HESI BSN 246 Part II

The client is being scheduled for a positron emission tomography (PET) scan. The nurse provides which of the following explanations to the client?

"The test detects abnormal glucose metabolism in the brain."

The client is having a diagnostic workup for colorectal cancer. Which of the following factors in the client's history will place the client at increased risk of this type of cancer? Select all that apply.

-A diet high in fats -A diet high in carbohydrates -A history of inflammatory bowel disease

The nurse notes during assessment and history taking that the older client exhibits visual changes. Which of the following are normal age-related changes of the eye? Select all that apply.

-Decreased visual acuity -Decreased tolerance of glare -Decreased peripheral vision

The student nurse is assisting with an assessment of a client's level of consciousness using the Glasgow Coma Scale. The student understands that which of the following categories of client functioning are included in this assessment? Select all that apply.

-Eye opening -Best verbal response -Best motor response

The client who sustained a severe sprain of the ankle is told by the physician that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which of the following interventions should the nurse anticipate will be included in the client's plan of care? Select all that apply

-Ice bags -Elevation -Compression by an elastic bandage

The client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which of the following actions are planned to promote client safety? Select all that apply.

-Provide the client with a soft toothbrush. -Instruct the client to use an electric razor. -Monitor all secretions for frank or occult blood.

The nurse teaching a group of adults about cancer warning signs presents to the group a list of the seven possible warning signs of cancer that is used by the American Cancer Society. What should this list include? Select all that apply.

-Sores that do not heal -Nagging cough or hoarseness -Indigestion or difficulty swallowing -Change in bowel or bladder habits

The nurse collecting data related to the client's risk factors associated with osteoporosis would include which of the following? Select all that apply.

-Thin body build -Smoking history -Postmenopausal age -Chronic corticosteroid use -Family history of osteoporosis

The nurse caring for a client admitted to the hospital with acute back pain understands that this problem can be most likely caused by which of the following? Select all that apply.

-Twisting of the spine -Hyperflexion of the spine -Herniation of an intervertebral disk

The nurse notes that the older adult client has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. The nurse correctly interprets the finding as alterations in blood vessels of the skin and defines them as:

Cherry angioma

The client has been diagnosed with gout. In developing a teaching plan for this client, the nurse should include a list that identifies which of the following foods to be avoided?

Chicken Liver

The client is undergoing an oral glucose tolerance test. The nurse interprets that the client's results are not compatible with diabetes mellitus if the glucose level is lower than which of the following cutoff values after 120 minutes (2 hours)?

140 mg/dL

The nurse is assessing the client's muscle strength and notes that when asked, the client cannot maintain his or her hands in a supinated position with the arms extended and eyes closed. How would the nurse correctly document this finding on the medical record?

Client is exhibiting pronator drift.

An adult client trapped in a burning house has suffered burns to the back of the head, upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what does the nurse determine the extent of the burn injury to be? (Enter the answer in the space provided.) Answer: __________%

22.5

The nurse is assisting in admitting a client who has a diagnosis of hypothermia. The nurse anticipates that this client will exhibit which of the following vital signs?

Decreased heart rate and decreased blood pressure

According to the American Cancer Society, fecal occult blood testing should be done annually after the age of _____ years.

50

The nursing student correctly describes the process of phagocytosis as:

A process whereby a particle is ingested and digested by a cell

A nurse is caring for a client diagnosed with Ménière's disease. The nurse plans care, understanding that this disorder is characterized by:

Dizziness

The nurse who is assessing the client's eyes notes that the pupil gets larger when looking at an object in the distance and gets smaller when looking at a near object. The nurse documents this finding as:

Accommodation

The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse should avoid which of the following errors in technique when implementing this procedure?

Ask the client to void, save the specimen, and note the start time.

Discharge teaching for a client recovering from an attack of chronic pancreatitis should include which of the following instructions?

Avoid caffeine, because it may aggravate symptoms.

The nurse is providing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse would plan to teach the client which of the following pieces of information about positioning in the postoperative period?

Avoid sleeping on the left side.

A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused around reduction of which specific problem associated with this type of heart failure?

Bilateral lung crackles

The client with frequent upper respiratory infections (URIs) asks the nurse why food doesn't seem to have any taste during illness. The nurse understands that this is because of which of the following?

