HESI LPN-RN
A client with a disturbed state of mind is under observation. Which statement made by the nurse indicates that the client is suffering from dementia? . Multiple selection question "The client is very depressed." "The client is not able to make decisions." "The client always tells about his/her failures." "The client is not able to perform purposeful work." "The client has a completely disturbed sleep/wake cycle."
"The client is not able to make decisions." "The client is not able to perform purposeful work." A client with dementia may not able to make decisions because it affects thinking ability. The client with dementia may suffer from apraxia in which the client is not able to perform purposeful work. In depression, the client will remain depressed but in dementia, the mood is affected superficially. A client with depression may tell about his/her failures, but in dementia, the client may or may not be able to recollect details of life. In dementia, the sleep/wake cycle of the client is a bit fragmented but in depression, it is completely disturbed.
A client who is formula feeding her infant complains of discomfort from engorged breasts. What should the nurse recommend that the client do? Multiple choice question Use warm, moist towels as compresses. Express milk from each breast manually. Apply cold packs and a snugly fitting bra. Restrict oral fluid intake to less than a quart a day.
Apply cold packs and a snugly fitting bra. Application of cold relieves discomfort, and a snug bra provides support and aids in pressure atrophy of acini cells so that milk production is suppressed. Warm, moist compresses are suitable for the breastfeeding mother experiencing discomfort from engorgement because it promotes comfort and stimulates milk production. Expressing milk manually is suitable for the breastfeeding mother who is experiencing engorgement, not one who is formula feeding, because it promotes comfort and stimulates milk production. Restriction of fluids will not prevent engorgement and may cause dehydration.
While reviewing the laboratory reports of a client, the nurse finds that the client has low sodium levels. Which hormonal imbalance should the nurse suspect in the client? Epinephrine Glucagon Calcitonin Cortisol
Cortisol Cortisol is the glucocorticoid secreted by the adrenal cortex that maintains sodium and water balance. Therefore, reduced sodium levels in the client indicate a cortisol imbalance. Additionally, depleted sodium levels in a client indicate hyponatremia. Epinephrine is a catecholamine, which helps in maintaining homeostasis. Glucagon increases blood glucose levels and does not play a role in maintaining electrolyte balance. Calcitonin helps in regulating serum calcium levels.
Schizophrenia is associated with both positive and negative symptoms. While assessing a client with schizophrenia, the nurse notes that the client is experiencing positive symptoms; what does the nurse observe that leads to this conclusion? Multiple selection question Poverty of speech Agitated behavior Lack of motivation Delusions of grandeur Auditory hallucinations
Delusions of grandeur Auditory hallucinations Agitated behavior Agitated and restless behaviors are positive symptoms of schizophrenia. A delusion is a fixed false belief that is resistant to reasoning; when a person believes that he or she is a famous, historical or fictional omnipotent character this is called a delusion of grandeur; a delusion is a positive symptom associated with schizophrenia. An auditory hallucination is a sensory perception involving the sense of hearing that occurs in the absence of an external stimulus and is a positive symptom associated with schizophrenia. Decreased verbalization, including a sudden stoppage in the flow of speech (blocking) and lack of inflection, is a negative symptom associated with schizophrenia. Lack of motivation (avolition) and apathy are negative symptoms associated with schizophrenia.
A primigravida asks the nurse, "I've got this blotchy skin on my face, my nipples are darker, and there's this dark line down the middle of my stomach. What causes that?" The nurse explains that the gland that causes these expected changes during pregnancy is the what? Multiple choice question Adrenal gland Thyroid gland Anterior pituitary gland Posterior pituitary gland
Hypersecretion of melanocyte-stimulating hormone (MSH) from the anterior pituitary gland causes darkened pigmentations during pregnancy. MSH is not secreted by the adrenal glands, thyroid gland, or posterior pituitary gland.
