Nursing Vocab of different things to study for the HESI

A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition? 1- 1+ 2-2+ 3-3+ 4-4+

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+.

Keratoconus

Keratoconus is a noninflammatory disease, where the anterior cornea thins and protrudes forward, taking on a cone shape.

Corneal ulcer

Tissue loss due to an infection of the cornea causes corneal ulcers; the infection can be due to bacteria, a virus, or fungi.

What gross motor skill is observed in children between 8 and 10 months old? 1 The child can creep on his or her hands and knees. 2 The child has predominant inborn reflexes. 3 The child can sit alone without any kind of support. 4 The child can bear his or her weight on forearms when prone

A child between 8 and 10 months old can creep on his or her hands and knees. A child between birth and 1 month old has predominant inborn reflexes. A child between 6 and 8 months old can sit alone without support. A child between 2 and 4 months old can bear his or her weight on his or her forearms when in the prone position

ketoacidosis (*******)

A serious diabetes complication where the body produces excess blood acids (ketones).

While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. What score on the Lovett scale can be given to the client? 1 Fair (F) 2 Good (G) 3 Trace (T) 4 Normal (N

According to the Lovett score, a full range of motion against gravity with some resistance can be categorized as G (good). F (fair) can be given if the client exhibits a full range of motion with no resistance. T (trace) score is given when the client exhibits slight contractility with no movement. N (normal) on the Lovett scale indicates full range of motion against gravity with full resistance.

Which diagnostic scan is used to detect diffuse or localized muscle weakness? 1 Arthroscopy 2 Radiography 3 Myelography 4 Electromyography

An electromyography is performed to detect diffuse or localized muscle weakness by determining the electric potential generated in an individual. Arthroscopy is used for the direct visualization of ligaments, menisci, and articular surfaces of a joint. A radiography is performed to detect bone density, alignment, swelling, and intactness of a joint. A myelography is performed to visualize the vertebral column, intervertebral discs, spinal nerve roots, and blood vessels.

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history? 1 Attention span 2 Primary language 3 Coping mechanisms 4 Activity and coordination

Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

The nurse is assessing a newborn for developmental dysplasia of the hip (DDH). Where does the nurse look for extra skinfolds? 1 Calf muscles 2 Popliteal area 3 Back of the thigh 4 Lower portion of the abdomen

With DDH there are extra skinfolds on the affected thigh, a result of the displacement of the head of the femur in the acetabulum. There are no extra folds in the calf muscles, popliteal area, or lower part of the abdomen in DDH.

A school-aged child with type 1 diabetes is admitted to the pediatric unit in ketoacidosis. What sign of ketoacidosis does the nurse expect to identify when assessing the child? 1 Sweating 2 Hyperpnea 3 Bradycardia 4 Hypertension

Deep, rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a compensatory mechanism associated with metabolic acidosis. Sweating is a physiological response to hypoglycemia. Tachycardia, not bradycardia, results from the hypovolemia caused by the polyuria associated with ketoacidosis. Hypotension, not hypertension, may result from the decreased vascular volume caused by the polyuria associated with ketoacidosis.

The nurse understands that research demonstrates that malnutrition occurs in as many as 50% of hospitalized clients. The nurse should assess a postoperative client with anorexia for what sign of malnutrition? 1-Dependent edema 2-Spoon-shaped nails 3-Loose, decayed teeth 4-Delayed wound healing

Delayed wound healing often is caused by a lack of nutrients, such as protein and vitamin C, in the diet. Dependent edema usually occurs with severe protein deficiency and heart failure. Spoon-shaped nails usually occur with iron deficiency anemia. Loose, decayed teeth usually indicate prolonged malnutrition.

A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? 1 "Do you have chest pain?" 2 "Are you feeling anxious?" 3 "Do you have any palpitations?" 4 "Are you feeling short of breath?

Females may present with atypical symptoms of myocardial infarction, such as absence of chest pain, overwhelming fatigue, and indigestion. Anxiety, palpitations, and shortness of breath are common clinical manifestations in both males and females who are experiencing a myocardial infarction.

A nurse is caring for a client with endocrine problems. Which lab finding will alert the nurse that aldosterone will be released? 1 Hypokalemia 2 Hypoglycemia 3 Hyponatremia 4 Hypochloremia

Hyponatremia stimulates the secretion of aldosterone. Hypoglycemia inhibits the secretion of insulin. Hyperkalemia, not hypokalemia, stimulates the secretion of aldosterone. Hypochloremia is associated with increased levels of antidiuretic hormone.