Blocked nasal passages impair the senses of smell and taste.

The nurse reviews the health record of a client with melasma. The nurse would anticipate that this client will exhibit:

Blotchy brown macules across the cheeks and forehead

The clinical picture of the client with osteitis deformans (Paget's disease) includes back and leg pain, a crouched forward posture, and legs that bow outward. The nurse plans care, knowing that these manifestations are caused by disturbances of which of the following?

Bone resorption and regeneration

The nurse would identify that which of the following foods should be increased in the diet to help decrease the risk of cancer development?

Broccoli

A client who visits the physician's office for a routine physical reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse continues to assess for which of the following?

Complaints of weakness and lethargy

The client receiving a cleansing enema complains of pain and cramping. The nurse takes which of the following corrective actions?

Clamp the tubing for 30 seconds, and restart the flow at a slower rate.

The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The physician states that because of fluid in the alveoli, surfactant production is falling. The nurse understands that the consequence of insufficient surfactant is:

Collapse of alveoli and decreased compliance

The nurse would determine that tracheal suctioning is needed if which of the following is noted?

Congested breath sounds in the lung fields.

The nurse understands that increasing the flow of oxygen to more than 2 L/min in the client with chronic obstructive pulmonary disease (COPD) could be harmful because it:

Decreases the client's oxygen-based respiratory drive

The client has been diagnosed with pyelonephritis. The nurse interprets that which of the following health problems has placed the client at risk for this disorder?

Diabetes mellitus

The nurse suspects the client may be experiencing dysfunction in the area of the semicircular canals of the ear if the client experiences:

Disturbance in balance

A nurse is caring for a client postoperatively following creation of a colostomy. Which of the following nursing diagnoses should the nurse include in the plan of care?

Disturbed body image

The nurse is assisting the physician with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse takes which of the following actions?

Document the accurate functioning of the tube

102. The client is resuming a diet after hemigastrectomy. To minimize complications, the nurse would tell the client to avoid doing which of the following?

Drinking liquid with meals

The nurse is assigned to the care of a client scheduled for surgery for a right colon tumor. Which of the following is the most characteristic manifestation of cancer at this site?

Dull abdominal pain exacerbated by walking

The nurse is receiving a client from the postanesthesia care unit following left above-knee amputation. The priority nursing action at this time is which of the following?

Elevate the foot of the bed.

The nurse should ask the client to do which of the following when testing the function of the spinal accessory nerve (CN XI)?

Elevate the shoulders

The nurse is caring for a client diagnosed with suspected acute pancreatitis. When reviewing the client's laboratory results, the nurse determines that which of these findings will support the diagnosis?

Elevated serum levels

A client is admitted to the hospital with a diagnosis of parasitic worms. The nurse understands that the primary cell type that will attack these foreign particles is:

Eosinophils

The client is diagnosed with a full-thickness burn. The nurse understands that which of the following structural areas of the skin is involved?

Epidermis, entire dermis, and epithelial portion of subcutaneous fat

The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture report interprets that which of the following organisms is not part of the normal flora of the skin?

Escherichia coli

The client is scheduled for oral cholecystography. For the evening meal prior to the test, the nurse provides a list of foods from which diet type?

Fat Free

The nurse is doing volunteer work in a homeless shelter. The nurse monitors the individuals in the shelter for which of the following initial symptoms of tuberculosis (TB)? Select all that apply.

Fatigue Lethargy Low-grade fever Morning cough

A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse would anticipate observing which sign or symptom?

Flushing

The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. The nurse understands that in cases in which the recipient rejects transplanted organs, the cells of the transplanted organs are seen by the body as a(n):

Foreign antigen

The nurse plans care for the older adult female client with a diagnosis of osteoporosis knowing that the client is at greatest risk for which of the following?

Fractures

The client with diabetes mellitus is being tested to determine long-term diabetic control. Which of the following results would the nurse expect to see if the client's long-term control is within acceptable limits?

Glycosylated hemoglobin of 6%

In which of the following optimal positions should the nurse plan to place the client after bolus feeding using a nasogastric tube?

HOB elevated 30 to 45 degrees, with client in the right lateral position for 60 minutes

The older adult client has been lying in a supine position for the last 3 hours. The nurse who is repositioning this client would be most concerned with examining which of the following bony prominences of the client? Select all that apply

Heels Elbows Sacrum Back of the head

The client is admitted to the hospital with a tentative diagnosis of bladder cancer. The nurse expects the client history to reveal which of the following earliest manifestations of the disease?

