HESI Practice - Fundamentals of Nursing Fall 2023

When conducting a client interview, which nurse's response is an example of back channeling? -"All right, go on..." -"What else is bothering you?" -"Tell me what brought you here." -"How would you rate your pain on a scale of 0 to 10?"

-"All right, go on..." **Such prompts encourage the client to complete the full story. **Probing: "What else is bothering you?" such open ended questions help obtain more information unit the client has nothing more to say. **open ended statements allows clients to explain his or her health concerns in their own words. **Close ended questions are used to obtain a definite answer.

During a routine physical, a 50 year old client asks why a stool specimen for occult blood testing was prescribed. Which response would the nurse utilize? -"You will need to ask your healthcare provider; this test is not part of the usual test for people your age." -"There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." -"Starting at your age, this test is performed routinely as part of an assessment for colon cancer." -"There must have been a positive finding after your healthcare provider performed a digital rectal examination."

-"Starting at your age, this test is performed routinely as part of an assessment for colon cancer."

Which documentation would the nurse utilize to report that a client's degree of edema has a depth of 8mm? -1+ -2+ -3+ -4+

-4+

Planning to provide self care health information for several clients, which client would the nurse anticipate will be most motivated to learn? -A 55 year old client who had a mastectomy and is very anxious about her body image -An 18 year old client who smokes cigarettes and is in denial about the dangers of smoking -A 56 year old client who had a heart attack last week and is requesting information about exercise -a 47 year old client who has a long leg cast after sustaining a broken leg and is still experiencing severe pain

-A 56 year old client who had a heart attack last week and is requesting information about exercise

Which definition does the World Health Organization (WHO) use to define "health"? -A condition when people are free of disease -A condition of life rather than pathological state -An actualization of inherent and acquired human potential -A state of complete physical, mental, and social well being

-A state of complete physical, mental, and social well being

Which potential health problem would the nurse include in the young adult's discharge teaching? -Kidney dysfunction -Cardiovascular disease -Eye problems, such as glaucoma -Accidents, including their prevention

-Accidents, including their prevention **Accidents are common during young adulthood because of immature judgement and impulsivity associated with this stage of development. **Cardiovascular disease is common in middle adulthood. **Glaucoma is common in older adults.

Which principle refers to the professional obligation of the nurse to assume responsibility for actions? -Accountability -Individuality -Responsibility -Bioethics

-Accountability

When informing the healthcare provider of a client requesting pain medication after surgery, which role did the nurse play? -Educator -Manager -Advocate -Administrator

-Advocate

Which nursing process would the nurse undertake when collecting the medical history of a client? -Diagnosis -Evaluation -Assessment -Implementation

-Assessment

While assessing the carotid pulses, which term refers to a blowing sound created by blood turbulence when passing through narrowed arteries? -Bruit -Ectropion -Entropion -Borborygmi

-Bruit **A bruit is an audible vascular blowing sound associated with turbulent blood flow through a carotid artery. **Ectropion is a condition in which the eyelid is turned outward away from the eyeball. **Entropion is a malposition resulting in an inversion of the eyelid margin. **Borborygmi are rumbling or gurgling noises made by the movement of fluid and gas in the intestines.

The nurse applies a cold pack to relieve musculoskeletal pain. Which rationale explains the analgesic properties of cold therapy? -Promotes analgesia and circulation -Numbs the nerves and dilates the blood vessels -Promotes circulation and reduces muscle spasms -Causes local vasoconstriction, preventing edema and muscle spasms

-Causes local vasoconstriction, preventing edema and muscle spasms **Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents selling and muscle spasms. May also numb the nerves and surrounding tissues, thus reducing pain.

Which statement is not true of concepts? -Concepts consist of interrelated theories. -Concepts help describe or label phenomena. -Concepts that affect the client system are physiological, psychological, sociocultural, developmental, or spiritual. -Concepts can be simple or complex and relate to an object or event that comes from individual perceptual experiences.

-Concepts consist of interrelated theories. **A theory consists of interrelated concepts.

Which statement describes a client in the stage of contemplation in the stages of change? -Considers change within the next 6 months -No intention of making changes within the next 6 months -Actively engages in strategies to change behavior; this lasts up to 6 month -Displays sustained change over time; this begins 6 months after action has started and continues indefinitely

-Considers change within the next 6 months

Which purpose describes the Nurse Practice Acts? -Describe and define the legal boundaries of nursing practice within each state -Reflet the knowledge and skills possessed by nurses practicing in their profession -Provide requirements that describe the minimum acceptable nursing care -Protect individuals from losing their health insurance when changing jobs by providing portability

-Describe and define the legal boundaries of nursing practice within each state **They help distinguish between nursing and medical practice and establish education and licensure requirement for nurses.

