Evolve Hesi Quiz Unit 8&9

What does a nurse do during the orientation phase of a helping relationship?

The nurse develops a healthy relationship with the client.

Aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis. The nurse understands that the drug is being used primarily for which of its properties? 1 Analgesic 2 Antipyretic 3 Antiinflammatory 4 Antiplatelet

Antiinflammatory R:The antiinflammatory action of aspirin reduces joint inflammation. Aspirin reduces fever, but this is not the rationale for prescribing it for clients with rheumatoid arthritis. Aspirin does not preserve bone integrity. Flexion contractures are prevented by exercise, not aspirin.

What client response indicates to the nurse that a vasodilator medication is effective

Blood pressure changes from 154/90 to 126/72 mm Hg R:Vasodilation will lower the blood pressure. The pulse rate is not decreased and may increase. Breath sounds are not directly affected by vasodilation, although vasodilator medications can decrease preload and afterload, which could indirectly affect breath sounds in heart failure. The urine output is not affected immediately, although control of blood pressure can help preserve renal function over time.

A nurse is providing discharge instructions about digoxin. Which response should a nurse include as a reason for a client to withhold the digoxin? 1 Chest pain 2 Blurred vision 3 Persistent hiccups 4 Increased urinary output

Blurred Vision R:Visual disturbances, such as blurred or yellow vision, may be evidence of digoxin toxicity. Chest pain is not a toxic effect of digoxin. Persistent hiccups are not related to digoxin toxicity. An increased urinary output is not a sign of digoxin toxicity; it may be a sign of a therapeutic response to the drug and an improved cardiac output

After a surgical thyroidectomy a client exhibits carpopedal spasm and some tremors. The client complains of tingling in the fingers and around the mouth. What medication should the nurse expect the primary health care provider to prescribe after being notified of the client's adaptations? 1 Potassium iodide 2 Calcium gluconate 3 Magnesium sulfate 4 Potassium chloride

Calcium gluconate; The client is exhibiting signs and symptoms of hypocalcemia, which occurs with accidental removal of the parathyroid glands; calcium gluconate is administered to treat hypocalcemia

The health care provider prescribes an oral hypoglycemic for the patient with type 2 diabetes. What will the nurse need to consider when developing the teaching plan?

Clients taking oral hypoglycemics may subconsciously relax dietary rules to gain a sense of control. r:Taking a tablet may give the client a false sense that the disease is under control, and this can lead to dietary indiscretions. Some oral hypoglycemics work by stimulating the pancreas to produce insulin, others work by decreasing carbohydrate absorption, and others work in a variety of other ways; therefore teaching should be specific to the drug prescribed. Oral hypoglycemic drugs can have serious adverse effects.

Which relationship does the nurse consider reflective of the relationship of naloxone to morphine sulfate? 1 Aspirin to warfarin 2 Amoxicillin to infection 3 Enoxaparin to dalteparin 4 Protamine sulfate to heparin

Protamine sulfate to heparin R:Protamine sulfate is the antidote for heparin overdose, and naloxone will reverse the effects of opioids such as morphine. Aspirin and warfarin both interfere with coagulation. While amoxicillin is used to treat some infections, an infection is not a medication, so amoxicillin cannot be considered an antidote. Both enoxaparin and dalteparin are low-molecular-weight heparins.

A client who is receiving multiple medications for a myocardial infarction complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of what drug?

Digoxin Signs of digoxin toxicity include cardiac dysrhythmias, anorexia, nausea, vomiting, and visual disturbances. Although nausea and heart block may occur with captopril, these symptoms rarely are seen; drowsiness and central nervous system disturbances are more common. Toxic effects of morphine are slow, deep respirations, stupor, and constricted pupils; nausea is a side effect, not a toxic effect. Toxic effects of furosemide are renal failure, blood dyscrasias, and loss of hearing.

A client is receiving combination chemotherapy for treatment of metastatic carcinoma. For which systemic side effect should the nurse monitor the client?

1 Ascites 2 Nystagmus Correct3 Leukopenia 4 Polycythemia R:Leukopenia, a reduction in white blood cells, is a systemic effect of chemotherapy as a result of myelosuppression. Ascites is not a side effect of chemotherapy. Chemotherapy does not affect the eyes; nystagmus is an involuntary, rapid rhythmic movement of the eyeballs. Also, nystagmus is a local, not a systemic, response. The red blood cells will be decreased, not increased.

