HESI/Saunders Online Review- Module 10-Physiological Health Problems

A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which of the following interventions does the nurse prepare the client?

A. An ultrasound examination. Rationale: A manual pelvic examination or any action that would stimulate uterine activity is contraindicated when vaginal bleeding is apparent in the third trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placental previa is made with the use of ultrasound. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus that is at risk for severe hypoxia, but internal fetal monitoring is contraindicated. Oxytocin would stimulate uterine contractions and is therefore contraindicated.

A nurse enters a client's room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first?

A. Beginning chest compressions. Rationale: According to the American Heart Association, detecting a pulse may be difficult. The healthcare provider should take not more than 10 seconds to check for a pulse; if the rescuer does not definitely feel a pulse within that period, he or she should start chest compressions. The acronym CAB (circulation, airway, and breathing) is used to prioritize the steps of cardiopulmonary resuscitation (CPR). Effective chest compressions are essential for providing blood flow during CPR. To provide effective chest compressions, the provider must push hard and fast. Current guidelines for CPR call for the initiation of compressions before ventilations. Oxygen may be helpful at some point, but the airway is opened before the administration of oxygen. Checking the client's pulse oximetry reading delays implementation of lifesaving measures.

A nurse is monitoring a client after transurethral resection of the prostate for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and the urine output is a light cherry color. The nurse performs a follow-up assessment 1 hour later and notes that the urine output is now bright red in color with clots and that the client's blood pressure has dropped. Which action by the nurse is appropriate?

A. Contacting the physician. Rationale: Some hematuria is normal for several days after transurethral resection of the prostate. If bright-red bleeding occurs, the physician needs to be notified, particularly if the client exhibits a change in vital signs. These findings are a potential sign of excessive blood loss and the need for emergency surgical intervention. Continuing to monitor the client delays necessary interventions. The nurse would not increase the rate of flow of an IV without a physician's order. Placing pressure on the bladder to aid expulsion of any additional clots is an inappropriate and unsafe action that could worsen the bleeding.

A nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. The nurse should tell the client to:

A. Limit sodium in the diet. Rationale: Limiting and fluids in the diet will help reduce the amount of endolymphatic fluid, which is excessive in Ménière disease. The client's room should be darkened to reduce the acute symptoms of vertigo. The client should limit head movement to prevent worsening of the symptoms of vertigo.

The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client states:

B. "I should sleep flat on my right side." Rationale: A side-lying position with head of the bed elevated is most likely to prevent reflux while sleeping. A flat position will increase reflux. The client is instructed to avoid eating in the 3 hours before bedtime because a full stomach may also cause reflux. Antacids and histamine antagonists may be prescribed for the client.

A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mg/dL. Which assessment findings does the nurse expect to note? Select all that apply.

B. Abdominal distention C. Trousseau sign. Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL reflects hypomagnesemia. Assessment signs include hypertension; gastrointestinal manifestations such as anorexia, nausea, abdominal distention, and decreased bowel sounds; shallow respirations; neuromuscular manifestations such as twitches, paresthesias, hyperreflexia, and the Trousseau and Chvostek signs; and irritability and confusion.

A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. The nurse immediately:

B. Assesses the client. Rationale: If a monitor alarm sounds, the nurse should first assess the clinical status of the client to see whether the problem is an actual dysrhythmia or a malfunction of the monitoring system. Asystole should not be mistaken for an unattached electrocardiogram wire. If the client is alert and the client's status is stable, the problem is likely an unattached cardiac lead or wire. Calling a code and obtaining a rhythm strip from the monitor device are unnecessary if the client's condition is stable.

A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse give the client?

B. Avoid rapidly moving the head and bending over for at least 3 weeks. Rationale: The client must avoid rapidly moving the head, bouncing, and bending over for at least 3 weeks to prevent disruption of the surgical site. The client should keep the affected ear dry at all times and should avoid getting the head wet, washing the hair, or showering for 1 week. The client should not rinse out the ear. The client also needs to avoid drinking through a straw for 2 to 3 weeks because the sucking action necessary to use the straw could cause disruption of the surgical site. The client should notify the physician if excessive ear drainage is noted.

A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse immediately:

B. Contacts the physician. Rationale: In the immediate postoperative period, the nurse assesses the client for stridor (a coarse, high-pitched sound on inspiration when auscultating over the trachea), a sign of airway edema, and for signs of bleeding. A drop in blood pressure and an increase in pulse are indicators of bleeding. The physician is notified immediately if either of these events occurs. Suctioning is performed to remove secretions that cannot be expectorated by the client. Increasing the rate of the client's IV solution is not done without a physician's prescription. A pulse oximeter may be needed, but this is not the action to be taken immediately.

