracranial pressure

a nurse is assessing a client ECG reading the clients arterial and ventricular heart rates are equal at 88 beats per minute the PR interval is 0.14 seconds and the QRS with is 0.10 seconds rhythm is regular with normal p waves in QRS complexes how will the nurse interpret this rhythm

normal sinus rhythm

a six-year-old child has a fractured arm and multiple injuries child maltreatment is suspected what parental characteristic supports this suspicion

offering inconsistent stories about the injuries

which condition is characterized by infection of a client's bone or bone marrow

osteomyelitis

a nurse in the Pediatric Clinic is assessing an 11-month old client who is sitting on the mother's life crying and taking it the right ear what likely problem does this Behavior indicates

otitis media

what findings should a nurse expect when examining the laboratory part of a preschooler with rheumatoid fever

positive antistreptolysin

an older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen one day the client says I'm not going to any more activities all these old crappy people do is talk about their problems what defense mechanism does a nurse concludes that the client is using

projection

a nurse is caring for a client with Somatoform disorder what should the nurse anticipate that this client will do

redirect the conversation with the nurse to physical symptoms

which Professionals in a healthcare organization can be delegators

registered nurses

a client on hospice care is receiving palliative treatment a palliative approach involves planning measures aimed to do what

relieve the clients comfort