HESI Adaptive Quiz #3 n125

While assessing a client's hair, a nurse notices that the client has head lice. The nurse teaches the client about hair hygiene and lice control. Which statements made by the client indicates an understanding of the teaching?

"I should use a dilute vinegar solution to loosen the nits." "I should use a shampoo treatment once every 24 hours." "I will clean my comb in ammonia water."

A nurse is teaching a client about measures to promote health. Which statements made by the client indicate effective learning? Select all that apply.

"I will assess my own pulse rate after exercising." "I will follow my hypertension treatment plan consistently." "I will perform a self-assessment of my heart rate using the carotid pulse."

A nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STI). Which statement of the client indicates effective learning?

"I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia."

A nurse is teaching a client about different prevention and detection practices to ensure breast health. Which statement made by the client indicates the need for further teaching?

"I will increase my meat consumption."

After reviewing otoscope use for assessment of the ear with the nursing staff, which response from a participant reflects safe follow-up care for when there is earwax covering the tympanic membrane?

"I will perform warm water irrigation to remove the wax."

The nurse is performing a breast assessment. Which statement made by the client indicates the risk of breast cancer? Select all that apply.

- "My first child was born when I was 32." - "I noticed a slight discharge from a nipple." - "I consume two to four glasses of alcohol a day."

A registered nurse notices that a student nurse who is assessing the blood pressure in a client is deflating the cuff too rapidly. What is the probable reading of blood pressure that the student nurse could have obtained if the actual blood pressure of the client is 140/90 mm Hg?

130/100 mm Hg

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be?

33° C

Which scenario would contribute to health disparities?

An English-speaking nurse conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English.

The nurse is assessing a client who reports shortness of breath. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error?

Assess the client's lungs.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

Blood lab results

A nurse is assessing clients with gastrointestinal problems. Which client does the nurse suspect to have shigellosis?

Client 2

A nurse is assessing four different clients. Which findings depict that the client is at risk for heart disease?

Client 2 Bluish-Nail beds, lips, mouth, skin

while caring for four different clients, the nurse assess their breathing pattern. which clients assessment findings indicate cheyne-stokes respiration?

Client 3 irregular, alternating apnea and hyperventilation

A nursing student has prepared pulse assessment plans for several clients. Which client's assessment plan is correct and will yield effective results?

Client C

Which client is at a high risk for a rise in blood pressure based on the given data?

Client C 40 yrs old 50bpm, increased

The nurse is assessing the body temperature of four febrile clients over 4 days. Which client is suffering from remittent fever?

Client C: 103F, 101F, 104F, 102 F

While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness?

Cutting nails after soaking them for 10 minutes in warm water.

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client?

D. The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.

After conducting a falls risk assessment education session for the staff and observing falls risk assessment on the unit, which staff action needs review for correction?

Delegating falls assessment to assistive personnel

when interviewing and assessing a 17 year old client, which findings alert the nurse to explore substance abuse with adolescent?

Failing grades Blood Spots on clotting Absenteeism from school long-sleeved shirts in warm weather

The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement?

Find a way to interview the client in private

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply.

Flushed face Increased pulse rate

When preparing to assess a client with Clostridium Difficile, which piece of protective equipment is necessary for the nurse before entering the client room?

Full plastic Gown

While performing a neck assessment, the nurse finds the client has enlarged lymph nodes. The client also had a history of intravenous drug use and bisexual activity. What would be the possible diagnosis?

Human immunodeficiency virus (HIV) infection

A nurse is assigned to care for a newly admitted client. The nurse performs a physical assessment and reviews the admission form and the health care provider's prescriptions. What should the nurse identify as the priorities in this client's plan of care?

Hygiene and comfort

A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit?

Loss of body weight

When preparing to assess a client with active tuberculosis, which piece of protective equipment is necessary for the nurse before entering the client room?

N95 Respiratory Mask

which involuntary physiological response in a client experiencing pain should the nurse monitor for?

Perspiring

Which action would the nurse take upon entering an examination room for assessment of a confused client?

Plan a focused physical assessment

Which assessment items need to be documented on a client in restraints? Select all that apply. One, some, or all responses may be correct.

Pulse near the restrained area Temperature of the restrained area Skin integrity surrounding the restraint Behavior leading to the need for restraint

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Select all that apply.

Respiratory rate of 14 breaths/minute Blood pressure of 120/80 mmHg Oxygen saturation of 95%

Which interventions would the nurse suggest after a home assessment for fall risk in the older adult? Select all that apply

Securing rugs to prevent movement Removing excessive pieces of furniture Wearing corrective lenses for distance vision Performing exercises to strengthen lower extremities

When the nurse is assessing an older client as he or she walks into the examination room, which finding is documented as abnormal?

The client is wearing an excessive amount of cologne.

A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change?

The client may have a dysrhythmia

which related factor is appropriate for a nursing diagnosis

Trauma of incision

After presenting information about falls risk assessment to nursing staff, which reply needs review for correction regarding interventions that would be implemented?

We will use the admission fall assessment for the entire stay

the nurse is assessing the level of consciousness of four different clients. which client would have the lowest neurological function

client 2 opens on pain flaccid incomprehensible sounds

Which client is suspected of having hypertension based on the given data?

client B cardiac output increased peripheral resistance increased hematocrit increase

While assessing a pediatric client, an ophthalmologist notices that the child is unable to focus on an object with both eyes simultaneously. Which other findings in the client confirms the diagnosis as strabismus? Select all that apply.

crossed eyes appearance; impaired extraocular muscles

which client would the nurse anticipate needing a referral for a support group for people with vision loss?

obstruction of central vision

A 50-year-old client is diagnosed with chronic obstructive pulmonary disease. The clinical data on admission are as follows: a heart rate of 100 beats/min, a blood pressure of 138/82 mm Hg, a respiratory rate of 32 breaths/min, a tympanic temperature 98.2, and an oxygen saturation of 80%. Which vital signs obtained by the nurse indicates a positive outcome? SATA

respiratory rate, blood pressure, oxygen saturation

While assessing a client's skin, a nurse notices that the skin is dry. What is the probable etiology of the condition? Select all that apply.

use of hard soap frequent bathing

The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse use to form a data cluster? Select all that apply.

- The client reports pain with movement. - The client has pain over the surgical area .- The client rates the pain as 8 on a scale of 0 to 10.

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply.

1. Nursing diagnoses involve the client when possible 4. Nursing diagnoses involve the sorting of health problems within the nursing domain 5. Nursing diagnoses involve clinical judgment about the client's response to health problems.

The registered nurse (RN) is teaching the student nurse about various sites for assessing body temperature. Which statement(s) made by the student nurse is/are correct? Select all that apply. One, some, or all responses may be correct.

"The axilla is recommended to measure body temperature in unconscious clients." "The tympanic membrane is a preferred site of measuring body temperature in infants." "The temporal artery is a preferred site of thermometer placement to measure rapid changes in core temperature."

While demonstrating the method of measuring blood pressure to a student nurse, the registered nurse measures the blood pressure in a client as 130/80 mm Hg. After the demonstration, when the student nurse is measuring the blood pressure in the same client, it is found to be 120/90 mm Hg. What could be the possible reasons for this difference? (Choose all that apply)

1. Poor fitting of the cuff 3. Deflating the cuff too quickly

A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. What would be the client's total score? Record your answer using a whole number.

13

Which client is likely to have a health promotion nursing diagnosis?

The client who is willing to take a 30-minute walk daily.

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about having had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation?

Data collection by the nurse was incomplete, and as a result the treatment was insufficient