HESI Week 11

A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Select all that apply. a. Ascites b. Hunger c. Pruritus d. Jaundice e. Headache

a. Ascites c. Pruritus d. Jaundice

A nurse is reviewing the laboratory report of an adolescent child with nephrotic syndrome. What does the nurse expect analysis of the child's urine to reveal? a. High protein level b. Low specific gravity c. Numerous red blood cells d. Several crystalline particles

a. High protein level Protein (albumin) is present in the urine of children with nephrotic syndrome; it is evidence of kidney damage. Proteinuria, combined with oliguria, results in an increased urine specific gravity. Only rarely do red blood cells (RBCs) or RBC casts filter through the glomerular basement membrane. Crystals are not found in the urine of children with nephrotic syndrome.

which sign of symptom supports the nurse's suspicion that a client has overflow incontinence? a. constant dribbling of urine b. abrupt and strong urge to void c. loss of urine with physical exertion d. large amount of urine loss with each occurance

a. constant dribbling of urine there is an involuntary loos of urine due to overdistention of the bladder when the bladder's capacity reaches the maximum

A client with jaundice associated with hepatitis expresses concern over the change in skin color. What does the nurse explain is the cause of this color change? a. stimulation of the liver to produce an excess quantity of bile pigments b. Inability of the liver to remove normal amounts of bilirubin from the blood c. increased destruction of RBC during acute phase of the disease d. decreased prothrombin levels, leading to multiple sites of intradermal bleeding

b. Inability of the liver to remove normal amounts of bilirubin from the blood

a client is admitted to the hospital with a diagnosis of peptic ulcer. Which common complication would the nurse assess for in this client? a. perforation b. hemorrhage d. pyloric obstruction d. esophageal varices

b. hemorrhage Hemorrhage because of erosion of blood vessel walls is the most common complication of peptic ulcer disease. The complication of gastric perforation usually occurs after, and is not as common as, hemorrhage. Pyloric obstruction is not a common complication of peptic ulcer disease. Esophageal varices occur with portal hypertension, not peptic ulcer disease.

which microorganism would the nurse suspect as the cause of acute glomerulonephritis? a. haemophilus b. streptococcus c. pseudomonas d. staphylococcus

b. streptococcus

A client with gastric ulcer disease asks the nurse why the health care provider has prescribed metronidazole. What purpose does the nurse provide? a. To augment the immune response b. To potentiate the effect of antacids c. To treat Helicobacter pylori infection d. To reduce hydrochloric acid secretion

c. To treat Helicobacter pylori infection

a client is admitted with an acute onset of right lower quadrant pain at Mcburney point, and appendicitis is suspected. for which clinical indicator would the nurse assess the client to determine if the pain is secondary to appendicitis? a. urinary retention b. gastric hyperaciditity c. rebound tenderness d. increased lower bowel motility

c. rebound tenderness classic subjective sign of appendicitis

a nurse is performing the physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. The nurse expects to observe what skin conditions? Select all that apply. a) Vitiligo b) Hirsutism c) Melanosis d) Ecchymoses e) Telangiectasis

d) Ecchymoses e) Telangiectasis telangiactasis is a vascular lesion formed by dilation of a group of small blood vessels (spider vein); bruising is normal within the skin or mucous membrane

An emergency department nurse assesses an older client who reports cramping pain in the left lower quadrant, weakness, bloating, and malaise. The client also has a low-grade fever. Which condition does the nurse suspect as the most likely cause of the client's clinical findings? a. pancreatitis b. appendicitis c. cholecystitis d. diverticulitis

d. diverticulitis Although diverticula can occur at any point within the gastrointestinal tract, they are most common in the sigmoid colon; therefore, pain associated with diverticulitis occurs in the left lower quadrant.