HESI 2d semester Fundamental Skills practice questions

Which hormone causes skin discoloration?

Estrogen

What is the most commonly reported sexually transmitted infection (STI)?

Chlamydia

A nursing team holds a conference to develop goals for the care of a withdrawn, shy male client with low self-esteem who is afraid to talk to members of the opposite sex. Which objective should be given priority and documented in the client's plan of care?

"The client will increase his self-esteem. If the goal to increase the client's self-esteem is met, the client's relationship with others should improve in all aspects, including sexual. Increasing insight may be helpful but should not receive priority. The client may or may not have a sexual disorder. Examining his feelings toward women is not appropriate at this time; examining these feelings is nonproductive until the client's self-esteem improves. Increasing the client's knowledge of sexual function may be done, but improvement of self-esteem should receive priority.

An 80-year-old client is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated, because she is alert and able to care for herself. The nurse's best response is:

"The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased.

Which type of allergic skin condition in a client is associated with immunological irregularity, asthma, and allergic rhinitis?

Atopic dermatiti Atopic dermatitis is an allergic skin condition that is a genetically influenced, chronic, relapsing disease. It is associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma. Urticaria is an allergic skin condition that results in a local increase in permeability of capillaries, causing erythema and edema in the upper dermis. Psoriasis is an autoimmune chronic dermatitis but not an allergic skin condition. Acne vulgaris is an inflammatory disorder of sebaceous glands.

Which conditions result in humoral immunity? Select all that apply.

Atopic diseases, Bacterial infection, Anaphylactic shock

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what?

Causing local vasoconstriction, preventing edema and muscle spasms

Which medical condition could most probably result in clients developing primary diabetes insipidus (DI)?

Defect in hypothalamus A defect in the hypothalamus (thirst center) could be the most probable cause of primary DI. Meningitis or a brain tumor could interfere with the synthesis, transport, or release of antidiuretic hormone (ADH) and cause central DI. Lithium therapy affects the renal response to ADH and results in nephrogenic DI, or drug-related DI.

Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies?

Explanation

Arrange the series of reactions that occurs when plasma volume and osmolarity are disturbed.

Extracellular fluid volume decreases during conditions such as posture changes and blood loss. This results in release of rennin enzyme, which converts angiotensinogen to angiotensin I. In the presence of angiotensin-converting enzyme, angiotensin I is converted to angiotensin II, which is an active form of angiotensin. Angiotensin II stimulates the adrenal secretion of aldosterone, which increases the reabsorption of water and sodium. This results in increased blood volume.

What is an important nursing assessment for a school-aged child who is undergoing long-term steroid therapy?

Frequent testing of stools for occult blood Because steroids decrease production of prostaglandins that have a role in protecting the stomach, gastrointestinal bleeding may occur; stools should be checked for frank and occult blood. Steroids do not cause pulse irregularities, mucus in the urine, or ulceration of mucous membranes.

Which mechanism of action does norepinephrine promote to manage anaphylaxis?

Increases blood pressure and cardiac output

Ranitidine has been prescribed to help treat a client's gastric ulcer. The nurse expects this drug to act specifically by which mechanism?

Inhibiting the histamine at H2 receptors

The nurse provides education about signs and symptoms of hypoglycemia to a client with newly diagnosed type 1 diabetes. The nurse concludes that the teaching was effective when the client acknowledges the need to drink orange juice when experiencing which symptoms?

Nervousness and weakness are the most commonly reported symptoms of hypoglycemia and are related to increased sympathetic nervous system activity. Feeling flushed and short of breath are adaptations of hyperglycemia. Being thirsty, having a headache, being nauseated, or having abdominal cramps are symptoms of hyperglycemia.

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply.

Oliguria, Irritability, Hypotension

A low-dose intravenous dopamine hydrochloride infusion drip is prescribed for a client in acute renal failure (ARF). Which method is most appropriate for the nurse to administer this medication to the client?

Peripherally inserted central catheter (PICC) line Dopamine hydrochloride is a vesicant, and if it infiltrates into the skin it can cause tissue necrosis. It must be infused through a central line catheter such as a PICC line. An angiocatheter and butterfly needle are not central lines. A femoral line is a central line but is used only in extreme emergencies because of the risk of insertion site infection.

