HESI Elsevier questions
A client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is admitted to the intensive care unit with a serum sodium level of 112 mEq/L or mmol/L. Which protocol prescription should the nurse implement first? Obtain serum sodium levels every 4 hours. Provide oral sodium chloride supplements. Monitor fluid restriction and document hourly intake and output. Initiate normal saline IV at 100 mL/hour.
A client diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) can experience sodium levels that are dangerously below the norm range of 136 to 145 mEq/L or 136 to 145 mmol/L (SI units). The first action is to evaluate the client's serum sodium levels to determine fluid and electrolyte correction with isotonic saline based on the client's status of hypotonic hyponatremia.
A new resident in an assisted living facility is an older client who is experiencing short-term memory loss and confusion. Which activity should the registered nurse (RN) schedule the client to do during the day? Arts and crafts. Current events discussion group. Group sing-along. Daily exercise group.
A daily exercise group allows the client to mirror the leader and minimizes the client's stress to remember.
What information should the nurse include about perineal self-care for a client who is 24-hours post delivery? Use cool water to decrease swelling of the perineum. Perineal care should be done at least twice per day. Reapply ice packs to perineum after each voiding. Spray warm water from front to back using a squeeze bottle.
A postpartum client should use a squeeze bottle after each void and clean from front to back (D). Use of cool water (A) in the perineal bottle does not significantly reduce edema after the first 24 hours post partum. Perineal care (B) should be implemented each time the client toilets, not BID (B). Ice applications (C) are not usually indicated after the first 24 hours post delivery.
The charge nurse is assigning a room for a newly-admitted client, diagnosed with acute Pneumocystis carinii pneumonia, secondary to acquired immunodeficiency syndrome (AIDS). Which room would be best to assign to this client? A private room fully equipped with an outside air ventilation system. A semi-private room shared with an bed-ridden elder who would enjoy the company. A semi-private room with a bed available nearest to the bathroom. A semi-private room that does not have a client in the other bed at this time.
A semi-private room without a roommate is the best assignment because the room can be easily blocked to create a private room should the client require isolation measures due to the pneumonia (the AIDS diagnosis alone does not affect the type of room assignment).
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH), which is manifested by which symptoms? Loss of thirst, weight gain. Dependent edema, fever. Polydipsia, polyuria. Hypernatremia, tachypnea.
SIADH occurs when the posterior pituitary gland releases too much ADH, causing water retention, a urine output of less than 20 ml/hour, and dilutional hyponatremia. Other indications of SIADH are loss of thirst, weight gain, irritability, muscle weakness, and decreased level of consciousness.
When discussing birth in a home setting with a group of pregnant women, which situation should the nurse include about the safety of a home birth? Only the woman and her midwife should be present during the delivery. The woman should live no more than 15 minutes from the hospital. The woman's extended family should be allowed to attend the home birth. Medical backup should be available quickly in case of complications.
Access to quick emergency care should be available in the event that an unforeseen complication arises (D) during a home birth. Although the nurse-midwife should be a competent healthcare provider during a home birth (A), access to emergency, surgical, and resuscitation assistance should be readily available. A 15-minute drive to the hospital is ideal, but (B) does not ensure the safest situation. The presence and support of family during the home birth (C) does not necessarily ensure a safe home birth.
The nurse is examining a neonate at age 10 minutes. Which assessment finding should the nurse report to the healthcare provider? Diamond shaped anterior fontanel. Bluish coloring of the tips of nailbeds. Mottling of color in cooler temperatures. Edema of the eyes and face.
Acrocyanosis is normal, and cyanosis of the nailbeds at 10 minutes of age should be reported to the healthcare provider.
A client with heart failure (HF) is being discharged with a new prescription for the angiotensin-converting enzyme (ACE) inhibitor captopril (Capoten). The nurse's discharge instruction should include reporting which problem to the healthcare provider? Weight loss. Dizziness. Muscle cramps. Dry mucous membranes.
Angiotensin-converting enzyme (ACE) inhibitors are used in HF to reduce afterload by reversing vasoconstriction common in heart failure. This vasodilation can cause hypotension and resultant dizziness. Weight loss is desired if fluid overload is present, and may occur as the result of effective combination drug therapy such as diuretics with ACE inhibitors. It does not reuiqre reporting to the healthcare provider. Unlike ACE inhibitors, diuretics may result in hypokalemia and excessive diuretic administration may result in fluid volume deficit manifested by symptoms of dehydration.
A nulliparous client telephones the labor and delivery unit to report that she is in labor. What action should the nurse implement? Emphasize that food and fluid intake should stop. Tell the woman to stay home until her membranes rupture. Ask the client to describe why she thinks she is in labor. Suggest the client to come to the hospital for labor evaluation.
