HESI Exam Semester 2

jaundice

yellow skin The sclera is the best site to inspect for jaundice. Because the skin may become pale due to anemia or jaundice, a skin inspection is not recommended.

A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition?

4+ Edema of 8 mm is documented as 4+. If the edema has a depth of 2 mm, then it is documented as 1+. If the edema has a depth of 4 mm, it is documented as 2+. If the edema has a depth of 6 mm, then it is documented as 3+.

Normal Temp Range

97-99

Diagnostic Label

A diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association International (NANDA-I). It describes the essence of the client's response to health conditions in as few words as possible. The etiology of a nursing diagnosis is a condition that responds to nursing interventions. All NANDA-I approved diagnoses have a definition that describes the characteristics of the client's response to health conditions. The related factor of a nursing diagnosis is identified from the client's assessment data and associated with the diagnosis.

Different nursing roles

A nurse administrator's function is to prepare the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development. A certified registered nurse anesthetist provides surgical anesthesia under the guidance and supervision of an anesthesiologist. The nurse practitioner provides comprehensive care and directly manages the medical care of clients who are healthy or have chronic conditions. Nurse educators provide knowledge about current nursing practices, trends, theories, and necessary skills in laboratories and clinical settings. A case manager is an advanced practice nurse who coordinates a client's acute care in the hospital and follows up with the client after discharge. A nurse manager delegates work appropriately to the nursing staff on the unit. A registered nurse provides direct care to the client at the bedside. The nurse executive is often the vice president or strategic director of nursing in a healthcare organization.

A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes?

A nurse should provide a personal point of view During the process of negotiating outcomes, the nurse is required to provide a personal point of view. Negotiations may take place informally at the client's bedside or in a formal setting. After gathering relevant information regarding an ethical dilemma, the nurse is required to examine his or her own values and formulate an opinion regarding the matter. When verbalizing the problem, the group agrees to a statement of the problem to begin discussions. This step is performed before negotiating outcomes. Negotiations take place after determining all possible courses of action.

Pulses

A pulse strength of 3+ is considered full or strong. A bounding pulse is 4+. A pulse strength is considered normal and expected when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+.

Which interview technique is the nurse using when asking a client to score the pain on a scale from 0 to 10?

Closed-ended question Asking a client to score pain on a scale of 0 to 10 is a type of closed-ended question. These types of questions specify the cause of the problem or the client's experience of the illness. Asking whether anything else is bothering the client is an example of probing. A response by the nurse such as "All right," or "Go on," when a client says something is called back channeling. This interview technique encourages a client to provide more details. The nurse asks open-ended, nonspecific questions such as "What brought you to the hospital today?" to elicit the client's side of story. Such questions are related to the client's health history and can strengthen the nurse-client relationship.

In a clinical study, subjects were given chlorhexidine and betadine as antiseptics. How will a nurse researcher categorize this research?

Experimental research The nurse will categorize this study as experimental research. In experimental research, the investigator gives variables randomly to the subjects. In this case, subjects are given chlorhexidine and betadine to test their efficacy in reducing infection. Evaluation research is an initial study that refines a hypothesis, such as testing a new exercise in older dementia clients. In a descriptive study, the characteristics of a person or a situation are measured. For example, a researcher may examine the nurses' bias while caring for obese clients. Correlational research is used to find out the relationship between different variables without the interference of a researcher. An example would be determining the educational status of nurses and their satisfaction with the job provided.

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.

What critical thinking skill is applicable when knowledge and experience is used to care for clients?

Explanation When the nurse is using his or her experience to care for clients, the skill called explanation is involved. Analysis is applicable when the information is collected with an open mind. Evaluation is applicable when the information is used to determine nursing actions. Interpretation is involved when orderly data is collected.

interviewing techniques

Exploring is a technique used to obtain more information to better understand the nature of the client's statement. Reflecting is a technique used to either reiterate the content or the feeling message. In content reflection (paraphrasing), the nurse repeats basically the same statement; in feeling reflection, the nurse verbalizes what seems to be implied about feelings in the comment. Refocusing is bringing the client back to a previous point; there is no information that this was discussed previously. Acknowledging is providing recognition for a change in behavior, an effort a client has made, or a contribution to a discussion

Types of motivation

If the client is not motivated, then the client may not attempt to eradicate the illness and feel depressed because of the illness. If the client is intrinsically motivated, then the client shows more interest in taking their medications on their own rather than because of pressure from other individuals. The client is motivated extrinsically with or without self-determination when they may take medication regularly when reminded to do so or when pressured by others.

A client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, what is the best nursing intervention in this situation?

Immediately involve pastoral services while caring for the client. The Macmillan nurse usually has the knowledge of advanced practice and possesses specialty training. This practice enhances the nurse to gain an in-depth knowledge about spiritual, social, and psychologic needs and the pathophysiology of clients living with advanced diseases. Therefore the nurse involves pastoral services while caring for the client. Involving a family member may decrease anxiety in the client but may not fulfill the wishes of the client. Just listening to the client's request without implementation or giving false promises can cause loss of trust in the client.

Which skill in critical thinking requires to be orderly in data collection?

Interpretation Interpretation is involved in the orderly collection of data. When information about a client is collected with an open mind, then the skill called analysis is being used. When the data collected about the client helps in solving an existing problem, then the skill called inference is being used. Evaluation is used when the results of nursing actions are determined.