The nurse receives information about a client through another nurse. The nurse then finds that information has some missing facts. Which critical thinking attitude would the nurse use to clarify the information after talking to the client directly?

Perseverance

An older adult in an acute care setting is experiencing emotional stress because of a recent surgery. Which intervention would be most appropriate for the client?

Reality orientation

What are the clinical manifestations during the fulminant stage in a client with inhalation anthrax? Select all that apply.

Septic shock, Pleural effusion, Body temperature of 104 °F

The nurse is caring for a client with a possible pulmonary embolism (PE). Which diagnostic test should the nurse initially anticipate will be prescribed for this client because it is the evidence-based gold standard for a PE diagnosis?

Spiral (helical) computed tomographic angiography (CTA)

A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include?

Teaching the client to use head movements to scan the left field of vision

Which cerebral lobe includes the speech area that allows the client to process words into coherent thoughts?

Temporal lobe Wernicke's area (language area), which allows processing of words into coherent thought and understanding of written or spoken words, is located in the temporal lobe. The limbic lobe controls the emotional and visceral patterns in the brain. The frontal lobe consists of Broca's area, which is the speech area responsible for formation of words into speech. The occipital lobe contains the primary visual center.

Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait?

The client must be able to bear weight on both legs

What are the primary nursing interventions to check the circulation in a client? Select all that apply

The nurse should monitor the vital signs, especially the pulse The nurse should maintain vascular access with a large-bore catheter

What is the priority of care to promote client safety directly after esophagogastroduodenoscopy? Select all that apply.

The priority for care to promote client safety after esophagogastroduodenoscopy (EGD) is to prevent aspiration. Signs of perforation such as bleeding, pain, and fever are also monitored as priority care. Reminding the client not to drive is low priority. The client is advised to use throat lozenges to relieve throat discomfort, which is a low priority care. Hoarseness of voice persists for several days after EGD. Therefore the client is taught about hoarseness of voice, which is considered low priority.

A couple approaches the primary healthcare provider to seek guidance on permanent contraception. Which surgeries are suggested to the couple? Select all that apply.

Vasectomy, Tubal ligation

A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic?

Warfarin initially is prescribed day by day, based on INR blood test results. This test provides a standard system to interpret prothrombin times. APTT is used to evaluate the effects of heparin, which acts on the intrinsic pathway. Bleeding time is the time required for blood to cease flowing from a small wound; it is not used for warfarin dosage calculation. Sedimentation rate is a test used to determine the presence of inflammation or infection; it does not indicate clotting ability.

A client with dementia who feels highly anxious and confused believes that the current day is actually different than what it is. Which statement made by the nurse is an example of validation therapy?

"Yes, today is the day that you just mentioned."

A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement?

Auscultate the lungs

A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man?

"Do you have chest pain? Females may present with atypical symptoms of myocardial infarction, such as absence of chest pain, overwhelming fatigue, and indigestion. Anxiety, palpitations, and shortness of breath are common clinical manifestations in both males and females who are experiencing a myocardial infarction.

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "alternative medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate?

"Nontraditional approaches to health care can be beneficial."

Which client is at greatest risk for the development of a venous thrombosis?

68-year-old male on bed rest following a left hip fracture Venous thrombosis is the result of inflammation to a vein, hypercoagulability, venous stasis, or a combination of the three, known as Virchow triad. Bed rest and hip fracture are two major risk factors for the development of a thrombosis. While the other options present risk factors (cigarette smoking, drug abuse, and clotting disorders), the combination of the two (venous stasis and vessel injury) results in greatest risk for thrombus development.

Arrange in order how the items of personal protection equipment (PPE) should be removed after exiting a medical or surgical isolation area.

According to the Centers for Disease Control and Prevention, gloves should be removed first when exiting medical or surgical isolation in order to avoid those gloves touching and possibly contaminating other equipment outside of the isolation area. Next, the nurse removes the face shield, followed by the gown and then the mask. Handwashing is the next step that should occur after removing all personal protection equipment (PPE).