A client who has sustained an accident says, "I have a dream of conquering the world's highest mountain range." To which level of need does the given scenario refer to, according to Maslow's hierarchy of needs?

1 The given scenario relates to the first level that includes physiological needs. Incorrect2 The given scenario relates to the fourth level that includes self-esteem needs. Correct3 The given scenario relates to the final level that includes self-actualization needs. 4 The given scenario relates to the second level that includes safety and security needs R:The given scenario relates to the final level of Maslow's hierarchy of needs: the self-actualization needs. The self-actualization need refers to self-fulfillment. Physiological needs refer to the need for clean air, water, and food. Self-esteem needs refer to self-confidence, usefulness, achievement, and self-worth. Safety and security needs refer to physical and psychological security.

The nurse provides discharge teaching to a client with tuberculosis. Which treatment measure does the nurse reinforce as the highest priority? 1 Getting sufficient rest 2 Getting plenty of fresh air 3 Changing the current lifestyle 4 Consistently taking prescribed medication

Consistently taking prescribed medication Tubercle bacilli are particularly resistant to treatment and can remain dormant for prolonged periods; medication must be taken consistently as prescribed. Although getting sufficient rest, getting plenty of fresh air, and changing the current lifestyle are important, the microorganisms must be eliminated with medication.

Which program is an example of a continuing education program?

Correct1 A program on caring for the elderly with dementia offered by a university 2 A program on culturally sensitive approaches in health care for the hospital nursing staff 3 A training on the use of computers to maintain health records by the health care institution 4 A program on safe principles for administering chemotherapy for nurses in the oncology department Rationale:The program on caring for the elderly with dementia offered by a university is an example of a continuing education program. Such programs are formal, organized educational programs offered by universities, hospitals, or professional nursing organizations. An in-service education program is held in the institution or health care agency to increase the competencies of the nurses employed there. Therefore the programs on culturally sensitive approaches in health care, use of computers, and safe principles for administering chemotherapy are in-service educational programs.

While assessing a client, the nurse finds that the client has swelling and skin discoloration in the lower limbs. Which component of nursing process does this information indicate? Correct

Correct1 Input 2 Output 3 Content 4 Feedback Rationale:Input is the data or information that comes from a client's assessment, such as how the client interacts with the environment and the client's physiological function. Output is the end product of a system. The content is the information about nursing interventions for clients with specific healthcare problems. Feedback involves the assessment of how a system functions.

A client with type 1 diabetes receives 30 units of NPH insulin at 7 am. At 3:30 pm the client becomes diaphoretic, weak, and pale. What does the nurse determine that these physiologic responses are associated with? 1 Diabetic coma 2 Somogyi effect 3 Diabetic ketoacidosis 4 Hypoglycemic reaction

Hypoglycemic reaction R:These are sympathetic nervous system responses to hypoglycemia; the peak action of NPH insulin is 8 to 12 hours after administration, and 8.5 hours have elapsed since it was given. The signs and symptoms of diabetic coma are dry mucous membranes; hot, flushed skin; deep, rapid respirations (Kussmaul breathing); acetone odor to the breath; nausea and vomiting; and, as with hypoglycemia, weakness. The Somogyi effect includes wide swings in blood glucose levels between hyperglycemia and a profound hypoglycemia caused by insulin rebound. Ketoacidosis results from excess use of fats for energy when carbohydrates cannot be used. Lipids are metabolized incompletely, and dehydration, acidosis (both ketotic and lactic), and electrolyte imbalance result. It is not the result of insulin administration.

Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Which is the priority nursing assessment? 1 Apical heart rate 2 Electrolyte levels 3 Signs of bleeding 4 Tissue compatibility

Sings of bleeding R:Assessment for bleeding is a priority when administering a thrombolytic agent because it may lead to hemorrhage. While it is important to assess the heart rate and other vital signs, a failure to do so would not be potentially life-threatening. Electrolyte levels are not affected. Tissue compatibility assessment is not necessary.

A client is receiving doxorubicin as part of a chemotherapy protocol. The nurse should assess the client for which major life-threatening side effect of doxorubicin?

