Fund Hesi Nursing Process Evaluation

A client is scheduled for skin cancer surgery and has not signed the consent form. Which situation will cause the nurse to legally delay signing the operative consent?

A sedative type of medication has been given recently. Sedation may interfere with the client's knowledge of the consent form.

A 6-week-old infant has surgery for hypertrophic pyloric stenosis (HPS). When encouraged to participate in caring for her infant, the mother readily assists with all aspects of care but is reluctant to resume feeding her baby. The mother states, "I just can't stand to watch him choke and cough." What is the most likely reason that the mother does not feed her infant?

Afraid that her babies vomiting will resume. Previous experiences with projectile vomiting are frightening; the nurse should explain that this should not recur and encourage the mother to resume feeding her baby

An older adult client who has type 1 diabetes and chronic bronchitis is prescribed atenolol for the management of angina pectoris. Which clinical manifestation should alert the nurse to the fact that the client may be developing a life-threatening response to the drug?

Difficulty breathing Atenolol is associated with the adverse reactions of bradycardia, heart failure, and pulmonary edema; these are the most serious responses to atenolol

A client is admitted to the postanesthesia care unit after abdominal hysterectomy. Which assessment should the nurse report to the primary healthcare provider immediately?

Decreased urine output Accidental ligation of a ureter is a serious complication of total abdominal hysterectomy. A decrease in urine output should be reported immediately to the surgeon.

The nurse evaluates that the teaching about myasthenic and cholinergic crises is understood when a client who is diagnosed with myasthenia gravis states that which characteristic is common to both crises?

Difficulty Breathing Because of the decrease in tone and strength of the respiratory muscles, difficulty breathing is a prominent feature of both crises.

The registered nurse (RN) is teaching a novice RN about delegating tasks to licensed practical nurses (LPN) and unlicensed assistive personnel (UAP). Which statement made by the novice RN indicates a need for further teaching?

"I will delegate the task of assisting the client with bathing to the LPN" Assisting the client with bathing is related to providing basic care, comfort, and hygiene and is a task better suited to unlicensed assistive personnel.

A 17-year-old client tells the nurse that her sister had an ectopic pregnancy about 3 months ago and had to have her fallopian tube removed. The nurse determines that this young woman needs additional information when she makes which statement?

"My sister is lucky, because she won't have her period again"

A nurse who is observing a sleeping newborn at 2 hours of age identifies periods of irregular breathing and occasional twitching movements of the arms and legs. The neonate's heart rate is 150 beats/min; the respiratory rate is 50 breaths/min; and the glucose strip reading is 60 mg/dL (3.3 mmol/L). What does the nurse conclude that these findings indicate?

Expected adaptations During periods of active or irregular sleep, healthy newborns have some twitching movements and irregular respirations; the heart rate, respirations, and blood glucose level are within expected limits.

The nurse is teaching a client undergoing intravenous gentamicin therapy for the treatment of acute osteomyelitis. Which statement by the client indicates effective learning?

I should report any hearing loss to the HCP Acute oseteomyelitis is treated with antibiotics such as gentamicin. Gentamicin use can cause ear toxicity; therefore, the client should report any hearing loss to the primary healthcare provider.

While conducting prenatal teaching, the nurse should explain to clients that there is an increase in vaginal secretions during pregnancy called leukorrhea. What causes this increase?

Increased production of estrogen Increased estrogen production during pregnancy causes hyperplasia of the vaginal mucosa, which leads to increased production of mucus by the endocervical glands. The mucus contains exfoliated epithelial cells.

The nurse is teaching a client with multiple sclerosis methods to reduce fatigue. Which statement indicates an understanding of the education

Rest in an air conditioned room Fatigue is a common symptom in clients with multiple sclerosis[1][2]. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided.

The registered nurse delegates a task to the unlicensed assistive personnel (UAP). After the UAP starts the task, the registered nurse (RN) asks for feedback related to the task. Which right of delegation is the RN following?

Supervision The delegation right of supervision refers to obtaining feedback, monitoring, and evaluating the delegatee appropriately

A nurse is teaching a client with pruritus about personal care interventions. Which statement made by the client indicates the nurse needs to intervene?

"I will not file the edges of my fingernails" The nurse should intervene if the client states that fingernail edges will not be filed to correct this misconception. Rough edges of fingernails should regularly be filed to prevent skin damage and secondary infection

A primigravida in her first trimester visits the prenatal clinic for the first time. Which statement illustrates a psychologic reaction to pregnancy that usually occurs in the first trimester?

"I'm excited about the baby, but I'm not sure that I'm ready to be a mother." The response "I'm excited about the baby, but I'm not sure that I'm ready to be a mother" reflects the ambivalence about the pregnancy that is typical during the first trimester.

The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for hydrocephalus are taught about postoperative positioning that helps prevent pressure on the valve site. What statement indicates that they understand the teaching

"The flat left side-lying position is the safest position for our baby." The side-lying position on the unaffected side helps prevent pressure against the valve; the flat position prevents too-rapid drainage of cerebrospinal fluid.

A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required?

"We'll have to have the baby fitted with prosthetic devices before he'll be able to walk." Prosthetic devices are generally not needed for this condition.

A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 120/76 to 60/40, and the heart rate has risen from 82 to 121. Which does the nurse recognize as the most likely reason for the assessment findings?

Hemorrhagic shock The client has become hypotensive and tachycardic in response to hypovolemic or hemorrhagic shock related to acute blood loss from the long bone and pelvic fractures.

A nurse recalls that the focus of environmental (milieu) therapy is to do what?

Manipulate the clients environment to bring out positive changes in behavior. Environmental (milieu) therapy is aimed at having everything in the client's surroundings geared toward helping the client.

A vaginal examination reveals that a client's cervix is 90% effaced and dilated to 6 cm. The fetus's head is at station 0, and the fetus is in a right occiput anterior (ROA) position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor?

Midway through first stage of labor The cervix is 90% effaced and dilated 6 cm during the active phase of the first stage of labor. When the cervix is dilated 6 cm, the individual is beyond the early stage of labor.

A healthcare provider prescribes enalapril for a client. Which is the most important nursing action?

Monitor the clients blood pressure during therapy - meds that end in -pril are ACE inhibitors (stop angiotensin 1-> angiotension 2) and will effect blood pressure. (enalapril is an antihypertensive)_

A nurse provides education to a client with myasthenia gravis about how to prevent myasthenic crisis. The nurse evaluates that the teaching is effective when the client makes which statement?

My HCP may need to adjust the dosage of my medication if I'm more active Increased activity without an increase in medication can precipitate a myasthenic crisis[1][2]. Self-medication may result in drug interactions; a change in medical therapy can have serious consequences

A nurse is assessing a newborn with caput succedaneum. How does the nurse explain the cause of this fetal condition to the new mother?

Swelling of the soft tissue of the scalp as a result of pressure during labor Caput succedaneum is a diffuse pattern of edema above the periosteum; it results from an even distribution of pressure on the fetal head during labor.

The victims of a mass casualty are brought to the emergency department. One of the healthcare team members re-evaluates some of the clients and realizes the need for immediate transfer to the orthopedic care unit. Who would take up the responsibility of re-evaluation of the client's acuity

Triage officer The triage officer is responsible for evaluation of each person who is brought to the hospital with triage tags, and re-evaluation of client acuity for assignment of the client to the appropriate area within the emergency department