HESI

A client with a history of hypothyroidism reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as heat stroke? 1. Increased heart rate 2. Increased blood pressure 3. Decreased respiratory rate 4. Increased circulatory damage

1 Prolonged exposure to the sun or a high environmental temperature overwhelms the body's heat-loss mechanisms. These conditions cause heat stroke, which manifests as giddiness, excessive thirst, and nausea. An increased heart rate (HR) characterizes a heat stroke. A low blood pressure (BP), increased respiratory rate, and increased circulatory and tissue damage are not indicators of heat stroke.

A student nurse is assessing the blood pressure of a client with the client's arm unsupported. What are the expected errors in the obtained readings? 1. False high reading 2.False low diastolic reading 3.False high systolic reading 4.False high diastolic reading

1 Repeated assessments of blood pressure too often result in a false high systolic reading. Deflating the cuff too slowly results in a false high diastolic reading.

Which response by the nurse during a client interview is an example of back channeling? 1. "All right, go on..." 2. "What else is bothering you?" 3. "Tell me what brought you here." 4. "How would you rate your pain on a scale of 0 to 10?"

1. Back channeling involves the use of active listening prompts such as "Go on...", "all right", and "uh-huh." Such prompts encourage the client to complete the full story. The nurse uses probing by asking the client, "What else is bothering you?" Such open-ended questions help to obtain more information until the client has nothing more to say. The statement, "Tell me what brought you here" is an open-ended statement that allows the client to explain his health concerns in his or her own words. Closed-ended questions such as, "How would you rate your pain on a scale of 0 to 10?" are used to obtain a definite answer. The client answers by stating a number to describe the severity of pain.

What is the correct order of steps of the nursing diagnostic process? 1. Assess the client's health status. 2. Cluster data. 3. Interpret the meaning of the data. 4. Validate the data with other sources. 5. Look for defining characteristics. 6. Formulate nursing diagnoses. 7. Identify the client's needs.

1. Assess health status 2. validate data with other sources 3. interpret the meaning of the data 4. cluster data 5. look for defining characteristics 6. ID client needs 7. formulate nursing diagnosis

Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply. 1. Interventions to restore tissue integrity 2. Interventions to optimize neurologic functions 3. Interventions to manage restricted body movements 4. Interventions to promote comfort using psychosocial techniques 5. Interventions to provide care before, during, and immediately after surgery

1. interventions to restore tissue integrity 2. interventions to optimize neurologic function 5. interventions to provide care before, during and after surgery

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding? 1. Skin condition 2. Fluid and electrolyte balance 3. Food intake 4. Fluid intake and output

2

Which statement best describes a diagnostic label? 1.It is a condition that responds to nursing interventions. 2.It describes the essence of the client's response to health conditions. 3. It describes the characteristics of the client's response to health conditions. 4.It is identified from the client's assessment data and associated with the diagnosis.

2

A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns can be expected in this client? 1. Spoon-shaped nails 2. Transverse depressions in nails 3. Softening of nail beds and flat nails 4. Red or brown linear streaks in nail bed

3

What is the appropriate blood pressure of a 12-year-old client? 1. 95/65 mm Hg 2. 105/65 mm Hg 3. 110/65 mm Hg 4. 119/75 mm Hg

3

Which therapeutic communication technique is useful when the nurse and a client have a conversation and the client begins to repeat the conversation to himself or herself? 1. Focusing 2. Clarifying 3. Paraphrasing 4. Summarizing

3 Focusing is a therapeutic communication technique that is useful when clients begin to repeat themselves. Clarification helps to check whether the client's understanding is accurate by restating an unclear or ambiguous message. Paraphrasing involves restating a message more briefly using one's own words. Summarizing is a concise review of key aspects of an interaction.

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1. The nurse notes nonverbal signs of discomfort. 2. The nurse observes the client's position in bed. 3. The nurse asks the client to explain the surgery. 4. The nurse asks the client to rate the severity of pain.

3 The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client's positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.

When caring for a client with venous insufficiency, the nurse would implement which nursing measure? 1. Apply abdominal girdle as needed. 2. Remove compression stockings for client ambulation. 3. Elevate the client's legs above heart level. 4.Keep the upper extremities elevated

3 Venous insufficiency occurs when vascular damage impedes the body's ability to move blood from the legs toward the heart. This causes blood to pool in the legs, where it can cause swelling; pain; and, in some cases, leaking fluid in the skin or ulcers. Elevation of the legs above the level of the heart makes use of gravitational forces to drain blood through the veins toward the heart. Clients should not wear tight restrictive pants and should avoid wearing a girdle or garter, which may impede venous return. Compression stockings prevent blood pooling. Elevating the upper extremities will not decrease edema in lower extremities.

An older adult in an acute care setting is experiencing emotional stress because of a recent surgery. Which intervention would be most appropriate for the client? 1. Touch 2. Reminiscence 3. Reality orientation 4. Validation therapy

3. Orientation Reality A client who has undergone surgery may experience emotional stress leading to disorientation. Reality orientation is an appropriate intervention to minimize the client's disorientation. Touch is a therapeutic tool that helps to induce relaxation, provide physical and emotional comfort, and communicate interest. Reminiscence helps to bring meaning and understanding to the present and resolve current conflicts by recollecting the past. Validation therapy is a communication technique that can help a client in a confused state.

Which integumentary finding is related to skin texture? 1. Elasticity 2.Vascularity 3.Fluid buildup 4. Character of the surface

4

Which positioning should be avoided while assessing a client with a history of asthma? 1. Sitting 2. Supine 3. Dorsal recumbent 4. Lateral recumbent

4

Which statement is true for collaborative problems in a client receiving healthcare? 1. They are the identification of a disease condition. 2. They include problems treated primarily by nurses. 3. They are identified by the primary healthcare provider. 4. They are identified by the nurse during the nursing diagnosis stage.

4. ID by nurse during diagnostic process The nurse assesses the client to gather information to reach diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary healthcare provider based on the results of diagnostic tests.

Which intervention reflects the nurse's approach of "family as a context"? 1. Trying to meet the client's comfort 2. Evaluating the client family's coping skills 3. Evaluating the client family's energy level 4. Trying to meet the client family's nutritional needs

ANS: 1 In the "family as context" approach, the focus is on the client. The nursing care aims at meeting the client's comfort, hygiene, and nutritional needs. The "family as a client" approach focuses on the family's needs as a whole to determine their coping skills. This approach also includes assessment of the family's energy level to determine if the family would be able to meet the client's needs. In addition, the approach "family as a client" involves assessment of the family's nutritional needs.

A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal? Select all that apply. 1. Loss of turgor 2.Urinary incontinence 3. Decreased night vision 4. Decreased mobility of ribs 5. Increased sensitivity to odors

loss of turgor, decreased night vision, decreased mobility of ribs