A nurse is planning to teach facts about hyperglycemia to a client with diabetes. What information should the nurse include in the discussion about what causes diabetic acidosis?

Breakdown of fat stores for energy In the absence of insulin, which facilitates the transport of glucose into cells, the body breaks down proteins and fats to supply energy; ketones, a by-product of fat metabolism, accumulate, causing metabolic acidosis (pH below 7.35). The pH of food ingested has no effect on the development of acidosis. The opposite of excessive secretion of endogenous insulin is true. Cholesterol level has no effect on the development of acidosis.

Which function of a client's eyes ensures formation of a single image of close objects being seen?

Convergence Convergence action of the eyes ensures that only a single image of close objects is seen. Mydriasis is pupil dilation when exposed to reduced light or looking at a distance. The process of maintaining a clear visual image when the gaze is shifted from a distant to a near object is known as accommodation. Pupillary constriction and dilation control the amount of light that enters the eye.

Which surgical procedure is appropriate for the removal of a vocal cord due to laryngeal cancer?

Cordectomy

A pregnant client at 30 weeks' gestation begins to experience contractions every 5 to 7 minutes. She is admitted with a diagnosis of preterm labor. Although the client is being given tocolytic therapy, her cervix continues to dilate, and it is determined that a preterm birth is inevitable. Which medication does the nurse expect the primary healthcare provider to prescribe?

Dexamethasone

What are the mediators of injury in IgE-mediated hypersensitivity reactions? Select all that apply.

Mast cells, Histamines, Leukotrienes Mast cells, histamines, and leukotrienes are the mediators of injury in IgE-mediated hypersensitivity reactions. Cytokines are the mediators of injury in the delayed type of hypersensitivity reaction. Neutrophils are the mediators of injury in the immune-complex type of hypersensitivity reaction.

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority?

Observe the client for increasing confusion.

A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing?

Persecutory delusions

Which developmental changes should be evaluated in girls around 12 years of age?

Skeletal growth

Which cervical changes are observed during pregnancy? Select all that apply.

The cervical tip becomes soft., The volume of cervical muscles increases., The elasticity of cervical collagen-rich connective tissue increases

A 2-year-old child who has been restricted to bed rest because of a diagnosis of meningitis is now allowed out of bed. The nurse suggests going to the playroom. The child responds by shaking the head vigorously from side to side, screaming, "No! Won't!" However, the child is trying to climb out of the crib at the same time. In light of these behaviors, what is the most likely conclusion by the nurse?

The child is confused as a result of increased intracranial pressure

Which type of joint is present in the client's shoulders?

The spheroidal joint is a ball and socket joint that provides flexion, extension, adduction, abduction, and circumduction in the shoulders and hips. The pivotal joint provides rotation in the atlas and axis, and at the proximal radioulnar joint. The saddle joint, which is at the carpometacarpal joint of the thumb, provides flexion, extension, abduction, adduction, and circumduction of the thumb-finger. The condyloid joint is a wrist joint between the radial and carpals; it provides flexion, extension, abduction, adduction, and circumduction.

Why does the nurse establish "moderately hard" client-centered goals? Select all that apply.

To prevent the client from quitting before the goal is achieved To prevent the client from losing motivation toward achieving the goal

When assessing the laboratory values of a client with type 2 diabetes, what would the nurse expect the results to reveal?

Urine negative for ketones and positive glucose in the blood The reason for the lack of ketonuria in type 2 diabetes is unknown. One theory is that extremely high hyperglycemia and hyperosmolarity levels block the formation of ketones, stimulating lipogenesis rather than lipolysis. Ketones in the blood but not in the urine do not occur with type 2 diabetes. Glucose in the urine but not in the blood is impossible; if glycosuria is present, there must first be a level of glucose in the blood exceeding the renal threshold of 160 to 180 mg/dL (8.9 to 10 mmol/L). Urine and blood positive for glucose and ketones are expected in type 1 diabetes.

A client admitted with a myocardial infarction is prescribed docusate and morphine and takes digoxin and fluoxetine at home. Which drug should the nurse recognize as a risk factor for straining due to constipation?

morphine Morphine is an opioid. Opioids decrease intestinal peristalsis, which may precipitate constipation; straining at stool should be avoided to prevent the Valsalva maneuver, which increases demands on the heart. Digoxin is unrelated to intestinal peristalsis and the potential for constipation. Docusate sodium is a stool softener which would relieve, not cause, constipation. A side effect of fluoxetine is diarrhea, not constipation.Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.

