HESI Remediation

Which substance can cause life-threatening dysrhythmias when inhaled? Select all that apply. One, some, or all responses may be correct. Glue Gasoline Nicotine Cannabis Paint thinner

Glue Gasoline Paint thinner

The nurse is caring for a client with emphysema. During assessment, the nurse expects to auscultate which type of breath sounds? pleural friction rub crackles and gurgles diminished breath sounds expiratory wheeze and cough

diminished breath sounds

Which statements provided by the student nurse about neuromuscular manifestations of alkalosis with hypocalcemia indicate the need for further learning? Select all that apply. One, some, or all responses may be correct. "The client would show signs of twitching." "The client would show signs of hyporeflexia." "The client would show signs of paresthesias." "The client would show signs of muscle cramping." "The client would show signs of skeletal muscle weakness."

"The client would show signs of hyporeflexia." "The client would show signs of paresthesias."

The nurse is caring for a client who is vomiting. When caring for this client, the nurse recalls that the vomiting reflex follows a set pattern. List the steps in the order that they occur. 1. Initiation of reverse peristalsis in the stomach 2. Contraction of abdominal muscles 3. Closure of the trachea to prevent aspiration 4. Relaxation of the upper esophageal sphincter

1 2 4 3

Which intervention would the nurse use to promote the safety of a client experiencing alcohol withdrawal? Infuse IV fluids Monitor anxiety level Obtain frequent vital signs Administer chlordiazepoxide.

Administer chlordiazepoxide. The nurse would administer chlordiazepoxide to prevent injury because alcohol withdrawal can cause seizures and autonomic hyperactivity. Administering intravenous fluids maintains hydration. Monitoring anxiety levels does not affect client safety. Obtaining frequent vital signs allows the nurse to assess for autonomic hyperactivity but does not directly affect client safety.

Which are the adverse effects of mirtazapine? Select all that apply. One, some, or all responses may be correct. Asthenia Dyskenesia Drowsiness Gynecomastia Abnormal dreams

Asthenia Drowsiness Abnormal dreams Mirtazapine is a SECOND-generation antidepressant medication with potential adverse effects of asthenia, drowsiness, and abnormal dreams. Dyskinesia and gynecomastia are the side effects of FIRST-generation antidepressant medications.

During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Which additional assessment would the nurse report immediately to the health care provider? Inc appetitie Recent weight loss Feelings of warmth Fluttering in the chest

Fluttering in the chest Many of these problems are associated with hyperthyroidism; palpitations may indicate cardiovascular changes requiring prompt intervention. The increased metabolism associated with hyperthyroidism can lead to heart failure. Although an increased appetite becomes a compensatory mechanism for the increased metabolism associated with hyperthyroidism, it is not life threatening. Although unexplained weight loss can result from catabolism associated with hyperthyroidism, it is not life threatening. Although a feeling of warmth caused by the increased metabolism associated with hyperthyroidism is uncomfortable, it is not life threatening.

What does the nurse consider to be the priority nursing intervention for a client on diuretic therapy who has developed metabolic alkalosis? Preventing falls Monitoring electrolytes Administering antiemetics Adjusting the diuretic therapy

Preventing falls

Which blood gas result would the nurse expect an adolescent with diabetic ketoacidosis to exhibit?

pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) indicate metabolic acidosis - low ph (acidic) and low HCO3

Which physical assessment of the skin indicates that a client is addicted to phencyclidine? Burns Vasculitis Diaphoresis Red and dry skin

Red and dry skin

Which assessment would the nurse perform while caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS)? Quality of the cry Signs of dehydration Coughing up of feedings Characteristics of the stool

Signs of dehydration

Which outcome would indicate a client who was hospitalized with severe anxiety is ready to be discharged? Follows rules of the milieu Maintains anxiety at a manageable level Verbalizes positive aspects about the self Recognizes that hallucinations can be controlled

Maintains anxiety at a manageable level Maintaining anxiety at a manageable level would indicate the client is ready to be discharged. Maintenance of anxiety at a manageable level results from teaching the client to recognize situations that provoke anxiety and how to institute measures to control its development. Following the rules of the milieu and verbalizing positive aspects about the self are not priority outcomes for discharge; the client has probably had little difficulty in these areas. No evidence was presented in the scenario to indicate that the client is hallucinating.

Which type of rehabilitation is an essential component to a client's recovery from Guillain-Barré syndrome? Physical Therapy Speech Therapy Fitting with a vertebral brace Follow up on cataract progression

Physical Therapy Rehabilitation needs for a client with Guillain-Barré syndrome focuses on physical therapy and exercise for the lower extremities because of muscle weakness and discomfort. A client with Guillain-Barré syndrome does not need speech or swallowing exercises. A client with Guillain-Barré syndrome does not need vertebral support. Problems with cataracts are not associated with Guillain-Barré syndrome. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you analyze your ability to think critically. Usually your first answer is correct, and you should not change the answer without reason.

