HESI Fundamentals of Nursing

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for what?

Blood Clotting Rationale:Calcium is important for blood coagulation. When tissue damage occurs, serum calcium is necessary to promote coagulation by activating certain clotting factors. Calcium acts as a catalyst in the clotting process in both the extrinsic and intrinsic pathways. Calcium is responsible for a number of body functions, such as bone health, blood clotting, and muscle contraction and nerve impulses; however, it is not directly related to bile and blood production or digestion of fats.

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment?

Pain history, including location, intensity, and quality of pain Pain pattern, including precipitating and alleviating factors Rationale:Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain, and its assessment helps the nurse anticipate and meet the needs of the client. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Assessment of the precipitating factors helps the nurse prevent the pain and determine its cause. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience, and therefore the nurse has to ask the client directly instead of accepting the statement of the family members.

A block nurse is caring for an elderly couple in the neighborhood. What kind of service does block nursing offer to the elderly clients?

Running Errands Rationale: Block nursing involves the services of nurses living within a neighborhood. The nurse generally provides services for older clients or those who are unable to leave their homes. Therefore running errands is one of the services offered by the block nurse. The primary health care provider's offices provide primary health care, which includes diagnostics and treatment. School health, occupational health, primary health care provider's offices, and community health centers provide health screening. Communicable disease control is offered by occupational health services.

A nursing student is learning about Henderson's theory. Which of these statements by the student indicates effective learning?

"Henderson's theory focuses on assisting an individual." "Henderson's theory defines the role of a nurse in helping a client achieve a peaceful death." "Henderson's theory describes the spiritual domain of an individual." Rationale: A client's self-care needs are best described under Orem's theory for maintaining health and well-being. As per Henderson's theory, there are 14 basic needs of an individual which should be fulfilled. Henderson's theory focuses on the nurse assisting an individual to carry out any daily activities that will contribute to an individual's health. The nurse should also help the client have a peaceful death in case of severe morbid conditions. Henderson's theory describes different domains of an individual's life such as the physiological, psychological, sociocultural, spiritual, and developmental domains.

A nurse is evaluating situations based on the responses of several clients. Which client's statement confirms that he or she has reached the Integrity versus Despair stage according to Erikson's theory of psychosocial development?

"Looking back at my entire life, I find that I have actually achieved nothing." "In the twilight of my life, I regret not fulfilling the promises I made to my wife." "Now that I am at the end of the road, I think I am the luckiest person on the earth because God has given me everything that I had asked for." Rationale:According to Erikson's theory of psychosocial development, the Integrity versus Despair stage deals with older adults who view their lives with a sense of satisfaction or consider themselves as failures. A client who says that he or she realizes that he or she has achieved nothing is in the Integrity versus Despair stage. Another example of this stage is a client who states that he or she regrets not fulfilling the promises made to his or her partner. A further example is a client who says that he or she believes himself or herself to be the luckiest person on the earth because God has given him or her everything that he or she had asked for. An example of the Intimacy versus Isolation stage is a client who says that he or she was in love but his or her partner ditched him or her for someone who is good-looking, An example of the Generativity versus Self-Absorption stage is a client who requests good medications that can help him or her get back to work as soon as possible in order to support his or her family.

A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect?

Contact Dermatitis Rationale: A client who is allergic to latex may experience an allergy after a physical examination with latex gloves. Itching is one of the clinical signs of latex allergy. Contact dermatitis is a delayed immune response that occurs 12 to 48 hours after exposure. Eczema is a skin condition that can be worsened with excessive drying. Hypersensitivity is an immediate allergic reaction that occurs due to chemicals that are used to make gloves. Anaphylactic shock is also an immediate allergic reaction that occurs due to natural rubber latex.

A client is hospitalized for treatment of severe hypertension. Captopril and alprazolam are prescribed. Shortly after admission, the client says, "I don't think any of you know what you are doing. You are just guessing what I need." What does the nurse determine as the probable cause of this behavior?

Fear of the health problem Rationale:Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear. There is no evidence that the client denies the existence of the health problem. Although disorders such as brain attacks and atherosclerosis, which are associated with hypertension, may lead to cerebral anoxia, there is insufficient evidence to support this conclusion. Captopril (an antihypertensive) is a renin-angiotensin antagonist that reduces blood pressure and does not cause behavioral changes; alprazolam is prescribed to reduce anxiety.

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding?

Fluid and electrolyte balance Rationale: Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and therefore not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and therefore not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and therefore is not the best choice.

A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the healthcare provider's writing. Who should the nurse ask for clarification of this prescription?

Healthcare provider who wrote the prescription Rationale: The healthcare provider who wrote the prescription should be called for clarification. The nurse is liable and responsible if the prescription is misinterpreted. Only the healthcare provider who wrote an undecipherable prescription can correctly clarify the prescription, not the nurse practitioner, house healthcare provider, or nurse manager.

Which of these measures does a nurse take during the working phase of a helping relationship?

Using appropriate self-disclosure and confrontation Rationale:During the working phase of a helping relationship, the nurse uses appropriate self-disclosure and confrontation. Evaluation of goal achievements with the client is performed during the termination phase. The nurse anticipates health concerns or issues that may arise during the preinteraction phase. The nurse prioritizes the client's problems and identifies his or her goals during the orientation.