Exam 1 Hesi

The nurse assesses an older client with cognitive impairment. Which statement(s) made by the client confirm the nurse's conclusion? SATA. a. "I have difficulty judging things." b. "I occasionally forget to take medications." c. "I am unable to do financial calculations." d. "I sometimes get confused about the proper date or time." e. "I am unable to recall words during conversations with my family."

a. "I have difficulty judging things." c. "I am unable to do financial calculations." e. "I am unable to recall words during conversations with my family."

Which intervention would the nurse implement when providing health education to an elderly client? a. Assess the client for pain before teaching. SATA. b. Take notes while talking to the client. c. Ensure that the client is not preoccupied or anxious. d. Explain one concept at a time based on the client's interest. e. Teach a family caregiver if the client does not respond quickly.

a. Assess the client for pain before teaching. c. Ensure that the client is not preoccupied or anxious. d. Explain one concept at a time based on the client's interest.

Which feature distinguishes the nursing diagnosis from the medical diagnosis? SATA. a. Nursing diagnoses involves the client when possible. b. Nursing diagnoses are based on the results of diagnostic tests and procedures. c. Nursing diagnoses are the identification of a disease condition in the client. d. Nursing diagnoses involve the sorting of health problems within the nursing domain. e. Nurses diagnoses involve clinical judgment about the client's response to health problems.

a. Nursing diagnoses involves the client when possible. d. Nursing diagnoses involve the sorting of health problems within the nursing domain. e. Nurses diagnoses involve clinical judgment about the client's response to health problems.

Which nursing intervention would the nurse include in the plan of care for a client after a hip replacement? SATA. a. Place a pillow between the client's legs. b. Require the client to sit in an armless chair. c. Cross the client's legs at the ankles and knees. d. Require the client to use an elevated toilet seat. e. Keep the client's hip in a neutral, straight position.

a. Place a pillow between the client's legs. d. Require the client to use an elevated toilet seat. e. Keep the client's hip in a neutral, straight position.

Which situation belongs to the first level of needs according to Maslow's hierarchy? SATA. a. a client who is homeless b. a client reports feeling dizzy for 2 days c. a client reports a neighbor frequently d. a client reports an inability to consume food because of throat pain e. a client with a leg amputation reports they will walk one day

a. a client who is homeless b. a client reports feeling dizzy for 2 days d. a client reports an inability to consume food because of throat pain

Which is a normal finding during the regular checkup of an older adult? SATA. a. loss of turgor b. urinary incontinence. c. decreased night vision d. decreased mobility of ribs e. increased sensitivity to odors

a. loss of turgor c. decreased night vision d. decreased mobility of ribs

When obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include? SATA. a. pain history, including location, intensity, and quality of pain b. client's purposeful body movement in arranging the papers on the bedside table c. pain pattern, including precipitating and alleviating factors d. vital signs, such as increased blood pressure and heart rate e. the client's family statement about increases in pain with ambulation

a. pain history, including location, intensity, and quality of pain c. pain pattern, including precipitating and alleviating factors

Which methods qualify as alternative therapies for pain? SATA. a. prayer b. hypnosis c. medication d. aromatherapy e. guided imagery

a. prayer b. hypnosis d. aromatherapy e. guided imagery

When assessing an older adult male client, which clinical finding would the nurse expect as a response to the aging process? SATA. a. slowed neurological responses b. lowered intelligence quotient c. long-term memory impairment d. forgetfulness about recent events e. reduced ability to maintain an erection

a. slowed neurological responses d. forgetfulness about recent events e. reduced ability to maintain an erection

The nurse is explaining the nursing process to a student nurse. Which step of the nursing process would include interpretation of data collected about the client?

Assessment

The nurse is performing nursing care therapies and including the client as an active participant in care. Which step in the nursing process is involved in this situation?

Implementation

Which point requires correction regarding wellness promotion in the older adult? SATA. a. "Older adults need to prevent injuries when promoting wellness." b. "Curing diseases or other illnesses completely is essential to promote wellness in the older adult." c. "It is important to assess the level of fear of falling and provide support accordingly when caring for older adults." d. "It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries." e. "An older adult should live in social isolation to prevent stress."

b. "Curing diseases or other illnesses completely is essential to promote wellness in the older adult." d. "It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries." e. "An older adult should live in social isolation to prevent stress."