Which feelings are often the basis of obsessive-compulsive disorder? Anxiety and guilt Anger and hostility Embarassment and shame Hopelessness and powerlessness

Anxiety and guilt Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although angry and hostile feelings may be present, these feelings do not precipitate the rituals. Embarrassment and shame or hopelessness and powerlessness may occur because of the compulsion, but the basic feelings precipitating the rituals are usually anxiety and guilt.

A high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. Which would the nurse instruct the student to do? Breath into cupped hands Pant using rapid, shallow breaths Use a rapid deep-breathing pattern Hold the breath for as long as possible

Breath into cupped hands Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. A rapid breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A fast deep-breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A person who is experiencing a panic attack will not be able to hold his or her breath.

Which intervention would the nurse add to the plan of care for a client who engages in ritualistic behavior? Redirect the client's energy into activities to help others. Teach the client that the behavior is not serving a realistic purpose. Administer antianxiety medications that block out the memory of internal fears. Help the client understand that the behavior is caused by maladaptive coping with increased anxiety.

Help the client understand that the behavior is caused by maladaptive coping with increased anxiety. The nurse would help the client understand that the behavior is caused by maladaptive coping with increased anxiety. Helping clients understand that a behavior is being used to control anxiety usually makes them more amenable to psychotherapy. Redirecting the client's energy into activities to help others is inappropriate. Treatment includes activities to help the client, not others. The client usually understands already that the behavior is not serving a realistic purpose. Although antianxiety medication can be given, it is not to block out the memory of internal fears. It is to help decrease the anxiety to manageable levels. However, antidepressants have been proven to be more helpful.

An adolescent diagnosed with new-onset type 1 diabetes mellitus has stress and reports not having a menstrual cycle for a long time. Which condition is the adolescent experiencing? Dysmenorrhea Primary amenorrhea Female athlete triad Hypogonadotropic amenorrhea

Hypogonadotropic amenorrhea Hypogonadotropic amenorrhea may occur in type 1 diabetic adolescents experiencing stress. This condition can also result from sudden and severe weight loss, eating disorders, strenuous exercise, and mental illness. Dysmenorrhea is painful periods. Primary amenorrhea occurs for many reasons; however, no menses has occurred. The female athlete triad is eating disorders, loss of bone density, and amenorrhea.

Which acid-base imbalance would the nurse anticipate in a client in the progressive stage of shock? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkolosis

Metabolic acidosis

Which intervention would provide comfort to the client experiencing alcohol toxicity? Dim the lights Use distraction Offer activities Stay with the client

Stay with the client Agitation and anxiety are common in clients experiencing alcohol toxicity. Staying with the client as much as possible will help decrease their anxiety and provide the opportunity to reorient them as needed. Dimming the lights may place the client at risk for injury due to their impaired judgment and lack of coordination. Distraction and activities are not appropriate nursing interventions at this time.

Which statement about benzodiazepines requires correction? They are indicated for ethanol withdrawal. These medications increase the activity of gamma-aminobutyric acid. Benzodiazepines are the first-line medications used in chronic anxiety disorders. These medications depress activity in the brainstem.

These medications increase the activity of gamma-aminobutyric acid. Benzodiazepines act by decreasing the activity of gamma-aminobutyric acid, which is an inhibitory neurotransmitter. Apart from their indication in the treatment of depression, benzodiazepines are also prescribed for ethanol withdrawal, insomnia, and muscle spasms. Benzodiazepines are the first-line medications of choice in acute and chronic anxiety disorders. Benzodiazepines act by depressing activity in the brainstem and the limbic system.

A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event would the nurse document in the client's clinical record? Select all that apply. One, some, or all responses may be correct. diaphoresis retinopathy acetone breath Increased arterial bicarbonate level Decreased arterial carbon dioxide level

acetone breath dec. arterial cardon dioxide levels

The nurse is caring for a client with cirrhosis of the liver. The nurse anticipates a prescription for neomycin enemas based on which abnormal laboratory test? ammonia level culture and sensitivity white blood cells ALT level

ammonia level Increased ammonia levels indicate that the liver is unable to detoxify protein by-products. Neomycin reduces the amount of ammonia-forming bacteria in the intestines

A client with severe gastritis vomits a large amount of blood. The nurse performs gastric lavage, as prescribed, using an irrigating solution that is room temperature. Which response would the nurse expect? coagulation of blood neutralization of acids constriction of blood vessels stimulation of the vagus nerve

constriction of blood vessels Lavage removes blood from the stomach, and the irrigating solution produces vascular constriction, which helps control bleeding by limiting blood flow to the area. Lavage does not cause the blood to clot. Neutralization of acid by water irrigation will take time; antacids may be instilled to alter the pH. Stimulation of the vagus nerve is not the purpose of a lavage for gastric hemorrhage. Test-Taking Tip: Do not read too much into the question or worry that it is a "trick." If you have nursing experience, ask yourself how a classmate who is inexperienced would answer this question from only the information provided in the textbooks or given in the lectures.