A nurse is teaching a client about the normal pathway followed during the cardiac cycle. In which sequence should the nurse list the structures, beginning with the first?

1. Sinoatrial node, 2. Atrioventricular node, 3. Bundle of His, 4. Bundle branches, 5. Purkinje fibers The cardiac cycle begins with an impulse that is generated from a small concentrated area of pacemaker cells high in the right atria called the sinus or SA node. The impulse quickly reaches the AV node located in the area called the AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular filling during relaxation or ventricular diastole. The electrical impulse then is conducted rapidly through the bundle of His to the ventricles via the left and right bundle branches. The bundle branches divide into smaller and smaller branches, finally terminating in tiny fibers called Purkinje fibers that reach the myocardial muscle cells or myocytes.

What is an example of a type I hypersensitivity reaction?

Anaphylaxis An example of a type I hypersensitivity reaction is anaphylaxis. Serum sickness is a type III immune complex reaction. Contact dermatitis is a type IV delayed hypersensitivity reaction. A blood transfusion reaction is a type II cytotoxic reaction.

The registered nurse is teaching a nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education?

I should monitor weight and food intake once in a month

Which nursing process involves delegation and verbal discussion with the healthcare team?

Implementation

A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what?

Loosen pulmonary secretions Postural drainage and percussion also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficulty and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.

A client with a 20-year history of excessive alcohol use has developed jaundice and ascites and is admitted to the hospital. What is the priority nursing action during the first 48 hours after the client's admission?

Monitor vital signs The vital signs, especially pulse and temperature, will increase before the client demonstrates any of the more severe signs and symptoms of withdrawal from alcohol. Increasing fluid intake is contraindicated initially because it may cause cerebral edema and the client has ascites. Although the client will be more comfortable on a foam mattress, it is not the priority. Improving nutritional status becomes a priority after problems of the withdrawal period have subsided.

The nurse is caring for a client with trauma in the emergency unit. Which action should the nurse perform as the highest priority?

Providing adequate oxygen supply The nurse should prioritize care while caring for a client with trauma in the emergency department. Evaluation of chest expansion, respiratory effort, and an evidence of chest wall trauma helps to assess breathing, a primary survey. The highest priority intervention is to establish a patent airway by providing adequate oxygen supply, thereby reducing the brain injury and progression to anoxic brain death. Direct application of pressure on the bleeding site with thick, dry dressing material helps to reduce external hemorrhage.

A client has been taking 3 mg of risperidone twice a day for the past 8 days. At the follow-up appointment, the client reports tremors, shortness of breath, a fever, and sweating. What will the nurse do?

Take the client's vital signs and arrange for immediate transfer to a hospital. These clinical manifestations signal the presence of neuroleptic malignant syndrome; the cardinal sign of this condition is a high body temperature. Therefore the nurse first should document the hyperthermia and then arrange for immediate hospitalization. Unless the client is experiencing impaired ventilation, it is important to complete a focused assessment before transfer. The care needed can be provided in an emergency department or medical unit, not a psychiatric unit. Neuroleptic malignant syndrome may occur without an overdose; this syndrome can occur when a high-potency antipsychotic drug is prescribed, with typical onset within 3 to 9 days after initiation of the medication. Benztropine will have little or no effect on neuroleptic malignant syndrome.

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia?

Deficiency of thiamine (deficiency of vitamin B1)

Which physiologic changes may occur during the first trimester of pregnancy? Select all that apply.

Fatigue, Morning sickness, Breast enlargement

Which does the nurse explain is true about preschoolers?

They need around 1800 calories in a day

A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider?

A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death. The client pushing the airway out is an expected response; the client will push out the airway as the effects of anesthesia subside. Respirations of 16 breaths per minute is a common response postoperatively. If the client is experiencing a depressant effect of anesthesia, the nurse will assess shallow and slow respirations.

Which type of immunity will clients acquire through immunizations with live or killed vaccines?

