HESI Fundamentals

which statements regarding acne are correct

Stress and family history may cause acne formation. The causative organism is Propionibacterium acnes. acne is commonly found in the face chest upper back and neck rationale: acme is not a hormonal disease rather it is a skin disease due to hormonal imbalance

which is the priority intervention for the infant with developmental dysplasia of the hip

abduction of the hip will enable the head of the femur to fit into the acetabulum thereby correcting the dysplasia

which critical thinking skill demonstrates maturity in the nurse 1. eagerness to acquire knowledge 2. being tolerant of different views 3. trust in own reasoning processes 4. ability to reflect on own judgments

4. ability to reflect on own judgments rationale: trusts in his or her own reasoning process.

infant skills

6 to 8 months transfer object from hand to hand 10 to 12 months hold a pencil 8 to 10 months show a hand preference 10 to 12 months able to place objects in a container

The nurse is caring for a client with a hip replacement two days prior which nursing intervention with the nurse perform next 1. provide perineal care 2. turn in position the client 3. give a complete bed bath 4. document the bowel movement

1. provide perineal care providing perineal care helps preserve skin integrity for the client who is incapable of providing self-care turning in positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown but is not an immediate client need giving a complete bed bath is not necessary after each bowel movement because only the perineal areas typically soiled documenting the bowel movement should be done only after meeting immediate needs of the client

which approach is a comforting approach that communicates concern and support 1. touch 2. listening 3. knowing the client 4. providing a positive presence

1. touch is a comforting approach that involves reaching out to clients to communicate concern and support listening is a critical component of nursing care and is necessary for meaningful interactions with clients knowing the client comprises both the nurses understanding of a specific client and his or her subsequent selection of interventions providing presence is a person-to-person encounter thatconveys closeness and a sense of caring

antidiuretic hormone ADH

ADH is released by the posterior pituitary gland It is released mainly in response to either a decrease in blood volume or an increased concentration of sodium or other substances in the plasma It acts decrease the production of urine by increasing the reabsorption of water by renal tubes

Keller's motivational learning model

Keller proposed a motivational learning model that includes four factors: attention, relevance ,confidence and satisfaction. (ARCS) relevance strategies involve linking the person's needs interests and motives for learning the attention strategies include arousing and sustaining one's curiosity and interest confidence strategies include helping people develop a positive expectation for goal achievement satisfaction strategies provide extrinsic and intrinsic reinforcement for efforts

which assessment finding is associated with depression

The client has islands of intact memory. rationale: depression me occur with major changes in life A client with depression has selective or patchy memory loss with islands of intact memory A client with dementia has impaired recent and remote memory The onset of delirium may be a breast causing impaired reason and immediate memory a client with delirium is forgetful and requires step-by-step instructions to complete simple tasks

the five realms or processes of the family health system

The realms are interactive developmental coping integrity and health This approach is a method for family assessment used to determine areas of concern and strengths and to help develop an effective care plan The component of integrity includes family rituals family relationships are a part of interactive processes family life stressors and daily hassles are considered components of coping processes health processes include family care takings and responsibilities.

Venus insufficiency

Venus insufficiency occurs when vascular damage impedes the body's ability to move blood from the legs towards the heart This causes blood to cool in the legs where can cause swelling pain and in some cases leaking fluid in the skin or ulcers elevation of the legs above the level of the heart makes use of gravitational forces to drain blood through the veins towards the heart clients should not wear tight restrictive pants and should avoid wearing a girdle or garter which may impede venous return compression stockings prevent blood pulling elevating the upper extremities will not decrease edema in the lower extremities

paralytic ileus

after abdominal or pelvic surgery clients are at risk for paralytic alias as a result of receiving and anesthetic agent the nurse can prevent or minimize paralytic ilias by increasing movement as soon as possible after surgery through actions such as turning and early emulation evidence of bowel function returning to normal includes auscultation bowel sounds and passing of lattice and stool colitis stomatitis and gastrocolic reflux are not postoperative complications related to anesthetic agents

critical thinking skills

analysis- when information about a client is collected with an open mind, avoid making assumptions inference-when the data collected about the client helps in solving an existing problem, focus on the meaning of the findings and it's significance evaluation- used when the results of nursing actions are determined by looking at the data objectively interpretation- involved in the orderly collection of data explanation is the act of supporting your findings and conclusions as well as using knowledge and experience to choose strategies to use in the care of clients

anti embolisms elastic stockings

applying anti embolism elastic stockings in the morning before the legs are lower to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity

packed red blood cell transfusion

blood and blood products for transfusion should be infused/diluted only with 0.9% normal saline solution solutions other than normal saline or incompatible and may cause RBC destruction by hemolysis