What is the priority nursing intervention for a school-aged child with lead poisoning who is undergoing chelation therapy? 1 Scrupulous skin care 2 Provision of a high-protein diet 3 Careful monitoring of intake and output 4 Daily blood sampling for liver function tests

Kidney function must be adequate to excrete the lead; if it is not adequate, nephrotoxicity or kidney damage may result. Skin breakdown is not associated with chelation therapy. A high-protein diet is not necessary. Liver damage does not occur with chelation therapy.

Which drug is administered to women after delivery to prevent postpartum uterine atony and hemorrhage but is not given to augment labor? 1 Dinopristone 2 Mifepristone 3 Indomethacine 4 Methylergonovine

Methylergonovine is given to prevent postpartum uterine atony and hemorrhage but should not be used for the augmentation of labor or during a spontaneous abortion. Dinopristone is to terminate a pregnancy. Mifepristone is also used to induce an elective termination of a pregnancy. Indomethacin is used to maintain a pregnancy during preterm labor.

Which should the nurse anticipate for a 5-year-old client related to play? Select all that apply. 1-Solitary play 2-Parallel play 3-Dress-up play 4-Team sport play 5-Cooperative play

The 5-year-old preschool-age client would be expected to participate in dress-up play due to the preoccupation with magical thinking and the beginnings of cooperative play. Solitary play is expected for the infant and toddler. Parallel play is expected for the toddler and young preschool-age client. Team sport play is expected for the school-age client.

A client is receiving oxycodone postoperatively for pain. The healthcare provider's prescription indicates that the dose should be administered every 3 hours for eight doses. What should the nurse assess before administering each dose of oxycodone? 1 Respiratory rate and level of consciousness 2 Color, character, and amount of urine output 3 Intravenous site and patency of the intravenous catheter 4 Amount and character of drainage in the portable drainage system

Oxycodone is an opioid that depresses the central nervous system, resulting in a decreased level of consciousness and depressed respirations. The medication should be administered, delayed, or held, depending on the client's status. Although urinary output of postoperative clients should be assessed, urinary output is not related directly to the administration of opioid medications. Oxycodone is administered via tablets, not intravenously. Wound drainage is unrelated to the administration of oxycodone.

A group of bomb blast victims needs to be transported to the hospital immediately. Which staff members of an emergency unit are most appropriate to handle this situation? 1 Triage officer 2 Medical command physician 3 Prehospital care providers 4 Emergency medicine physician

Prehospital care providers are the first caregivers who provide transport to the emergency department by ambulance or helicopter for clients in an emergency situation. Triage officers are responsible for evaluating each client to determine priorities for treatment. The medical command physician decides the number, acuity, and resource needs of clients. Emergency medicine physicians have specialized education and training in emergency client management.

While assessing a newborn the nurse notes the following findings: arms and legs slightly flexed; smooth, transparent skin; abundant lanugo on the back; slow recoil of the pinnae; and few sole creases. What complication does the nurse anticipate in light of these findings? 1 Polycythemia 2 Hyperglycemia 3 Postmaturity syndrome 4 Respiratory distress syndrome

The assessment findings are indicative of a preterm infant; therefore the nurse should monitor the infant for signs of respiratory distress syndrome. Polycythemia may develop in a preterm large-for-gestational-age (LGA) infant; however, there are no data to indicate that the infant is LGA. Preterm infants may become hypoglycemic, not hyperglycemic. The neonate is preterm, not postterm.

Which physical assessment of the skin indicates that a client is addicted to phencyclidine? 1 Burns 2 Vasculitis 3 Diaphoresis 4 Red and dry skin

Red and dry skin is associated with phencyclidine abuse. A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse. Diaphoresis is associated with chronic abuse of sedative hypnotics.

Retinal detachment

Retinal detachment is separation of the sensory retina and the underlying pigment epithelium with fluid accumulation between the two layers.

The nurse is reviewing the amount of drainage on the dressing of a client after discharge from the postanesthesia care unit (PACU). On which area should the nurse focus for this assessment? 1 Foley catheter 2 Nasogastric tube 3 Intravenous fluids 4 Surgical incision site

Reviewing the amount of drainage on the dressing of a client is an observation the nurse would make when reviewing the surgical incision site. Focused assessment of the Foley catheter and the nasogastric tube should be made when observing tubes attached to client after an operation. When observing the intravenous fluids, the nurse should check for the type of infused solution.

Strabisms

Strabismus is a condition of double vision; it can be due to neuromuscular problems of the eye.