Artificial active immunity Artificial active immunity is acquired through immunization with live or killed vaccines. Natural active immunity is acquired when there is natural contact with antigens through a clinical infection. Natural passive immunity is acquired through the transfer of colostrums from mother to child. Artificial passive immunity is acquired by injecting serum from an immune human.

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency?

Autonomic hyperreflexia Autonomic hyperreflexia, an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200 mm Hg systolic; it is a medical emergency. While hemorrhage and hypovolemic shock could occur from the trauma, the scenario stated that no other injuries occurred. Although gastrointestinal atony can result from immobility, it is not a medical emergency.

The nurse is teaching a client receiving peritoneal dialysis about the reason dialysis solution is warmed before it is instilled into the peritoneal cavity. Which information will the nurse share with the client?

Because it encourages removal of serum urea by preventing constriction of peritoneal blood vessels

The nurse observes a window washer fall 25 feet (7.6 m) to the ground, rushes to the scene, and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

Begin chest compressions According to the American Heart Association and Heart and Stroke Foundation of Canada for CPR, the first step is to feel for a pulse after unresponsiveness is established. In this case, the nurse has established that the client has no pulse when cardiopulmonary arrest was determined. Therefore, chest compressions should be initiated immediately. Never leave the client to call for assistance; either call the emergency medical services (EMS) by dialing 911 in the US or 112 in Canada on a cellular phone (and leave the phone on so that EMS can find you) or shout out to others in the area for assistance in seeking EMS. The longer the client goes without circulation, the higher the risk of death, so initiating chest compressions has highest priority when cardiopulmonary arrest has been established. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.

What is an example of third spacing in a burn injury?

Blister formation

A client with systemic lupus erythematosus is taking prednisone. The nurse anticipates that the steroid may cause hypokalemia. What food will the nurse encourage the client to eat?

Broccoli

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte?

Calcium The muscle contraction-relaxation cycle requires an adequate serum calcium-phosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation. Sodium's major route of excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps to balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorus is closely related to calcium, because they exist in a specific ratio, phosphorus is not related to the development of tetany.

Which Food and Drug Administration pregnancy risk category do drugs that have not undergone any studies in animal and pregnant women belong to?

Category C Category C constitutes drugs on which no studies have been done. It also constitutes the drugs that have shown positive fetal risks in animal studies but with no studies conducted in humans. Category X constitutes drugs that have shown risks of fetal abnormalities in both animal and human studies. Category B constitutes drugs that show no fetal risk in animals; these drugs have not been involved in controlled studies in humans. Category D constitutes drugs that show a fetal risk in human studies but cannot be prohibited because of the safety of use.

The nurse is caring for clients with disaster triage tags after a natural disaster. Which client should be treated immediately according to disaster triage tag system?

D bruises and laceration on skin The disaster triage tag system categorizes triage priority by color. Clients with minor injuries that can be managed in a delayed fashion are categorized as green-tagged. Therefore client D with bruises and lacerations on the skin is green-tagged. Client A, with the life-threatening condition of an airway obstruction is red-tagged. Client B with large wounds and open fractures needs treatment within 30 minutes to 2 hours and is yellow-tagged. Client C with critical massive head trauma is black-tagged.

What does the professional nurse consider to be the center of decision-making when providing client care?

Ethics of care

Which professional standard does the nurse feel is most important for critical thinking?

Evaluation criteria An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients?

Explanation Explanation requires knowledge and experience for choosing strategies for care of clients. Analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. The skill of inference is associated with noticing relationships in the findings. Interpretation is associated with an ordered data collection.

A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to?

Explanation The critical-thinking skill of explanation involves using knowledge and experience to provide client care. The nursing practice of assessing whether the obtained data is true is called analysis. Using criteria such as expected outcomes, pain characteristics, and learning objectives to determine results of nursing actions is an evaluation skill. The nursing practice of being orderly in data collection and looking for patterns to categorize data refers to interpretation.

Which factor is used to assess the quality of health care provided to a client?

Functional health status of the client after discharge

Which bacterial skin infections are caused by group A β-hemolytic streptococci? Select all that apply.