1 Anemia Correct2 Cardiotoxicity 3 Pulmonary fibrosis 4 Ulcerative stomatitis R:Heart failure and dysrhythmias are the primary life-threatening toxic effects unique to doxorubicin. When bone marrow is depressed to precarious levels, the dose is altered or blood components administered. Pulmonary fibrosis is not an adverse effect of doxorubicin or of any of the other antineoplastic agents. Ulcerative stomatitis is an uncomfortable side effect of doxorubicin, but it is not life threatening as are the primary life-threatening toxic effects unique to doxorubicin.

What is the duty of a nurse while caring for a client?

Correct1 The nurse should determine the client's care preferences. 2 The nurse should hide serious information from the family. 3 The nurse should inform the family after taking the required steps. 4 The nurse should instruct the family to keep the client from doing things himself or herself. R:The nurse must determine the client's care preferences. The nurse should incorporate the client's beliefs, needs, and understanding into care. The nurse should be honest with the family of the client. The nurse should seek permission from the family before taking any necessary steps for the client rather than inform them after taking steps. The nurse should instruct the family to motivate the client to do as much for himself or herself as possible.

A client with arthritis is taking large doses of aspirin. What symptom does the nurse include when teaching the client about the clinical manifestations of aspirin toxicity?

Disturbance in hearing R:Ringing in the ears occurs because of its effect on the eighth cranial nerve and is a classic symptom of aspirin toxicity. Feelings of drowsiness are not side effects of aspirin; aspirin promotes comfort, which may permit rest. Aspirin may cause diarrhea, nausea, and vomiting, not intermittent constipation. A metallic taste in the mouth is not a side effect of salicylates such as aspirin.

A nurse is caring for a postoperative client who has a nasogastric (NG) tube set to low intermittent suction. The nurse recalls that the primary reason that an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium has been prescribed is to prevent which complication?

Electrolyte imbalance When clients do not receive nutrients or fluids by mouth and have loss of electrolytes through the removal of gastric secretions via an NG tube, then electrolyte imbalance is a primary concern. Constipation is usually not a concern in this type of situation. Although dehydration is a possible effect of an NG tube removing gastric secretions and fluid, electrolyte balance is still the priority. An NG tube set to low intermittent suction usually relieves nausea and vomiting.

Dexamethasone has been prescribed for a client after a craniotomy for a brain tumor. When evaluating the effectiveness of the medication, the nurse expects what physiologic response?

Reduced cerebral edema Dexamethasone is a corticosteroid with antiinflammatory effects, which will reduce cerebral edema. Dexamethasone will not keep the tumor from growing; it will reduce fluid content and therefore cell size, not the number of cells. Dexamethasone does not promote fluid reabsorption, which is undesirable because it increases fluid retention and therefore cerebral edema. Dexamethasone does not promote sedation; sedation is not desired because it may mask the client's adaptations to the craniotomy.

The nurse provides seaweed soup as a first meal to a Korean client who just gave birth and requested a meal. Which nursing theory is the nurse following?

1 Roy's theory 2 Watson theory 3 Leininger's theory/Correct3 4 Betty Neuman's theory Rationale: The major concept of Leininger's theory is cultural diversity, where the goal is to provide a client with culturally specific nursing care. Some Korean clients believe that seaweed soup cleanses the blood and promotes healing and lactation. Therefore, by giving seaweed soup to a postpartum client, the nurse is providing culturally specific care. According to Roy's theory, the goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. According to Watson's theory, the goal of nursing is promoting and restoring health and preventing illness. As per Betty Neuman's theory, the role of nursing is to stabilize the client when stressors are present. The nurse should assess the stressors, the client's response to the stressors, identify the nursing diagnosis, plan patient-centered care, implement interventions, and determine if the stressor is resolved.

A nursing student is trying to understand the elements of an article. What are the characteristics of the abstract section of an article? Select all that apply.

Correct1 The abstract section summarizes the purpose of the article. Correct2 The abstract section mentions the major themes and implications for nursing practice. Incorrect3 The abstract section contains brief supporting evidence regarding the importance of the topic. Correct4 The abstract section is a brief summary that informs the reader whether the article is research or clinically based. 5 The abstract section has detailed information regarding the level of science or clinical information available on the topic. Rationale:The abstract section summarizes the purpose of the article. It also mentions the themes or findings as well as the implications for nursing practice. The abstract section is a brief summary that informs readers whether the article is based on research or clinical evidence. The introduction contains brief supporting evidence regarding the importance of the topic. The literature review section contains detailed information regarding the level of scientific or clinical information available on the topic.