Which role is the nurse fulfilling when explaining the reason for the intravenous infusion and kit to the client? -Educator -Manager -Advocate -Caregiver

-Educator

Which variable is an internal variable? -Family practices -Emotional factors -Cultural background -Socioeconomic factors

-Emotional factors

Which program is least likely to focus on medication delivery process modification? -Evaluation research -Quality improvement -Experimental research -Performance improvement

-Experimental research

Which research design would the nurse researcher utilize when examining subjects responses to chlorhexidine and povidone iodine as antiseptics? -Evaluation research -Descriptive research -Correlation research -Experimental research

-Experimental research **The investigator gives variables randomly to the subjects. **Evaluation an initial study that refine a hypothesis such as testing a new exercise in older patients with dementia. **Descriptive the characteristics of a person or a situation are measured. **Correlation find out the relationship between different variables without the interference of a researcher.

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

-Explanation **Explanation requires knowledge and experience for choosing strategies for care for clients. **Analysis requires open mindedness while looking at the clients information ** Inference is not associated with noticing relationships in the findings. **Interpretation is associated with ordered data collection

The nurse is discussing discharge plans with a client. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." Which interviewing technique did the nurse use? -Exploring -Reflecting -Refocusing -Acknowledging

-Exploring **Exploring is technique used to obtain more information to better understand the nature of the client's statement. **Reflecting: either reiterate the content or the feeling message. the nurse repeats the same question. **Refocusing is bringing the client back to a previous point. **Acknowledging is providing recognition for a change in behaviors, an effort a client has made, or a contribution to a discussion.

School health nursing programs have which goal? -Health promotion -Disease management -Chronic care management -Environmental surveillance

-Health promotion

A client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, which is the correct nursing intervention in this situation? -Immediately involve pastoral services while caring for the client. -Involve the family member in the clients care instead of pastoral support. -Listen to the client's request for support and then carry on with the clinical work. -Family promise that pastoral services has been contacted and plan to see the client.

-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 psychological needs and the pathophysiology of clients living with advanced diseases. The nurse involves pastoral services while caring for the client.

Which step in the nursing process would involve promoting a safe environment for the client? -Planning -Diagnosis -Assessment -Implementation

-Implementation

Which skill in critical thinking requires the nurse to be orderly in data collection? -Analysis -Inference -Evaluation -Interpretation

-Interpretation **Interpretation is involved in the orderly collection of data. **Analysis: when information about a client is obtained with an open mind **Inference: when the data collected about the client helps in solving an existing problem **Evaluation: the results of nursing actions are determined

Which database would the nurse use to find studied related to allied health sciences? -EMBASE -MEDLINE -National Guidelines Clearinghouse -Cochrane Database of Systematic Reviews

-MEDLINE **The MEDLINE database includes studied in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. **EMBASE includes biomedical and pharmaceutical studies. **The National Guidelines Clearinghouse includes repository for structured abstracts about clinical guidelines and their development. It also includes a condensed version of the guidelines. **Cochrane Database includes full text of regularly updated systematic reviews reprared by the Cochrane Collaboration as well as completed reviews and protocols.

Which statement correctly describes middle range theories? Select all that apply. -These theories are systematic and broad in scope and complexity. -Middle range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. -These theories do not address a specific phenomenon and do not reflect practices such as administration, clinical, or teaching. -Middle range theories include Mishel's theory if uncertainty in illness, which focuses on a client's experiences with cancer while living with continual uncertainty. -These theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations.

-Middle range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. -Middle range theories include Mishel's theory if uncertainty in illness, which focuses on a client's experiences with cancer while living with continual uncertainty. -These theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations.

Which point would the nurse not associate with grand theories of nursing? -Require further specification through research -Systematic and broad in scope and complex -Mishel's theory of uncertainty in illness -Do not provide guidance for specific nursing interventions

-Mishel's theory of uncertainty in illness **Mishel's theory of uncertainty in illness is not an example of a grand theory; it is a middle range theory.

Which member of the interprofessional team in a palliative care setting serves as the client advocate, evaluating the physical, emotional, and spiritual needs of the client? -Nurse -Pharmacist -Music therapist -Primary health care provider

-Nurse

Which client assessment finding would the nurse document as subjective data? -Blood pressure 120/82 beats/min -Pain rating of 5 -Potassium 4.0 mEq -Pulse oximetry reading of 96%

-Pain rating of 5

Which group benefits from Medicare? -Self insured employers -People who are 65 years or older -Members of low income families -Children who are not poor enough for Medicaid

-People who are 65 years or older

Which theory focuses on developing the interpersonal relationships between the nurse, client, and the clients family? -Orem's theory -Peplau's theory -Leininger's theory -Henderson's theory

-Peplau's theory

Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues? -Palpation -Inspection -Percussion -Auscultation

-Percussion

Which activity places a client at risk for hyperthermia? -Snowmobiling -Skiing in the winter -Hiking Alaskan mountains -Performing strenuous activity in high humidity

-Performing strenuous activity in high humidity **Reduces heat loss from the body and results in hyperthermia. **The other activities may cause hypothermia because they occur in cold temperatures and may lower body temperature.