Which result does the nurse anticipate when providing care to a preschool-age child who successfully completes tasks associated with this stage of Erikson's theory of psychosocial development? 1 Faith and optimism 2 Devotion and fidelity 3 Direction and purpose 4 Self-control and willpower

Successful resolution of initiative versus guilt, which happens between the ages of 3 and 6 according to Erikson, results in direction and purpose. Resolution of trust versus mistrust (birth to 1 year) results in faith and optimism. The resolution of identify versus role confusion (puberty) results in devotion and fidelity. The resolution of autonomy versus shame and doubt (1 to 3 years) leads to self-control and willpower.

A child who is recently admitted to school is introverted and prefers being alone at the school. What is the temperament of the child according to Stella Chess and Alexander Thomas's longitudinal study? 1 The easy child 2 The difficult child 3 The hyperactive child 4 The slow to warm-up child

The child will be categorized as a slow to warm-up child. These children are uneasy or cautious in new situations or with unfamiliar people. They react negatively with mild intensity to new stimuli. An easy child is open and adaptable to change and displays a mild-to-moderately intense mood that is typically positive. A difficult child adapts slowly to new routines, people, or situations. This type of child has intense mood expressions with negative behavior. A hyperactive child usually has problems concentrating and paying attention.

Tissue loss due to an infection of the cornea causes corneal ulcers; the infection can be due to bacteria, a virus, or fungi. 1. Evaluating the client's adjustment to the unit 2.Providing the client with a sense of security and safety 3. Exploring the client's memory loss and fear of going out 4.Assessing the client's perception of reasons for the hospitalization

The client is anxious and afraid of leaving home; the priority is the client's safety and security needs. Unless the client is provided with a sense of security, adjustment probably will be unsatisfactory, because the anxiety will most likely escalate. Exploring the client's memory loss and fear of going out cannot be done until anxiety is reduced. The client is experiencing memory loss and may not be able to remember what precipitated admission to the hospital; some memory loss may be a result of high anxiety and thought blocking.

After a mass causality scene, the nurse finds that a group of victims with minor injuries arrived to a hospital in a private vehicle. Which disaster triage tag does the nurse finds on victims? A Red B Black C Green D Yellow

The green-tagged victims have minor injuries, can move themselves to hospital from a mass causality scene in a private vehicle, and are also called "walking wounded" victims. Red- tagged victims can't ambulate themselves as they are severely injured. The black-tagged victims are dead or expected to die and require ambulances to transfer them. The yellow-tagged victims can have large wounds that require assistance to ambulate.

What are the most common hormones produced in excess with hyperpituitarism? Select all that apply. 1 Prolactin 2 Growth hormone 3 Luteinizing hormone 4 Antidiuretic hormone 5 Melanocyte-stimulating hormone

The most common hormones produced in excess with hyperpituitarism are prolactin and growth hormone. Excessive stimulation of luteinizing hormone and antidiuretic hormone is also associated with hyperpituitarism, but less commonly than prolactin and growth hormone. Secretion of melanocyte-stimulating hormone stimulates adrenocorticotropic hormone, which indirectly stimulates the pituitary gland, thus leading to hyperpituitarism.

How many words should the nurse expect the 3-year-old child to acquire each day? 1 2 to 3 2 5 to 6 3 8 to 10 4 11 to 13

The nurse would expect the 3-year-old toddler-age child to acquire 5 to 6 new words each day. Two to 3 new words, 8 to 10 new words, and 11 to 13 new words are not expected parameters for language development.

The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy, and crackles can be felt. How does the nurse describe this assessment finding? 1 Stridor 2 Crepitus 3 Pitting edema 4 Chest distention

There is air in the tissues, and palpation results in a crackling sound referred to as crepitus. Stridor is a harsh, high-pitched sound usually produced on inspiration because of airway obstruction. Pitting edema is excessive accumulation of fluid in tissue spaces. The size of the chest is determined by the bony structure; a barrel chest with an increase in the anteroposterior (AP) diameter is associated with chronic obstructive pulmonary disease (COPD), not cancer of the lung.

Which clinical manifestation occurs in a client with vasopressin deficiency? 1 Impotence 2 Hypotension 3 Amenorrhea 4 Decreased libido

Vasopressin regulates fluid level and blood pressure. A vasopressin deficiency causes hypotension. Impotence, amenorrhea, and decreased libido in both men and women are clinical manifestations of luteinizing and follicle-stimulating hormone deficiencies.