A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client?

B. Semi-Fowler. Rationale: After cataract extraction surgery, the client should be placed in the semi-Fowler position or on the unaffected side to prevent edema at the surgical site. Supine, on the affected side, and prone are all incorrect because they will result in increased edema at the site.

A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though "something ripped." For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply.

B.Severe chest pain C. Absence of fetal heart tones. Rationale: Signs of uterine rupture vary with the degree of rupture. Signs and symptoms include abdominal pain and tenderness, chest pain, hypovolemic shock, signs associated with impaired fetal oxygenation, an absence of fetal heart tones, cessation of uterine contractions, and palpation of the fetus outside the uterus if the rupture is complete. Signs of hypovolemic shock include tachycardia; tachypnea; pallor; cool, clammy skin; and anxiety.

A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states:

C. "I don't need medication unless I'm having a severe attack." Rationale: Treatment of gout includes both nutrition and medication therapy. The client should be encouraged to limit the use of alcohol and reduce the consumption of foods high in purines. Such foods include sardines, herring, mussels, liver, kidney, goose, venison, and sweetbreads. Medication therapy is a primary component of management for clients with gout, and the physician normally prescribes a medication that will promote uric acid excretion or reduce its production. Fluid intake is important in preventing the development of uric acid stones. Fad or starvation diets can precipitate an acute attack because of the rapid breakdown of cells they induce. Excessive physical and emotional stress can exacerbate the disease.

A nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction?

C. "I should avoid all exercise when my joints are inflamed." Rationale: The client should avoid activities (other than gentle range of motion) when the joints are inflamed. Isometric exercises are also helpful when the joints are inflamed. Daily range-of-motion exercises are an important component of the program and will help relieve pain, but the client should exercise only to the point of fatigue or discomfort. All clients are taught to maintain good posture.

A client is found to have AIDS. What is the nurse's highest priority in providing care to this client?

C. Instituting measures to prevent infection in the client. Rationale: The client with AIDS has inadequate immune bodies and is at risk for infection. The priority nursing intervention is protecting the client from infection. The nurse would also provide emotional support to the client. Discussing the cause of AIDS and the ways in which AIDS is contracted are not priority interventions.

A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately:

C. Places the infant in the knee-chest position. Rationale: If a hypercyanotic episode occurs, the infant is calmed and placed in the knee-chest position, and the physician is notified. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to achieve this position and relieve chronic hypoxia. Oxygen is also administered to the infant.

A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply.

C. Skeletal muscle weakness D. Hyperactive bowel sounds. Rationale: Signs of hyponatremia include a rapid, thready pulse; skeletal muscle weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive bowel sounds; increased urine output; headache; and personality changes. The nurse must assess these changes from baseline. If muscle weakness is detected, the nurse should immediately check respiratory effectiveness, because ventilation depends on strength of the respiratory muscles.

During a client's yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. The nurse tells the client:

C. That the intraocular pressure in both eyes is normal. Rationale: Normal intraocular pressure ranges from 10 to 21 mm Hg. Therefore this client's intraocular pressure is normal. Increased intake of fluids is unrelated to increasing intraocular pressure.

A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction?

D. "I'll put lotion on my leg a few times a day." Rationale: The client should be instructed to don the prosthesis immediately on arising and to keep it on all day (once the incision has healed completely) to reduce residual limb swelling. "I can wash my leg with a mild soap," "I need to check my leg for irritation every day," and "I should wear a sock over my stump" are correct statements regarding residual limb and prosthesis care. The client should not use any lotions, alcohol-containing powders, or oils on the residual limb unless told to do so by the healthcare provider. The client should also perform range-of-motion exercises of the joints, as well as strengthening exercises, including the upper extremities, every day.

A client arrives at the emergency department with complaints of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first?

D. Administration of a subcutaneous injection of epinephrine (Adrenalin). Rationale: Once airway has been established, the client would be given subcutaneous epinephrine. IV corticosteroids and IV fluids may also be prescribed. Pain medication may or may not be prescribed.

A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves:

D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material. Rationale: To apply a cast, the skin is washed and dried well, but it is not soaked in a warm-water bath. Padding is applied and a stockinette is placed smoothly and evenly over the area to be casted. The plaster is then rolled onto the padding and the edges are trimmed or smoothed as needed. Local anesthesia of the fractured extremity is not necessary, although an analgesic may be administered to alleviate pain. A local anesthetic will block nerve sensation, and it is important for the client to be able to report any changes in sensations after the cast is applied. If the client has open wounds on the fractured extremity, a window will be cut in the cast to allow visualization and treatment of the wound. A wound would not be covered with cast material.

Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care?

D. Checking the skin integrity of the right leg at least every 8 hours. Rationale: Buck extension traction is a type of skin traction. It is important with skin traction to inspect the skin underneath at least once every 8 hours for irritation or inflammation. The nurse never releases the weights of traction unless specifically asked to do so by the physician. Applying lanolin to the skin could leave the skin slippery, making it difficult to maintain the belt or boot used for the skin traction. There are no pins to care for with skin traction.

A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which of the following assessment findings indicates to the nurse that the client may be experiencing hypotonic contractions?

D. Contractions that can be indented easily with fingertip pressure at their peak. Rationale: Hypotonic contractions, coordinated but too weak to be effective, usually occur during the active phase of labor, when progress normally quickens. Contractions are infrequent and brief and can easily be indented on the abdomen with fingertip pressure at their peak. These contractions cause minimal discomfort because the contractions are weak. Fetal hypoxia is not usually seen with hypotonic contractions.

A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates that he will:

D. Expect to experience pain, nausea, and vomiting after the procedure. Rationale: If the client experiences any pain that is unrelieved, redness around the eye, or nausea or vomiting, the physician must be notified, because such findings could be an indication of increased intraocular pressure. Usually the client is given a follow-up appointment on the day after the surgery, and the physician removes the eye patch at this time. The client is instructed to limit activity to sitting in a chair, resting, and walking to the bathroom for 24 hours. Aspirin or medications containing aspirin should not be taken by the client; rather, acetaminophen (Tylenol) should be used to alleviate discomfort.

A nurse is providing instructions to a nursing assistant about effective measures for communicating with a hearing-impaired client. The nurse instructs the nursing assistant to:

D. Face the client when talking, keeping the hands away from the mouth. Rationale: To facilitate communication with a client who is hearing impaired, the nurse should speak in a normal tone, not shout or raise the voice. The nurse should speak clearly and directly while facing the client and keep the hands away from the mouth so that the client can read the nurse's lips. It may be helpful for the nurse to move closer to the client and toward the better ear to facilitate communication, but it is not helpful to talk directly into the client's impaired ear. Smiling while talking will make it difficult for the client to lipread.

A nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion?

D. Limiting elevation of the head of the bed to 45 degrees. Rationale: To prevent graft occlusion, the nurse limits elevation of the head of the bed to 45 degrees. The nurse does assess the client for signs of graft occlusion, but assessment will not prevent occlusion. The signs of graft occlusion include changes in peripheral pulses, cool-to-cold extremities distal to the graft, white or blue extremities or flanks, severe pain, and abdominal distention. Bowel sounds and urine output are also assessed, but these parameters are unrelated to graft occlusion.

A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client's room and quickly assesses the client. The client appears to be having respiratory difficulty. The nurse should first:

D. Manually ventilate the client, using a resuscitation bag. Rationale: Because the client is experiencing respiratory distress, the client should be manually ventilated with the use of a resuscitation bag until the problem can be determined. Mechanical ventilators have alarm systems that warn the nurse of a problem with either the client or the ventilator. Such alarms must be activated and functional at all times. The low exhaled volume alarm sounds when there is a disconnection or leak in the ventilator circuit or a leak in the client's artificial airway cuff. A code is called when the client requires resuscitation. An anesthesiologist may be needed to insert an endotracheal tube or to assist with a code. Accumulation of secretions in the respiratory system and the need for suctioning would trigger the high-pressure alarm.

A nurse provides home care instructions to a client after a scleral buckling procedure. The nurse should tell the client:

D. That redness and swelling of the eyelids and conjunctiva are expected. Rationale: The scleral buckling procedure is performed to treat retinal detachment. In the preoperative period the nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may require bilateral patching. Redness and swelling of the eyelids and conjunctiva, the result of surgical manipulation, are expected. Blood loss in retinal detachment surgery is minimal, and only serous drainage is expected on the postoperative dressing. The client should not expect immediate return of vision. Postoperative inflammation and eye drops interfere with vision. Because healing takes place over weeks to months, vision will improve gradually. Strict bedrest for 48 hours is not required; however, depending on the location and size of the retinal break, activity restrictions may be needed to prevent further tearing or detachment and to promote drainage of any subretinal fluid.

A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic specialist?

D. The traction ropes are unable to move over the pulleys. Rationale: After skeletal traction pins are inserted and traction is applied, all ropes, knots, and pulleys are inspected to ensure that they are positioned properly. Traction knots and ropes must be intact and secure. Ropes should move easily over pulleys and weights, and the weights should hang freely at all times. The clamps on the traction frame should be tight.