Hematuria with no pain

The client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse would determine that which of the following documented in the client's record is an expected finding with this client?

Hyperinflation of lungs documented by chest x-ray

The nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit signs of thyroid storm. Which of the following is an early indicator of this complication?

Hyperreflexia

The client with glomerulonephritis has developed acute renal failure (ARF) as a complication. The nurse would expect to note which of the following abnormal findings documented on the client's medical record?

Hypertension

The client has been diagnosed with Cushing's syndrome. The nurse would monitor this client for which of the following expected signs of this disorder? Select all that apply.

Hypertension Moon facies Truncal obesity

The nurse is testing the client for graphesthesia and asks the client to close his eyes. Which of the following would the nurse have the client do?

Identify three numbers or letters traced in the client's palm.

Which of the following teaching points is the priority when the nurse is teaching the client about caring for a plaster cast

Immediately report any increase in drainage or interruption in cast integrity.

The client is experiencing an episode of hypoglycemia. The nurse understands that the physiological mechanism that should take place to combat this decrease in the blood glucose level is:

Increased glucagon secretion

he ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which of the following areas is unnecessary to emphasize when providing client education for blood pressure control?

Instruct the client to limit protein intake.

The client who has had intracranial surgery is experiencing diabetes insipidus. The nurse understands that the client is experiencing which of the following problems?

Insufficient production of antidiuretic hormone (ADH)

The nurse is preparing to administer a prescribed antibiotic to a client with bacterial meningitis. The nurse understands that the selection of an antibiotic to treat meningitis is based on which of the following?

It is able to cross the blood-brain barrier.

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope:

Just under the left-sided clavicle

The client with diabetes experiences breakdown of fats for conversion to glucose. The nurse determines that this response is occurring if the client has elevated levels of which of the following substances?

Ketones

The nurse is assisting the physician during a colonoscopy procedure. The nurse helps the client to assume which of the following positions for the procedure?

Left Sims

The nursing instructor is questioning a nursing student about the organs of the immune system and asks the student where Kupffer's cells are located. The student responds correctly by stating that these types of cells are located in the:

Liver

The nurse providing instructions to the client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that the primary benefit is to:

Maintain inflation of the alveoli.

The nurse is preparing to take an apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope at which cardiac site?

Mitral Valve

The client has been diagnosed with paronychia. The nurse understands that this is a disorder of the:

Nails

The nurse conducting an eye examination notes that the client exhibits rapid, involuntary, oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as:

Nystagmus

The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which of the following nursing actions is focused on the consequence of low albumin levels?

Palpating for peripheral edema

. The physician is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the physician asks the client to:

Perform the Valsalva maneuver.

A client is experiencing blockage of the eustachian tubes. Which of the following activities by the client may forcibly open the eustachian tube?

Performing the Valsalva maneuver

The nurse monitoring the oncological client for early signs of vena cava syndrome would include assessment for which of the following?

Periorbital edema

The nursing student understands that the primary purpose of neutrophils in the inflammatory response is to:

Phagocytize any potentially harmful agents.

A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which of the following foods that are most likely to have this taste for the client?

Pork

The nurse is caring for the client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which of the following?

Pork

The nurse is assisting in performing a physical assessment of a right-handed client's musculoskeletal system. Which of the following would be an abnormal finding?

Presence of fasciculations

The nurse who is collecting data from the client notes that the client's left-sided eyelid is drooping. The nurse documents that the client is exhibiting which of the following conditions?

Ptosis

The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which of the following assessment findings would be indicative of further fluid volume deficit?

Pulse rate increases from 100 beats/min to 136 beats/min

The nurse understands that the most significant rationale for the application of heat to an area of contusion 72 hours after the injury is to:

Reabsorb blood from the injured tissue

A nurse assessing a postoperative ureterostomy client will interpret that the stoma has normal characteristics if the stoma is:

Red and moist

The client complains of chronic pruritus. Which of the following diagnoses would the nurse expect to support this client's complaint?

Renal Failure

The nurse is attempting to inspect the lacrimal apparatus of the client's eye. Because of its anatomical location, the nurse should do which of the following?