Impetigo, Erysipelas Impetigo is caused by group A β-hemolytic streptococci, staphylococci, or a combination of both. Erysipelas is caused by group A β-hemolytic streptococci. Furuncle is a deep infection with staphylococci. Staphylococcus aureus and streptococci are the usual causative agents of cellulitis. Usually staphylococci are responsible for folliculitis.

An 8-year-old boy with asthma is being taught breathing exercises. The nurse uses several techniques in a play situation, and the child performs a repeat demonstration for the nurse. Which technique indicates that the child needs further teaching?

Moving a cotton ball when inhaling The goal for teaching a child with asthma breathing exercises is to lengthen expiratory time and expiratory pressure. This activity focuses on inhalation, not exhalation. Singing songs with long phrases forces the child to exhale until each phrase is completed. Activities such as puffing through a straw or blowing through a pipe encourage exhalation.

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider?

No prescription change The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure). There is no indication from the data that a prescription change is needed for this client. Increasing the furosemide or giving intravenous fluid to this client could result in a fluid imbalance.

Which term should the nurse use to describe bone loss greater than normal but less than that caused by osteoporosis?

Osteopenia

Which laboratory value may indicate hyperfunction of the adrenal gland in a client?

Potassium: 2.9 mEq/L The normal level of potassium is 3.5 to 5.0 mEq/L. The laboratory value of the potassium in the client is 2.9 mEq/L, which is below the normal level. Therefore, it may indicate the presence of adrenal gland hyperfunction in the client. The normal value of sodium is 136 to 145 mEq/L, bicarbonate is 23 to 30 mEq/L, and total calcium is 9 to 10.5 mg/dL. Thus, the laboratory values of sodium (143 mEq/L), bicarbonate (25 mEq/L), and total calcium (10 mg/dL) lie in the normal range, which does not indicate hyperfunction of the adrenal gland in the client.

The primary healthcare provider prescribes a neuroleptic drug to a client diagnosed with schizophrenia. On what basis would the primary healthcare provider choose the drug?

Side effects

The nurse is caring for victims of a biologic terrorism incident that has caused them to develop hemorrhagic fever. What does the nurse know about the treatment of this condition?

There is no established treatment for this condition. There is no established treatment for most viruses that cause hemorrhagic fever. Anthrax, plague, and tularemia are biologic agents of terrorism that can be treated effectively with antibiotics if sufficient supplies are available and the organisms are not resistant. Smallpox is a biologic agent of terrorism that can be prevented or the incidence reduced by vaccination, even when first given after exposure. Nerve agent poisoning is a chemical agent of terrorism; antidotes for nerve agent poisoning include atropine (AtroPen).

A client is admitted to the hospital with a diagnosis of intestinal obstruction. The healthcare provider prescribes intestinal suction via a nasoenteric decompression tube. The loss of which constituents associated with intestinal suctioning is most important to consider when caring for this client?

Water and electrolytes

A nurse assesses a client's intravenous site. What clinical finding, unique to infiltration, leads the nurse to conclude that the intravenous (IV) site has infiltrated, rather than become inflamed?

When an IV infiltrates, the IV solution entering the interstitial space is at room temperature (approximately 75° F [23.9° C]), whereas body temperature is approximately 98.6° F (37° C); therefore, the client's skin will feel cool to the touch at the site of an IV infiltration. The site of an inflammation will feel warm to the touch because of vasodilation and hyperemia. Pain may occur with both an inflammation and an infiltration. The pain of an inflammation is related to the pressure of edema on nerve endings. The pain of an infiltration is related to the IV solution in the interstitial compartment pressing on nerve endings. An increase in interstitial fluid occurs with both an inflammation and an infiltration. With an inflammation there is increased vascular permeability at the site; fluid, proteins, and leukocytes then move from the intravascular compartment into the interstitial compartment. With an infiltration the IV solution enters the interstitial compartment rather than the intravascular compartment. A cessation in flow of solution occurs with both an inflammation and an infiltration. An inflammation in the vein at the insertion site may close the lumen of the vessel, interfering with the flow of solution. An infiltration will cause excess fluid in the interstitial compartment to the extent that it will not accommodate more solution, interfering with the flow of the solution.