HESI WEEK 2 SU20
A client has tertiary syphillis, what body system does the RN need to monitor closely?
Cardiovascular
An adolescent who has had the diagnosis of conduct disorder since the age of 9 years is placed in a residential facility. The adolescent has a history of fighting, stealing, vandalizing property, and running away from home. The adolescent is aggressive, has no friends, and has been suspended from school repeatedly. What is the nurse's priority when developing a plan of care?
Clients with conduct disorder are at risk for inflicting physical, emotional, or sexual harm on themselves or others; safety of the client and others is the priority.
The presence of more than one fetus overdistends the uterus, which may result in uterine atony and thus postpartum hemorrhage.
Drinking orange juice can increase fetal movement. Fetal kick count, either the number counted in 30 minutes or the time it takes for 10 kicks to occur, is the accepted method of assessing the fetus for the appropriate amount of movement.
A client who retired a year ago tells the nurse in the community health center, "I don't have any hobbies or interests, and since I retired I feel useless and unneeded." According to Erikson's developmental theory, with which developmental conflict is the client faced?
Integrity versus despair is the task of the older adult; this client has not adapted to triumphs and disappointments, so there is no acceptance of what life is and was; this results in feelings of despair and disgust.
The nurse is planning care for a preschooler with Kawasaki disease. Which intervention should the nurse plan to implement?
Kawasaki disease is treated with high-dose IVIG in combination with aspirin to lower the risk of coronary artery abnormalities.
The laboratory report of a client indicates that the urinary urea nitrogen levels are 9 g/24 hr. What does the nurse anticipate from this finding?
Kidney damage or liver disease is suspected when the urea nitrogen is less than normal levels. The normal level of urea nitrogen in the urine ranges from 12 to 20 g/24 hr (0.43-0.71 mmol/24 hr). Normal kidneys are able to filter urea and other toxic byproducts of ammonia. An increased level of urea nitrogen is indicative of sepsis, dehydration, or high protein diet in the client.
A toddler receives a gastrostomy tube feeding every 4 hours. What is the priority nursing intervention for this child?
Positioning the child on the right side after feeding facilitates digestion because the pyloric sphincter is on this side and gravity aids emptying of the stomach.
Which should the nurse anticipate when assessing a toddler-age client's respirations?
Respirations for the toddler-age client continue to be abdominal during the toddler-age years.
Which finding about an adolescent may require further evaluation with a SLAP assessment?
SLAP is a mnemonic for specificity, lethality, accessibility, and proximity; these criteria are used to assess people with suicidal tendencies.
A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be?
The client is experiencing the expected discomforts of labor; the nurse should initiate measures that will promote relaxation.
Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%?
The expected value of a pulse oximetry reading is 95% to 100%. Nonrebreather mask will deliver high oxygen concentrations (95% to 100%) at a liter flow of 10 to 15 L/min. When using a nonrebreather mask, the client breathes only the oxygen source from the bag.
The nurse is caring for a client who is going to undergo surgery for pheochromocytoma. Which action of the nurse needs correction to ensure client safety?
The nurse should not palpate the abdomen of a client with pheochromocytoma. Abdominal palpation can cause sudden release of catecholamines and induce hypertension in the client.
The nurse is assessing several postpartum clients at the very beginning of her shift. Which problem does the nurse identify that might predispose a client to postpartum hemorrhage?
The presence of more than one fetus overdistends the uterus, which may result in uterine atony and thus postpartum hemorrhage.
A client with an intractable infection is receiving vancomycin. Which laboratory blood test result should the nurse report?
Vancomycin is a nephrotoxic medication. An elevated BUN can be an early sign of toxicity. The BUN of a healthy adult is 10 to 20 mg/dL (3.6-7.1 mmol/L).
A nurse is assessing a client with Crohn disease who is to have an upper gastrointestinal series. Which condition necessitates the cancellation of the upper gastrointestinal series?
When a client has a perforated viscera, barium can leak out of the intestinal tract and cause inflammation or an abscess. A
One day a nurse sits down by a depressed client's bed and says, "I'll be spending some time with you today." The client responds, "Go talk to someone else. They all need you more." What is the most therapeutic response by the nurse?
The nurse who spends time with the client conveys a feeling of importance and helps build the client's self-esteem.
Which is the priority action by the nurse when discharging a client with limited English proficiency?
The priority when discharging a client with limited English proficiency is to assess the need for a medical interpreter for client teaching.
A nurse is reviewing the history, physical examination, and diagnostic test results of a client with colitis. What clinical findings are associated with this disorder? Select all that apply.
Ulceration of the intestinal mucosa commonly occurs, causing blood loss and anemia. The inflammatory process tends to increase peristalsis, causing diarrhea, electrolyte imbalances, and weight loss.
What nursing intervention is the priority in the period immediately after an emaciated 13-year-old child's admission to the hospital for starvation resulting from anorexia nervosa?
Anorexic children are usually severely malnourished and have severe fluid and electrolyte imbalances. Unless these imbalances are corrected, cardiac irregularities and death may occur.
What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include?
Because physical signs of congenital syphilis are difficult to detect at birth, the infant should be screened immediately to determine whether treatment is necessary. Cleft palate is a congenital defect that occurs in the first trimester.
A client complains of fatigue, hair loss, and weight gain. On assessment, the client is found to have anemia. Which therapy does the nurse anticipate in the client's prescription?
Fatigue, hair loss, weight gain, and anemia are the clinical manifestations of hypothyroidism, which occurs due to deficiency of thyroid hormones. Treatment includes restoration of euthyroid state by hormone therapy, such as levothyroxine.
After a gastrojejunostomy (Billroth II) for cancer of the stomach, a client progresses to a regular diet. After eating lunch, the client becomes diaphoretic and has palpitations. What does the nurse conclude is the probable cause of these clinical manifestations?
Hypertonic food increases osmotic pressure and pulls fluid from the intravascular compartment into the intestine (dumping syndrome). Increased carbohydrates, not fats, are responsible for the increased osmotic pressure often associated with dumping syndrome.
What is the priority nursing care in the immediate postoperative period for a toddler with a newly applied hip spica cast?
Priority nursing care for any cast application includes checking the color and temperature of the area surrounding the cast to ensure that the cast is not too tight. A tight cast compresses arteries and veins, thereby impairing circulation.
What clinical finding is most important for the nurse to identify when assessing an adolescent child with Reye syndrome?
Reye syndrome affects the liver, causing problems with blood coagulation because the liver-dependent clotting factors such as prothrombin are diminished.
A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first?
Smoke inhalation can cause edema of the respiratory lumen, interfering with oxygenation; evaluation of respiratory status is the first, priority assessment.
After assessing the integumentary system of a client, the healthcare provider diagnoses the condition as telangiectasia. The nurse will anticipate which etiologies for this condition? Select all that apply.
Telangiectasia is a condition characterized by visibly dilated, superficial, cutaneous small blood vessels, commonly found on the face and thighs and caused by liver failure, sun exposure, aging, acne, alcohol, corticosteroids, radiation, certain systemic diseases, or skin tumors.
For which clinical indicators should the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice? Select all that apply.
When bile levels in the bloodstream are high, as in obstructive jaundice, there is bile in the urine, causing it to have a dark color. Jaundice (bile pigments causing yellow skin, sclera, and mucous membranes) results from failure of bile to enter the intestines, with subsequent backup into the biliary system and diffusion into the blood; the bilirubin is carried to all body regions. The stools are clay-colored, not brown, because the bile pigments are not present in the gastrointestinal (GI) tract as a result of the obstruction of the common bile duct.