HA Hesi Vocab

A client with terminal cancer is to receive 2 mg of hydromorphone (Dilaudid) intravenously (IV) every four hours as needed for severe breakthrough pain. It is supplied at 10 mg/mL. When the client complains of severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place, including leading zero if applicable. ___ mL

0.2 Solve the problem using ratio and proportion. Desired 2 mg × x mL Have 10 mg 1 mL 10 x = 2 x = 2 ÷ 10 x = 0.2 mL

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. This condition is known as: 1 Osteoarthritis 2 Osteoporosis 3 Muscle atrophy 4 Contracture

Correct4 Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints due to wear and tear. Osteoporosis is a metabolic disease process where the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles due to a lack of physical activity or a neurological or musculoskeletal disorder.

Contracture

a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints.

benztropine (Cogentin) Class of drug:

anticholinergic

Hemoptysis

coughing up blood from the respiratory tract

circumstantial thought process

excessive and unnecessary detail, usually relevant to the question, ultimately gives way to an answer

Tangential thinking is

similar to circumstantial thought processes, but the person never answers the question or returns to the central point of the conversation

The nurse in the emergency department identifies that the admission consent form signed by a critically ill client is not legible. Which statement best reflects the status of this consent? 1 Consent is legal. 2 Signature is illegal. 3 Critically ill clients cannot sign a consent form. 4 Family members should sign for clients whose signatures are illegible.

Correct1 If a competent adult gives informed consent and the signature is witnessed, it is a legal document even if the signature is illegible or the client is critically ill. The signature is legal even if it is illegible. The signature is legal even if the client is critically ill. A co-signature is not required as long as the client is competent and the signature is witnessed.

The physician orders 7,500 units erythropoietin (Procrit) to be administered subcutaneously weekly. The vial reads 10,000 units per milliliter. How much erythropoietin will the nurse give for each weekly dose? Include a leading zero if applicable. Record your answer using two decimal places. _____ mL

0.75 The nurse solves the problem as follows: 10,000 units/7,500 units = 1 mL/X 10,000 X = 7,500 X= 7,500/10,000 or 0.75 mL

A client is to receive doxorubicin (Adriamycin) as part of a chemotherapy protocol. The nurse should assess for which major life-threatening side effect? 1 Pancytopenia 2 Cardiotoxicity 3 Pulmonary fibrosis 4 Ulcerative stomatitis

Correct2 Congestive heart failure and dysrhythmias are life-threatening toxic effects unique to doxorubicin. When bone marrow is depressed to precarious levels, the dose is altered or blood components are administered. Pulmonary fibrosis is not a side effect of doxorubicin or of any of the other antineoplastic agents. Ulcerative stomatitis is a very uncomfortable side effect but is not life threatening.

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? 1 Postural drainage 2 Cupping the chest 3 Nasotracheal suctioning 4 Frequent changes of position

Correct4 Frequent changes of position minimize pooling of respiratory secretions and maximize chest expansion, which aids in the removal of secretions; this helps maintain the airway and is an independent nursing function. Postural drainage and cupping the chest are part of pulmonary therapy that requires a health care provider's prescription. Nasotracheal suctioning will remove secretions once they accumulate in the upper airway, not prevent their accumulation.

A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan? 1 Assault is a threat to do bodily harm to another person. 2 It is a legal wrong committed by one person against the property of another. 3 It is a legal wrong committed against the public that is punishable by state law. 4 Assault is the application of force to another person without lawful justification.

Correct1 Assault is a threat or an attempt to do violence to another. Assault implies harm to persons rather than property. A legal wrong committed against the public that is punishable by state law is too broad to describe assault. Application of force to another person without lawful justification is the definition of battery.

The most appropriate time for a nurse manager to schedule a 30-minute nursing education class is: 1 On each employee's day off 2 At the overlap of each shift 3 During the first part of each shift after report 4 Any day of the week after the staff members' lunch breaks

Correct2 Scheduling the class at the half-hour overlap of each shift economically and conveniently accommodates the most staff members while ensuring that there are enough nurses present to care for clients. Scheduling an educational session when some staff members are not reimbursed for their time contributes to low morale and resentment. If the class is scheduled during the first half hour of a shift after report, client care may be jeopardized. The nurses on the previous shift will have left and the unit will be understaffed during the class. Scheduling the class any day of the week after the staff's lunch breaks provides education only to staff members working on the day shift; more than one class needs to be scheduled. In addition, it may leave the unit understaffed during the class.

A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child's emotional development? 1 It provides rewards and punishment. 2 The child's development is supported. 3 It reflects the mores of a larger society. 4 It is where child's identity and roles are learned.

Correct4 Socialization, values, and role definition are learned within the family and help develop a sense of self. Once established in the family, the child can move more easily into society. Although important, providing rewards and punishments, supporting the child's development, and reflecting the mores of society are just one aspect of the family's influence and are not as important as identity and roles in relation to emotional development.

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiologic change does the nurse attribute the decreased blood pressure? 1 Dilation of blood vessels 2 Decreased response of chemoreceptors 3 Decreased strength of cardiac contractions 4 Disruption of cardiac accelerator pathways

1 Paralysis of the sympathetic vasomotor nerves after administration of a spinal anesthetic results in dilation of blood vessels, which causes a subsequent decrease in blood pressure. These receptors are sensitive to pH, oxygen, and carbon dioxide tension; they are not related to hypotension and are not affected by spinal anesthesia. The strength of cardiac contractions is not affected by spinal anesthesia. The cardiac accelerator center neurons in the medulla regulate heart rate; they are not related to hypotension and are not affected by spinal anesthesia.

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse should include which question when completing the initial assessment? 1 "Does walking for long periods of time increase your pain?" 2 "Does standing without moving decrease your pain?" 3 "Have you had your potassium level checked recently?" 4 "Have you had any broken bones in your lower extremities?"

Correct1 Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose veins often develop vascular related complications. The nurse should recognize that the relationship of symptoms to exercise will clarify whether the presenting problem is vascular or musculoskeletal. Pain caused by a vascular condition tends to increase with activity. Musculoskeletal pain is not usually relieved when exercise ends. Low potassium levels can cause cramping in the lower extremities, however, given the client's health history, vascular insufficiency should be suspected. Previously healed broken bones do not cause cramping and pain.

A client has corrective surgery for a bladder laceration. What nursing intervention takes priority during this client's postoperative period? 1 Turning frequently 2 Raising side rails on the bed 3 Providing range-of-motion exercises 4 Massaging the back three times a day

Correct1 Frequent position changes are important to ensure urinary drainage; gravity promotes flow, which prevents obstruction. Raising side rails on the bed is not a priority unless the client is sedated. Range-of-motion exercises are of minimal importance because the client is able to move without limitation. Back care is necessary, but it is not the priority. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response.

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection: 1 To the client from outside sources. 2 From the client to others. 3 From the client by using special techniques to destroy infectious fluids and secretions. 4 To the client by using special sterilization techniques for linens and personal items.

Correct1 Protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents because the client's own immune defense ability is compromised (neutropenia). Protective environment isolation is also referred to as reverse isolation. The other answer options are incorrect concepts related to protective environment isolation.

An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in a response to this client's question? Select all that apply. 1 "Ask your health care provider how and when you should be taking your medications." 2 "Stop taking a prescribed medication if you are not feeling better in a few days." 3 "Discard medications into the toilet that have exceeded the expiration date on the bottle." 4 "Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy." 5 "Inform your health care provider of the over-the-counter drugs, recreational drugs, and amount of alcohol you ingest."

Correct1 Correct4 Correct5 If unsure about any information, the client should be encouraged to ask for further instructions and more information. A client needs to be proactive and should check all aspects of the prescription with the pharmacist before leaving the pharmacy. A pharmacist may have permission to substitute a generic form of the drug or may change the number of pills that deliver the prescribed dose, both of which can confuse the client (e.g., one tablet may deliver 50 milligrams of a drug and be equal to two 25-milligram tablets). Because of the risk of drug interactions associated with polypharmacy and altered age-related physiological functioning that can cause drug toxicity, the client should inform the health team about all drugs (e.g., prescription, over-the-counter, recreational), herbal preparations, and amount of alcohol ingested to ensure safety. A client should stop taking a prescribed medication only after consultation with the health care provider. Unused and expired medications should not be discarded into the toilet because they can contaminate groundwater.

A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson's conflict of: 1 Initiative versus guilt 2 Integrity versus despair 3 Industry versus inferiority 4 Generativity versus stagnation

Correct2 According to Erikson, poor self-concept and feelings of despair are conflicts manifested in those who are older than 65 years of age. The initiative versus guilt conflict is manifested in early childhood between 3 and 6 years of age. The industry versus inferiority conflict is manifested during the ages from 6 to 11 years. The generatively versus stagnation conflict is manifested during middle adulthood, 45 to 65 years of age.

A 90-year-old female resident of a nursing home falls and fractures the proximal end of her right femur. The surgeon plans to reduce the fracture with an internal fixation device. The general fact about the older adult that the nurse should consider when caring for this client is that: 1 Aging causes a lower pain threshold. 2 Physiological coping defenses are reduced. 3 Most confused states result from dementia. 4 Older adults psychologically tolerate changes well.

Correct2 Aging causes a lowering of the physiologic coping reserve of various systems of the body. The pain threshold increases with aging. There are many etiologies for confusion (e.g., drug intolerance, altered metabolic state, unfamiliar surroundings). As individuals age they become more entrenched in ideas, environment, and objects that are familiar, and thus do not tolerate change well.

A client is hospitalized for treatment of severe hypertension. Captopril (Capoten) and alprazolam (Xanax) 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? 1 Denial of illness 2 Fear of the health problem 3 Response to cerebral anoxia 4 Reaction to the antihypertensive drug

Correct2 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 female client explains to the nurse that she sleeps until noon every day and takes frequent naps during the rest of the day. What should the nurse do initially? 1 Encourage her to exercise during the day. 2 Arrange a referral for a thorough medical evaluation. 3 Explain that this behavior is an attempt to avoid facing daily responsibilities. 4 Identify that the client is describing clinical findings associated with narcolepsy.

Correct2 This behavior is a sign of hypersomnia and the client needs a medical assessment; it frequently is caused by central nervous system damage or certain kidney, liver, or metabolic disorders. Exercise is appropriate for a client experiencing insomnia, not hypersomnia. This behavior is a sign of hypersomnia and medical causes should be ruled out before attributing it to a psychogenic cause. Narcolepsy consists of recurrent sudden waves of overwhelming sleepiness that occur during the day, even during activities such as eating or conversing. Study Tip: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

A client with ascites is scheduled to receive albumin. To have the greatest therapeutic effect, the nurse expects what infusion rate and what oral fluid intake? 1 Slow intravenous (IV) rate and liberal fluid intake 2 Slow IV rate and restricted fluid intake 3 Rapid IV rate and withheld fluid intake 4 Rapid IV rate and moderate fluid intake

Correct2 When albumin is administered slowly and oral fluid intake is restricted, fluid moves from the interstitial spaces into the circulatory system so it can be eliminated by the kidneys. Administration should not exceed 5 to 10 mL/min. Oral fluids are restricted to facilitate the optimal effects of the albumin, which shifts fluids from the interstitial spaces to the intravascular compartment. Rapid administration may cause circulatory overload; fluid is restricted, not withheld. Unrestricted fluid intake will limit the shift of fluid from the interstitial to the intravascular compartment, interfering with the optimal effects of the albumin.

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? 1 Prejudice 2 Stereotyping 3 Assimilation 4 Ethnocentrism

Correct3 Assimilation involves incorporating the behaviors of a dominant culture. Maintaining eye contact is characteristic of the American culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike. Ethnocentrism is the perception that one's beliefs are better than those of others.

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? 1 Sunken eyes 2 Dry, flaky skin 3 Change in mental status 4 Decreased bowel sounds

Correct3 Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin and decreased bowel sounds, because these can be prominent as general normal findings in the elderly client.

The health care provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to: 1 Chemically stimulate the loop of Henle. 2 Diminish the thirst response of the client. 3 Prevent reabsorption of water in the distal tubules. 4 Cause fluid to move toward the interstitial compartment.

Correct3 Sodium absorbs water in the kidneys' renal tubules. When dietary intake of sodium is decreased, water is not reabsorbed and edema is reduced. A decrease in sodium will prevent the reabsorption of water. Furosemide stimulates the loop of Henle to inhibit the reabsorption of sodium and chloride at the proximal and distal tubules. Adequate hydration is the major factor that diminishes the thirst response. A low-sodium diet will help move fluid from the interstitial compartment to the intravascular compartment.

An 80-year-old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. The nurse's best response is: 1 "The body's fluid needs decrease with age because of tissue changes." 2 "Access to fluid may be insufficient to meet the daily needs of the older adult." 3 "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4 "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

Correct4 For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake. There are no data to support the statement "The body's fluid needs decrease with age because of tissue changes." The statement "Access to fluid may be insufficient to meet the daily needs of the older adult" is not true for an alert person who is able to perform the activities of daily living. Research does not support progressive memory loss in normal aging as a contributor to decreased fluid intake.

A surgical nurse provides a newly hired nurse with information about proper client positioning during surgery. Which statement made by the new nurse indicates a need for further instruction/clarification? 1 "Proper positioning should provide optimum exposure to the surgical site." 2 "Proper positioning intraoperatively maintains body alignment and protects bony prominences." 3 "The client's position during surgery allows for airway maintenance and access for medication administration." Correct4 "The client's position for the surgical procedure is determined solely by the circulating nurse."

The surgeon's preference for the client's intraoperative position is taken into consideration. Therefore, it is key that the circulating nurse communicate with the surgeon regarding the surgical approach required and his or her preference. Correct positioning during surgery ensures optimum exposure to the surgical site as well as maintenance of proper body alignment and protection of bony prominences. Proper positioning also supports airway maintenance and access for medications.

The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? 1 Upright at 90 degrees 2 Supine position 3 Raised to 30 degrees 4 Raised to 10 degrees

3 Raised to 30 degrees

The health care provider orders 1000 mL normal saline to be infused over 8 hours for a client with a diagnosis of dehydration. The intravenous (IV) tubing delivers 15 drops per milliliter (drop factor). The nurse should administer the IV infusion at a rate of ____ gtts/minute. (Record your answer using a whole number.)

Administering 1,000 mL over 8 hours is equal to administering 125 mL over 1 hour (60 minutes). To find the number of milliliters per minute: 125/60 min = X/1 minute 60X = 125X = 2.1 mL/minute To find the number of drops/minute: 2.1 mL/X gtts = 1 mL/15 gtts X = 31 gtts/minute

he nurse recognizes that a client is experiencing an anaphylactic reaction secondary to a drug hypersensitivity. What action should the nurse take first? 1 Administer oxygen. 2 Insert an IV catheter. 3 Take the vital signs. 4 Obtain an arterial blood gas analysis.

Correct1 Administering oxygen should be the first action of the nurse for this client. With anaphylaxis there is bronchial constriction and subsequent vascular collapse; therefore, the airway is of primary concern. The vital signs should be checked after beginning the administration of oxygen. At this point it would be appropriate to insert an IV catheter to administer emergency medications and possibly obtain an arterial blood gas analysis to determine oxygenation status.

The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? Incorrect1 Risk for pressure ulcer 2 Risk for impaired skin integrity 3 Impaired skin integrity, related to infrequent turning and repositioning 4 Impaired skin integrity, related to the effects of pressure and shearing force

Correct4 The impaired skin integrity is physiologically a result of unrelieved pressure and shearing force. This is supported by the data provided that the client is non-ambulatory and has a reddened sacrum. Risk for pressure ulcer is not an approved NANDA-I nursing diagnosis. The client's problem is not being "at risk" because the client already has an actual problem. Not enough information is provided to make the assumption that the impaired skin integrity is related to infrequent turning and repositioning.

When providing preoperative teaching, the nurse should focus primarily on: 1 Helping the client and family decide if surgery is necessary. 2 Providing emotional support to the client and family. 3 Giving minute-by-minute details of the surgery to the client and family. 4 Providing general information to reduce client and family anxiety.

Correct4 The primary role of the nurse during preoperative teaching is to provide general information about the surgical experience and what to expect before and after surgery. Helping the client decide if surgery is necessary is not an appropriate intervention for the nurse. It is also not appropriate for the nurse to describe minute-by-minute details of the surgery unless the client and family request this information, at which time the surgeon should answer the questions. Emotional support is important and would be included as part of providing general information to reduce client and family anxiety.

PANCYTOPENIA

deficiency of all three cellular components of the blood: red cells, white cells, and platelets

Cerebral hypoxia is a form of:

hypoxia ,reduced supply of oxygen, specifically involving the brain; when the brain is completely deprived of oxygen it is called cerebral anoxia.

intentional tort

is a category of torts that describes a civil wrong resulting from an intentional act on the part of the tortfeasor (alleged wrongdoer).

Cholecystectomy

is a surgical procedure to remove your gallbladder — a pear-shaped organ that sits just below your liver on the upper right side of your abdomen. Your gallbladder collects and stores bile — a digestive fluid produced in your liver.

Thought blocking is a

sudden stoppage of the train of thought or in the middle of the sentence