An adolescent client with sickle cell anemia is experiencing a painful episode and has a PCA pump. The current pain rating is 5 on a scale of 1 to 10 at the right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. Which action would the nurse implement? -Turning on the television for diversion -Placing the prescribed as needed warm, wet compress on the elbow -Calling the primary healthcare provider for another analgesic prescription -Informing the client gently that they must wait until the pump reactivates to get more medication

-Placing the prescribed as needed warm, wet compress on the elbow

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? -Planning -Evaluation -Assessment -Implementation

-Planning

Two nurses are planning to help a client with one sided weakness move up in bed. Which principle of body mechanics would the nurses observe? -Instruct the client to position one arm on each shoulder of the nurses. -Direct the client to extend the legs and remain still during the procedure. -Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. -Position the nurses on either side of the bed with their feet apart, gather the turn sheet close to the client, turn toward the head of the bed, and then move the client.

-Position the nurses on either side of the bed with their feet apart, gather the turn sheet close to the client, turn toward the head of the bed, and then move the client.

Which cation regulates intracellular osmolarity? -Sodium -Potassium -Calcium -Calcitonin

-Potassium **A decrease in potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. **Sodium: most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid base balance. **Calcium: extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.

Which function is the role of the nurse administrator in a healthcare setting? -Providing surgical anesthesia under the guidance and supervision of an anesthesiologist -Preparing the budget, staffing, strategic planning of programs and services, employee evaluation, and employee development -Providing comprehensive care by directly managing the medical care of clients who are healthy or who have chronic conditions -Educating staff about current nursing practices, prends, theories, and necessary skills in laboratory and clinical settings

-Preparing the budget, staffing, strategic planning of programs and services, employee evaluation, and employee development

The nurse is caring for a child who has an external fixation device on the leg. Which is the nurse's priority goal when providing pin care? -Easing pain -Minimizing scarring -Preventing infection -Avoiding skin breakdown

-Preventing infection

Which term would the nurse use to document a client with drooping of the eyelid over the pupil? -Ptosis -Ectropion -Entropion -Nystagmus

-Ptosis

Which nursing practice is associated with self regulation skill? -Reflecting on one's experience -Contemplating one's own behavior -Supporting one's findings and conclusions -Clarifying any data that one is uncertain about

-Reflecting on one's experience

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? -Relapsing -Sustained -Remittent -Intermittent

-Remittent

While assessing a client after surgery, which finding would the nurse obtain from the primary source? -X-ray reports -Severity of pain -Results of blood work -Family caregiver interview

-Severity of pain

Which variable is an example of an external variable? -Spiritual factors -Developmental issues -Socioeconomic factors -Perception of functioning

-Socioeconomic factors

The nurse assesses a client's pulse rate and recorded the score as 3+. Which descriptor reflects the strength of the pulse? -Strong -Bounding -Expected -Diminished

-Strong

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. What is it important for the nurse to inform the client of? -That the client is acting irresponsibly. -That this action violates the hospital policy. -That the client must obtain a new primary healthcare provider for future medical needs. -That the client must accept full responsibility for possible undesirable outcomes

-That the client must accept full responsibility for possible undesirable outcomes

When developing a nursing diagnosis for a client after surgery, the nurse documents the "related to" factors as first time surgery. Which assessment activity enabled the nurse to draw this conclusion? -The nurse notes nonverbal signs of discomfort. -The nurse observes the client's position in bed. -The nurse asks the client to explain the surgery. -The nurse asks the client to rate the severity of pain.

-The nurse asks the client to explain the surgery. **The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery.

Which characteristic would the nurse associate with collaborative problems experienced by a client? -They are the identification of a disease condition. -They include problems treated primarily by nurses. -They are identified by the primary healthcare provider. -They are identified by the nurse during the nursing diagnosis stage.

-They are identified by the nurse during the nursing diagnosis stage.

Which is the role of a case manager in a healthcare organization? -To delegate work on the unit suitably -To follow up with the client after discharge -To provide direct care for the client at the bedside -To unite the strategic direction of the organization

-To follow up with the client after discharge

In which sequence of techniques would the nurse assess a client's abdomen? -Palpation -Inspection -Auscultation -Percussion

1. Inspection 2. Auscultation 3. Percussion 4. Palpation