Assessment, the first step of the nursing process, should include specific questions to determine if the woman is in labor (C). Current research does not support stopping oral intake (A). Spontaneous rupture of membranes (SROM) may not occur until labor has progressed, so (B) is not indicated. The client can describe over the phone what is happening, so (D) may not be necessary at this time.
When evaluating maternal bonding, which of the following maternal behaviors exhibited by the client would the nurse most likely expect to see when a new mother receives her infant for the first time? She eagerly reaches for the infant, undresses the infant, and examines the infant completely. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. Her arms and hands receive the infant and she then cuddles the infant to her own body. She eagerly reaches for the infant and then holds the infant close to her own body.
Attachment/bonding theory indicates that most mothers will demonstrate behaviors such as tracing the infant's profile with her fingertips during the initial visit with the newborn, which may be at delivery or later.
A preschooler is admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which statement indicates to the nurse the parents understand home care instructions? The healthcare provider should be notified if the child reports a funny feeling in the casted arm. Once in the morning, evening, and before bedtime the fingers should be checked for swelling. Ensure the child keeps the casted arm above the heart for the first 24 hours. Temperature monitoring should be done every four hours for the next two days.
Cast application to an extremity can impaired circulation to below the cast causing tingling, blueness, or skin discoloration. The parents should notify the healthcare provider if the child reports a funny feeling of tingling in the arm or fingers.
A school-aged child is taking methylphenidate hydrochloride (Ritalin, Biphentin) for the treatment of attention-deficit hyperactivity disorder (ADHD). The mother tells the nurse that she gives the medication at bedtime so it is 'working' during school the next morning. What modification to the administration plan should the nurse recommend to this mother? Continue administering the medication dose at bedtime. Give the medication when the child arrives at school. Take the medication with meals. Administer at least six hours before bedtime.
Central nervous system stimulants, such as Ritalin, should be taken at least six hours before bedtime to decrease insomnia.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? Sodium. Antidiuretic hormone. Potassium. Glucose.
Clients with primary hyperaldosteronism exhibit a profound decline in the serum levels of potassium (hypokalemia). Hypertension, along with the hypokalemia are the most prominent and universal signs for this condition. If both of these findings are present, there is 50% likelihood the client to be diagnosed with hyperaldosteronism.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take? Apply cold compresses to both breasts for comfort. Instruct the client run warm water on her breasts. Wear a loose-fitting bra to prevent nipple irritation. Express small amounts of milk to relieve pressure.
The client is experiencing engorgement even though she is bottle-feeding her infant, and applying cold compresses may help reduce discomfort.
A client has been told that there is cataract formation over both eyes. Which finding should the nurse expect when assessing the client? Decreased color perception. Presence of floaters. Loss of central vision. Reduced peripheral vision.
Decreased color perception occurs with cataract formation. Cataract formation is also associated with blurred vision and a global loss of vision so gradual that the client may not be aware of it.Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative care, eight edition., Ch. 47,
An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide? You are in the hospital, and I am the nurse caring for you. It must be difficult for you to control your anxious feelings. Go to occupational therapy and start a project. You are not in a war area now; this is the United States.
Delusions, which are often well-fixed, often generate fear and isolation. The nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others. The other responses are not indicated and do not distract the client or reassure that he is in a safe place.
A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, 'You fat tub of lard! Get something done around here!' What is the best initial action for the nurse to take? Have the orderly escort the client to his room. Tell the client his healthcare provider will be notified if he continues to be verbally abusive. Redirect the client's energy by asking him to tidy the recreation room. Call the healthcare provider to obtain a prescription for a sedative.
Distracting the client, or redirecting his energy, prevents further escalation of the inappropriate behavior. The other actions are not indicated at this time and could escalate the abuse unnecessarily.
An adult client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal the client's clothing. Which action should the nurse to take? Encourage the client to actively participate in assigned activities on the unit. Place a lock on the client's closet. Ignore the client's paranoid ideation to extinguish these behaviors. Explain to the client that his suspicions are false.
Diverting the client's attention from paranoid ideation and encouraging the client to complete unit assignments can be helpful in assisting develop a positive self-image. The other actions are not indicated.
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? Edema, basilar rales, and an irregular pulse. Increased urinary output and tachycardia. Shortness of breath, bradycardia, and hypertension. Regular heart rate and hypertension.
Edema, basilar rales, and an irregular pulse indicate cardiac decompensation and require immediate intervention.
A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? Notify the healthcare provider. Move the newborn to an isolation nursery. Document the finding in the infant's record. Obtain a culture of the vesicles.
Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonly referred to as 'flea bites,' but is a normal finding that is documented in the infant's record, and requires no further action.