Which nursing intervention would the nurse implement when providing postoperative care for a client who had a below-the-knee amputation? a. Maintain strict bed rest for 2 days postprocedure to reduce dependent edema. b. Elevate residual leg slightly while keeping the knee joint straight for first 24 hours. c. Hemorrhage rarely occurs during the early postoperative period. d. The surgeon will change the dressing within 48 hours after the procedure.

b. Elevate residual leg slightly while keeping the knee joint straight for first 24 hours.

The nurse leader finds a client, with a severe vitamin B12 deficiency, is extremely fatigued and at risk for falls. Which theory would the nurse anticipate the nurse leader would utilize to prioritize the client's needs? a. Role theory b. Maslow's theory c. Complexity theory d. Situational leadership theory

b. Maslow's theory

Which client situation will the nurse address first on priority basis of Maslow's hierarchy of needs? a. feels like is leading a worthless life b. has multiple fainting episodes due to lack of proper nutrition c. shows signs of lack of interest in carrying out social interaction d. conveys to the nurse that is estranged from all family members

b. has multiple fainting episodes due to lack of proper nutrition

The nurse is getting ready to perform an initial assessment interview of an older adult who does not speak English and is hard of hearing. Which should be available before starting the interview to minimize communication problems that may lead to health disparity? a. wheelchair and hearing aid b. hearing aid and interpreter c. interpreter and sphygmomanometer d. wheelchair and sphygmomanometer

b. hearing aid and interpreter

The nurse is completing an assessment on an older adult who fell and fractured the left hip. Which clinical indicator would the nurse identify as typical with a fractured hip?" a. left hip is ecchymotic b. left leg is noticeable shorter than the right c. left leg is internally rotated d. left leg is tender when touched

b. left leg is noticeable shorter than the right

After an above-the-knee amputation of the right leg, a client reports pain in the right foot. Which reason would the nurse explain to the client for the phantom limb pain? a. tactile illusions are associated with severed blood vessels b. nerve endings in the limb are still intact and react to stimuli c. an unconscious phenomenon aids with grieving over the lost body part d. hallucinations are secondary to the emotional distress of amputation

b. nerve endings in the limb are still intact and react to stimuli

After a home assessment of an older adult's fall risk, which intervention would the nurse suggest? SATA. a. dimming lighting to avoid squinting b. secure rugs to prevent movement c. remove excessive pieces of furniture d. wear corrective lenses for distance vision e. perform exercises to strengthen lower extremities

b. secure rugs to prevent movement c. remove excessive pieces of furniture d. wear corrective lenses for distance vision e. perform exercises to strengthen lower extremities

A client has a right above-the-knee amputation after trauma sustained in a work-related accident. Upon awaking from surgery, the client states, "What happened to me? I don't remember a thing." Which is the nurse's best response? a. "Tell me what you think happened." b. "You will remember more as you get better." c. "You were in a work-related accident this morning." d. "It was necessary to amputate your leg after the accident."

c. "You were in a work-related accident this morning."

Upon assessing an older client with a diagnosis of dehydration, which finding would the nurse identify as an early sign of dehydration? a. sunken eyes b. dry, flaky skin c. change in mental status d. decreased bowel sounds

c. change in mental status

A client involved in an accident says, "I have a dream of conquering the world's highest mountain range." According to Maslow's hierarchy of needs, to which level of need does the given scenario refer to? a. physiological needs b. self-esteem needs c. self-actualization needs d. safety and security needs

c. self-actualization needs

After a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. Which approach would the nurse take when interacting with this client? a. Explain why there is a need to increase activity b. Emphasize that with a prosthesis, there will be a return to the previous lifestyle. c. Appear cheerful and noncritical regardless of the client's response to attempts at intervention. d. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving

d. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving

Which step in the research process is similar to the assessment step of the nursing process? a. analyzing the results b. conducting the study c. developing hypothesis d. identifying the problem

d. identifying the problem

Which age-related finding would the nurse expect to discover when assessing an older adult client? a. big, wide opened eyes b. presence of facial hair c. a bruise on the elbow d. walking with the neck bent forward

d. walking with the neck bent forward