Retract the upper eyelid, and ask the client to look down.

The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which of the following positions?

Semi-Fowler's position

The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which of the following results would be consistent with the observation?

Serum potassium level of 2.8 mEq/L

The nurse explaining the procedure of indium imaging to a client with a bone infection would include which of the following?

Some of the client's white blood cells are tagged with indium, which will later accumulate in infected bone.

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube. Which of the following findings should be reported to the health care physician immediately?

Stridor

A client is admitted to the hospital with a diagnosis of Addison's disease. The nurse would monitor for which of the following problems associated with this disease? Select all that apply.

Syncope Hypotension Muscle weakness

A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders?

Systemic lupus erythematosus (SLE)

The client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which of the following changes in vital signs?

Tachycardia, hypotension

client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which of the following is the priority action taken by the nurse?

Take the vitals

The nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which of the following conclusions?

The cardiac output is below the normal range

The nurse notes that the client's serum calcium level is 6.0 mg/dL. Which of the following assessment findings would be anticipated in this client? Select all that apply.

Tetany Hypotension Prolonged QT interval Positive Chvostek's sign

A client's total cholesterol level is 344 mg/dL, low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL, and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL. Based on analysis of the data, how should the nurse direct client teaching?

The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught.

The client has sustained damage to Wernicke's area in the temporal lobe from a brain attack (stroke). Which of the following should the nurse anticipate when caring for this client?

The client will have difficulty understanding language.

The nurse is caring for a client who is scheduled to have electroencephalography. The nurse determines that the client is ready for the procedure after noting which of the following?

The client's hair has been shampooed.

A client has undergone abdominal perineal resection for a bowel tumor. The nurse interprets that the client's colostomy is beginning to function if which of the following signs is noted?

The passage of flatus

The client with an endocrine disorder complains of weight loss and diarrhea, and says that he can "feel his heart beating in his chest." The nurse interprets that which of the following glands is most likely responsible for these symptoms?

Thyroid

Tetanus toxoid is prescribed for a client who has sustained a foot laceration from a piece of metal while walking barefoot on the beach. The nurse understands that the toxoid is a(n):

Toxin produced by bacteria that has been altered so that it is no longer toxic

The nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. If the client were to examine the right breast, the nurse would tell the client to place a pillow:

Under the right shoulder

The client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/min range. The client is also complaining of nausea. The nurse interprets that these symptoms are because of stimulation of which cranial nerve (CN)?

Vagus CN: X

A client with angina complains that the anginal pain is prolonged, severe, and occurs at the same time each day, most often in the morning. On further assessment, a nurse notes that the pain occurs in the absence of precipitating factors. How would the nurse best describe this type of anginal pain?

Variant Angina

The client has a cerebellar lesion. The nurse would plan to obtain which of the following for use by this client?

Walker

A client is admitted to the hospital with cellulitis of the lower leg. The nurse would anticipate which of the following therapies to be prescribed?

Warm compresses to the affected area

The client is experiencing blockage of the common bile duct. Which of the following food selections made by the client indicates the need to plan for further diet teaching?

Whole milk

A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which of the following reflects appropriate intervention by the nurse?

Withhold oral fluids until the client's gag reflex has returned.

The nurse is listening to a 56-year-old client's apical heart rate before giving digoxin (Lanoxin) and notes that the heart rate is 48 beats/min. Which of the following would be an appropriate course of action taken by the nurse?

Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity.

The client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse gives the client suggestions for foods to aid in symptom management that are in which of the following diet types?

a low fiber diet

A 27-year-old female client is undergoing evaluation of lumps in her breasts. In determining whether the client could have fibrocystic breast disorder, the nurse should ask the client whether the breast lumps seem to become more prominent or troublesome at which of the following times?

before menses

The nurse would include which of the following in a list of the most helpful foods for the vegan client wishing to increase foods high in vitamin A?

carrots

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching regarding positioning?

laying on his or her back

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which of the following arterial blood gas (ABG) findings?

pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L

The nurse understands that which of the following hormones is directly responsible for maintaining the free or unbound portion of serum calcium within normal limits?

parathyroid hormone

The client with hypertension has been prescribed a low-sodium diet. The nurse teaching this client about foods that are allowed should plan to include which of the following in a list provided to the client?

summer squash