A client with rheumatoid arthritis is to begin taking ibuprofen 800 mg by mouth three times a day. The nurse provides education about the medication's side effects. The nurse concludes that the teaching was effective when the client makes which statement? Multiple choice question "I need to have my blood work checked periodically." "I need to balance exercise with rest." "I need to change positions slowly." "I need to take the medication between meals."
If the client will be taking the medication long term, periodic diagnostic tests are necessary because ibuprofen is nephrotoxic, is hepatotoxic, and prolongs the bleeding time. Balancing exercise with rest is important for all clients with arthritis; it is not related to ibuprofen. Ibuprofen does not cause postural hypotension. Ibuprofen causes epigastric distress and occult bleeding; it should be taken with meals or milk to reduce these adverse reactions.
client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco 2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate? Multiple choice question Hypernatremia Hyperchloremia Metabolic alkalosis Respiratory acidosis Eugene off target
Metabolic alkalosis The normal plasma pH value is 7.35 to 7.45; the client is in alkalosis. The normal plasma bicarbonate value is 23 to 25 mEq/L (23 to 25 mmol/L); the client has an excess of base bicarbonate, indicating a metabolic cause for the alkalosis. The normal plasma sodium value is 135 to 145 mEq/L (135 to 145 mmol/L); the client has hyponatremia. The normal plasma chloride value is 95 to 105 mEq/L (95 to 105 mmol/L); the client has hypochloremia because of vomiting of gastric secretions. With respiratory acidosis the pH is decreased to less than 7.35.
A nurse is teaching a birthing/prenatal class about breast-feeding. Which hormone stimulates the production of milk during lactation? Inhibin Estrogen Prolactin Progesterone
Prolactin Prolactin is the hormone that initiates and produces milk during lactation. Inhibin prevents the secretions of follicle stimulating hormone and gonadotropin releasing hormone. Estrogen and progesterone are the sex hormones produced by the ovaries.
A nurse is caring for a client with the diagnosis of schizophrenia, paranoid type. What should the nurse plan for the client's initial care? Multiple choice question Discussing important life events Providing a nonthreatening environment Concentrating on the content of delusions Limiting topics for discussion to recent situations
Providing a nonthreatening environment These clients are hypersensitive to external stimuli and respond with less anxiety to a minimally threatening environment. Discussing prominent life events is too threatening an approach and interferes with the goals of therapy. Focusing on delusional material will reinforce the delusional system. Limiting topics for discussion to recent situations is not therapeutic; it may trigger suspiciousness and hostile outbursts.
While performing patterned, paced breathing during the transition phase of labor, a client experiences tingling and numbness of the fingertips. What should the nurse do? Multiple choice question Tell the client to breathe into a paper bag. Place an oxygen mask over the client's face. Call the primary healthcare provider to report the client's response. Instruct the client to begin taking slow deep breaths.
Tell the client to breathe into a paper bag. A paper bag enables the client to rebreathe carbon dioxide, which helps correct the respiratory alkalosis resulting from hyperventilation. The client's oxygen level is increased; the client needs to increase the carbon dioxide level and decrease the oxygen level. The client should rebreathe her own exhalations first; if alkalosis persists, more intensive treatment may be needed. Carbon dioxide is too dilute in room atmosphere; deep breaths will not resolve the alkalosis.
A clinically depressed young mother whose husband has been killed tells the nurse that she sees no purpose in life and feels like ending it all. What is the best response by the nurse? Multiple choice question "How much consideration have you given to the method you'd use to kill yourself?" "Death is hard on everyone, but people make it through every day. You'll see; things will get better." "It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now." "You feel that way now, but you still have your whole life ahead of you. Why don't you try to make a new start?"
The response "It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now" validates the client's experience and opens a channel of communication for further exploration; empathy helps build trust. Asking how much consideration the client has given to the method she would use to kill herself is premature; the nurse should first explore the client's feelings before discussing thoughts and plans. Telling the client that death is hard on everyone but people make it through every day and that things will get better is false reassurance; it invalidates the client's experience. Telling the client that she has her whole life ahead of her and advising her to make a new start is false reassurance; it invalidates the client's experience.