Neutropenia

deficiency of neutrophils that compromises the client's immune defensibility so protective environment isolation would be directed to the client from outside sources, reverse isolation

which would the nurse consider to be the center of decision making when providing client care

ethics rationale a professional nurse always follows the ethics of care and considers caring to the center of decision-making The nurse must know what behaviors ethically appropriate while caring for a client The nurse is effectiveness and performing tasks is important to client care however client satisfaction comes from the effective dimension of care because ethics of care are unique to each client the nurse would not face decision-making only on analytical skills The nurse would not provide client care based only on intellectual principles or research knowledge caring is the most important factor because he considers client preferences and values

The nurse is caring for a client who has an implanted port how often would the nurse change the non-coring needle

every 7 days

to ensure the safety of a client who is receiving a continuous intravenous normal saline infusion the nurse would change the administration set how often

every 72 to 96 hours

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

explanation involves using knowledge and experience to choose strategies to use to care for clients evaluation is applicable when using criteria to determine the results of nursing actions interpretation is involved in the orderly collection of data self-regulation is applicable when the nurse identifies ways to improve his or her own performance

physiological changes by trimester

first trimester fatigue morning sickness breast enlargement second trimester increase libido third trimester Braxton Hicks contractions

which therapeutic communication technique is used when the nurse and a client have a conversation in the client begins to repeat the conversation to her self

focusing

which statement is true but the nursing model of team nursing

hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader and team leader to team members

which nursing process involves delegation and verbal discussion with the health care team

implementation. the implementation process involves delegation and verbal discussion with the health care team planning involves interpersonal or small group healthcare team sessions evaluation involves the acquisition of verbal and nonverbal feedback assessment involves verbal interviewing and talking with clients

goals of care associated with the family health system model

improving family health or well being providing assistance in family management of illness conditions achieving health outcomes related to the family's area of concern

which nursing interventions are classified under complex physiological domain according to the nursing interventions classification taxonomy

interventions to restore tissue integrity interventions to optimize neurological functions interventions to provide care before during an immediately after surgery

which intrinsic factors associated with the fall of an older adult

intrinsic risk factors would be lack of exercise or deconditioning. Wet floors poor lighting and inappropriate footwear are extrisnic factors

disease processes that place a client at risk for infection

leukemia lymphoma and emphysema

evaluation criterion

professional standard most important for critical thinking which skills and critical thinking requires the nurse to be orderly and data collection

which nursing practice is associated with a self-regulation skill

reflecting on one's experience

components of ethical decision making

responsibility refers to all duties and activities the nurse's employed to perform authority refers to the legitimate power of to give commands and make final decisions specific to a given position autonomy refers to the freedom of making choices and the responsibility for making those choices accountability refers to individuals being answerable for their actions

piagets theory of cognitive development

sensorimotor birth to two years old, preoperational p 2 to 7 years, concrete operational: performance of mental operations , formal operational: prevalence of egocentric thought

The nurse assesses bilateral plus 4 peripheral edema while assessing a client with heart failure and peripheral vascular disease which is the path of physiological reason for the excessive edema 1. shift of fluid into the interstitial spaces 2. weakening of the cell wall 3. increased intravascular compliance 4. increased intracellular fluid volume

shift of fluid into the interstitial spaces when the heart is unable to maintain adequate blood flow throughout the circulatory system the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces weakening of the cell wall may cause leakage of fluid but this is not the pathological reason related to heart failure increased intravascular compliance would prevent fluid from shifting into the tissue intercellular volume is maintained within the cell and not in the tissue.

which activity demonstrates fine motor skills and infants age two to four months?

showing good head control

which developmental change requires the nurse's assessment in a 12-year-old female

skeletal growth because girls are on the age of 12 years may develop scoliosis a lateral curvature of the spine

why would the nurse establish a moderately hard client-centered goals

to prevent the client from quitting before the goal is achieved to prevent the client from losing motivation towards achieving the goal If the girls are too hard to achieve the client may give up before completing however if the girls are too simple it may create a feeling that goals of no benefit or is not worth pursuing

fine motor skills in 8 to 10 month old infants

using pincer grasp well picking up small objects showing hand preference