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.

While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. What might be the type of skin lesion involved?

Macule A macule is a flat, nonpalpable change in skin color, which is smaller than 1 cm. A wheal is a localized edema, usually caused by a mosquito bite. Wheals are irregular in shape and have elevated surfaces. Papules are palpable, circumscribed solid elevations in the skin, smaller than 1 cm. Vesicles are small, circumscribed skin elevations, filled with serous fluid.

Medicare

Medicare is a health insurance program for people 65 years or older. The payment for the plan is deducted from monthly individual social security checks.

skin signs with different substance abuse

Needle marks of the skin indicate opioid abuse. Diaphoresis indicates sedative hypnotic abuse. Red, dry skin indicates phencyclidine abuse. Spider angiomas indicate alcohol abuse.

Which theory focuses on developing the interpersonal relationships between the nurse, client, and the client's family?

Peplau's Peplau's theory focuses on interpersonal relationships between the nurse, the client, and the client's family by developing the nurse-client relationship. Orem's theory focuses on the client's self-care needs. Leininger's theory recognizes the importance of culture and its influence on everything that involves the client and the providers of nursing care. Henderson's theory focuses on assisting the individual in the performance of activities that he or she can perform unaided that will contribute to health, recovery, or a peaceful death.

Which position is indicated to assess the musculoskeletal system and is contraindicated in clients with respiratory difficulties?

Prone Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Sims position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

Which nursing practice is associated with the self-regulation skill?

Reflecting on one's own experience Self-regulation involves reflecting on the nurse's experience. Evaluation involves reflecting on the nurse's own behavior. Explanation involves supporting findings and conclusions. Interpretation involves clarifying any data about which the nurse is uncertain.

The student nurse is reviewing the electronic health record for clients in a health care facility. Which action by the student nurse may inhibit clients from disclosing personal information?

Sharing client's data with family members Clients may not want their health information shared with others and may want to maintain their privacy. If the nurse retrieves client data from the electronic health records and shares it with family members, it may lead to clients not sharing information. The nurse can use client data for research without mentioning a client's personal details. The nurse can use client data for filing insurance to receive Medicaid payments. The nurse can discuss the client's illness with the client; doing so helps to understand the client's perspective and to provide effective care.

concomitant pain

Symptoms that accompany the primary symptom of the illness and worsen the health condition are called concomitant symptoms. An example is nausea that may accompany the primary symptom of pain

Medicaid

The Medicaid plan is a federally funded, state-run program that provides health insurance for low-income families

Which feature is characteristic of a risk nursing diagnosis?

The diagnosis does not have related factors A risk nursing diagnosis describes human responses to health conditions that may develop in a vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the nurse plan preventive measures. A health promotion nursing diagnosis can be applied to any individual with a desire to enhance health behaviors in any health state. An actual diagnosis is formed when the defining characteristics support the diagnostic judgment. There must be sufficient nursing assessment data to establish an actual diagnosis. A health promotion nursing diagnosis is a clinical judgment of an individual's readiness to increase well-being.

Maslow's Hierarchy of Needs

The third level contains love and belonging needs, which includes friendship, social relationships, and sexual love. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. The hierarchy of basic human needs includes five levels of priority. The second level includes safety and security needs, which involve physical and psychological security. The final level is the need for self-actualization.

Which assessment is expected when a client is placed in the lithotomy position during physical examination?

To assess the female genitalia Lithotomy position in female clients is used to assess and examine female genitalia and genital tracts. The lateral recumbent position is indicated in clients to assess the heart. The knee-chest position and Sims position are recommended for clients undergoing rectal examinations. The prone position is indicated in clients to assess the musculoskeletal system.

Which pulse site is used to perform Allen's test?

Ulnar The ulnar pulse site is used to perform Allen's test (to assess blood flow in hand). The brachial pulse site is used to assess the status of circulation to the lower arm and to auscultate blood pressure. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The dorsalis pedis site is used to assess the status of circulation in the foot.

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find?

brown or black mole with red, white, or blue areas Melanomas have an irregular shape and lack uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades over time. A patchy loss of skin pigmentation indicates vitiligo.

A nurse changing the dressing on the client's perineum would fall into which zone?

intimate zone Changing a client's dressing on the perineum falls under the intimate zone. For this action, the appropriate interpersonal distance between the nurse and the client should be between 0 and 18 inches. A nurse lecturing a class of students or speaking at a community forum lies within a public zone. A personal zone refers to a nurse sitting on the client's bedside, taking a client's history, or teaching a client individually. The vulnerable zone is where special care is needed.

pallor

pale skin The palms and conjunctiva are inspected to assess pallor.

The nurse finds that the client's fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of?

remittent In a remittent pattern, fever spikes and falls without returning to normal temperature levels. Periods of febrile episodes coupled with periods of acceptable temperature values are called a relapsing pattern. A constant body temperature continuously above 38° C (100.4° F) with little fluctuation refers to a sustained pattern. In an intermittent pattern, fever spikes are interspersed with normal temperature levels.

What is exploratory research?

study designed to develop or refine a hypothesis about the relationships among phenomena Exploratory research is an initial study designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena. Evaluation research is a study that tests how well a program, practice, or policy is working. Correlational research is a study that explores the interrelationships among variables of interest without any active intervention by the researcher. Descriptive research is a study that measures characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur.