HESI 4

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client? 1. Airborne precautions 2. Droplet precautions 3. Contact precautions 4. Protective environment

3. Contact precautions should be used for direct client or environmental contact with blood or body fluids from an infected client. This includes colonization of infection with multidrug-resistant organisms (MDRO) such as methicillin-resistant Staphylococcus aureus (MRSA), stool infected with Clostridium difficile, draining wounds where secretions are not contained, or scabies. Airborne precautions are used for infected droplets smaller than 5 mcg, such as measles, chickenpox (varicella), or pulmonary tuberculosis (TB). Droplet precautions are used for droplets larger than 5 mcg and when within 3 feet (0.9 m) of the client, such as streptococcal pharyngitis, mumps, and influenza. Protective environment focuses on clients with a compromised immune system to protect them from incoming pathogens.

Which nursing actions may help in effective assessment of older clients? Select all that apply. 1. The nurse makes eye contact with the client. 2. The nurse leans backward during the interaction. 3. The nurse smiles at the clients during the interaction. 4. The nurse shrugs her shoulders in response to a client's question 5. The nurse asks the clients to express details as quickly as possible.

A: 1 & 3 The nurse should make eye contact while interacting with the client. It shows that the nurse is interested to hear client issues. The nurse shows positivity and of good humor with a smile during an interaction. The nurse should lean forward while interacting with the client; this shows attention and interest. The nurse should answer questions verbally, not simply with body language. Older adults may need time to think and answer; therefore, the nurse should allow pauses and time while asking client to explain anything.

A client complains of anxiety before a diagnostic procedure. The nurse explores and collects a thorough assessment to find the reason for client's anxiety. Which critical thinking attitude is involved in this situation? 1. Discipline 2. Confidence 3. Responsibility 4. Thinking independently

A: 1. The nurse shows discipline in collecting a thorough assessment to find the source of the client's anxiety. Confidence involves completing a task or goal such as performing a procedure or making a diagnostic decision. Responsibility is applicable when performing a nursing skill by following standard care practices. Thinking independently involves reading the nursing literature, talking with other nurses, and sharing ideas about nursing interventions.

The nurse is assessing a client using the family health system (FHS). Which question should the nurse ask to assess the interactive process of the family? 1. "Who are the members of your family?" 2. "Does the family prepare and follow a budget?" 3. "How do the family members manage their health care?" 4. "Does any member of the family have any chronic illness?"

A: 1. Using the FHS, the nurse can determine if the client's family is nuclear, blended, or a single-parent family when the client speaks about the different members in the family. This question helps the nurse to identify the client's relationships and determine the family's interactive processes. The nurse examines the family's coping processes by inquiring if the client adheres to a budget. The nurse examines the health processes of a family by assessing the health patterns and health management. The nurse may also identify chronic illnesses that may be stressful to the family.

A nurse developed and implemented a discharge teaching plan based on the specific needs of a hospitalized client. Which element of decision-making does the primary nurse exhibit in this situation? 1. Authority 2. Autonomy 3. Responsibility 4. Accountability

A: 2. Autonomy refers to the freedom of making choices and the responsibility for making those choices. A professional nurse can make independent decisions and plan nursing care for a client within the scope of the nursing practice. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Responsibility refers to duties and activities an individual is employed to perform. Accountability refers to individuals being answerable for their actions.

A client has a platelet count of 49,000/mL (40 × 10 9/L). The nurse should instruct the client to avoid which activity? 1. Ambulation 2. Blowing the nose 3. Visiting with children 4. The semi-Fowler position

A: 2. Clients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma. The nurse should instruct the client to avoid blowing the nose, because this activity can increase the risk of bleeding. Ambulation, visiting with children, and the semi-Fowler position are not contraindicated with thrombocytopenia.

The nurse is using non-verbal active listening skills during a clinical therapeutic encounter with a client. Which non-verbal action best conveys engagement in this client interaction? 1. Sitting with a relaxed posture 2. Leaning toward the client 3. Making eye contact 4. Facing the client

A: 2. Leaning toward the client during a therapeutic communication encounter is the best way to convey engagement in a client interaction. Sitting with a relaxed posture conveys that the nurse may be comfortable but not necessarily engaged in the encounter. Facing the client can convey that the nurse is interested in what the client is saying, but the nurse may not yet be engaged in this encounter. Making eye contact can convey the nurse's willingness to listen to the client, but it does not demonstrate engagement in this interaction as well as leaning toward the client does.

The way individuals cope with an unexpected hospitalization depends on many factors. However, what is the one that is most significant? 1. Cognitive age 2. Past coping styles 3. Financial resources 4. General physical health

A: 2. Lifelong coping styles are most important in how a person will deal with stress. Age may influence defense mechanisms, but lifelong coping styles will most significantly affect a person's behavior. Financial resources and general physical health are factors to be considered, but past coping ability is the most significant factor to predict future coping.

What is a characteristic of the primary nursing model? 1. Care can be delegated. 2. Care is provided by the registered nurse to the client during a stay in a facility. 3. The registered nurse is responsible for all aspects of care for one or more clients during a shift of care. 4. The registered nurse leads a team of other registered nurses, practical nurses, and unlicensed assistive personnel.

A: 2. The primary nursing model includes one primary registered nurse who provides care to the same client during their stay in a facility. According to the total client care model, the care can be delegated. Total client care also involves the registered nurse being responsible for all the aspects of care for one or more clients during a shift of care. The team nursing model requires the registered nurse to lead a team of other registered nurses, practical nurses, and unlicensed assistive personnel.

The nursing team is providing care for a client. The team leader develops client care plans and coordinates care among the team members. Which member of the team acts as a team leader? 1. Charge nurse 2. Registered nurse 3. Licensed practical nurse 4. Unlicensed assistive personnel

A: 2. The registered nurse acts as a team member by creating a care plan for the client and coordinating the care among the team members. The registered nurse works directly with the client, family, and healthcare team members. The charge nurse assigns tasks to the other healthcare professionals if the registered nurse is absent. The licensed practical nurse provides care to the client under the supervision of registered nurse. The unlicensed assistive personnel are team members who provide care to the client under the supervision of the registered nurse.

The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is what? 1. White blood cell (WBC) count of 8200/mm 3 (8.2 X 10 9/L) 2. Bilateral 3+ pitting pedal edema 3. Oral temperature of 101.3° F (38.5° C) 4. Pale skin and nail beds

A: 3. An elevated temperature of 101.3° F (38.5° C) is most indicative of a systemic infection. A WBC count of 8200/mm 3 (8.2 X 10 9/L) is within the normal range of 5000 to 10,000/mm 3 (5 to 10 X 10 9/L). Pedal edema is generally not related to an infectious process. Pale skin and nail beds may be related to an infectious process, but not necessarily.

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on which principle about learning? 1. It reduces general anxiety. 2. It is negatively affected by aging. 3. It requires continued reinforcement. 4. It necessitates readiness of the learner.

A: 3. Neurologic aging causes forgetfulness and slower response time; repetition increases learning. The principle that learning reduces general anxiety is a general principle applicable to all learning. The older adult has no more difficulty learning than a younger person, although it may take longer. The principle that learning necessitates readiness of the learner is a general principle applicable to all learning.

A client who is receiving a screening test for tuberculosis (TB) asks the nurse what a positive reaction will mean. What should the nurse explain that a positive reaction indicates? 1. A depressed immune system 2. An active tuberculosis infection 3. A previous exposure to the organism 4. An imminent tuberculosis infection

A: 3. The presence of antibodies indicates past exposure to or infection with an organism that may be presently dormant. A positive response does not indicate the status of the immune system. A positive response does not necessarily indicate active TB infection; a purified protein derivative (PPD) test administered to an individual with active TB may cause a severe reaction. A positive PPD test does not predict forthcoming exposure or infection; it only indicates past exposure to the organism.

Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client? 1. Abnormal rapid heart rate 2. Abnormal rapid breathing 3. Increased body temperature 4. Increased expired carbon dioxide

A: 4. The first sign of malignant hyperthermia[1][2] is increased expired carbon dioxide, caused by an abnormal and continuous contraction of the skeletal muscles. Due to metabolic changes in the skeletal muscles, there may be abnormal rapid breathing (tachypnea) and abnormal rapid heart rate (tachycardia), but it is not considered the first sign of malignant hyperthermia. Increased body temperature is often late to appear during malignant hyperthermia.