The daughter of a female client with stage-1 Alzheimer's disease (AD) asks the nurse what changes should she expect her mother to demonstrate in this stage. What finding should the nurse tell the daughter is common? Inability to recognize one's location. Personality changes and agitation. Depression and emotional lability. Alterations in communication.
Evidence indicates that frequent incidences of confusion, such as being unable to recognize one's location in a familiar environment is associated with the early stages of Alzheimer's Disease. The other manifestations occur with later stages of AD.
A client with chronic schizophrenia illness is admitted after taking risperidone (Risperdal) 10 mg/day for three months. The nurse implements a daily assessment using the Abnormal Involuntary Movement Scale (AIMS). What findings should the nurse report to the healthcare provider? Cogwheel rigidity. Drowsiness and dizziness. Tremors and muscle twitching. Dry mouth, constipation, and blurred vision.
For a client with chronic mental illness, evidence-based pharmacological guidelines recommend first-line treatment using an atypical antipsychotic, such as risperidone (Risperdal), which can cause extrapyramidal symptoms (EPS) at dosages above 10 mg/day. The AIMS criteria measures tardive dyskinesia movements, such as facial, oral, tongue, teeth, and other akinesias of the trunk and extremity, such as tremors and muscle twitching, which should be reported.
A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, 'No, it's not MY fault. You can't blame me. I didn't kill him, you did.' What action is best for the nurse to take? Reassure the client by telling him that his fear of the admission procedure is to be expected. Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place. Assess the content of the hallucinations by asking the client what he is hearing. Ignore the behavior and make no response at all to his delusional statements.
Further assessment is indicated and the nurse should obtain information about what the client believes the voices are telling him--they may be telling him to kill himself or the nurse. The other actions are not indicated.
The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator of a rotator cuff tear? Inability to adduct the arm from the body. Inability to slowly lower the arm when abducted. Inability to externally rotate the arm. Inability to internally rotate the arm.
Inability to slowly lower the arm when abducted. Rotator cuff damage can be assessed with the Drop Arm test, in which the affected arm is passively abducted at 90 degrees and the client is unable to keep the arm elevated or slowly and smoothly lower the arm from this position without moving the shoulder forward to have the other muscles compensate for the torn rotator cuff muscle. Jarvis, (2016). Physical Examination and Health Assessment, 7th ed. chapter 22, p 632
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM X 1. What action should the nurse take immediately? Give the medication as prescribed and monitor for efficacy. Encourage the client to breastfeed rather than bottle feed. Have the client empty her bladder and massage the fundus. Call the healthcare provider to question the prescription.
Methergine is used to treat postpartum hemorrhage, but is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription because the client's elevated blood pressure.
Miotic drug therapy for the treatment of glaucoma is based chiefly upon which physiologic action? Enhancing aqueous humor outflow. Inhibiting aqueous humor production. Maintaining intraocular pressure. Preventing extraocular infection.
Miotic drugs act to enhance aqueous outflow through papillary constriction with the goal to reduce intraocular pressure.
A male client is brought to the emergency department by a police officer, who reports the client was 'disturbing the peace' by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary committment? (Choose all that apply.) Threats to kill his friend. Disruptive behaviors in a community setting. Hears voices telling him to kill himself. Reports he has not needed a bath in 4 months. Created extensive private property damage. Says he has not eaten in 3 days.
Most states provide for emergency involuntary hospitalization or civil commitment for a specified period to prevent dangerous behavior that is likely to cause harm to self or others. Police officers and healthcare providers may be designated by statute to authorize the detention of persons who are a danger to themselves or others or who are unable to provide for their own basic needs due to mental illness. The other behaviors are civil issues, not factors related to involuntary commitment.
The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? Notify your healthcare provider if there is an increase in heart rate. Increase fluid intake while taking an antihistamine or decongestant. Avoid allergy medications that contain pseudoephedrine or phenylephrine. Ophthalmic lubricating drops may be used for eye dryness due to allergy medications.
OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects, such as increased intraocular pressure, so a client with glaucoma should avoid using these OTC medications.
The nurse should expect the healthcare provider to prescribed what treatment regimen for a client with peptic ulcer caused by Helicobacter pylori ? (Select all that apply.) Clarithromycin (Biaxin). Sulfisoxazole (Gantrisin). Misoprostol (Cytotec). Omeprazole (Prilosec). Metronidazole (Flagyl). Sucralfate (Carafate).
Recommended medical treatment for Helicobacter pylori includes the use of at least 2 different antibiotics and a proton pump inhibitor to decrease the incidence of antibiotic resistance. Clarithromycin Omeprazole Metronidazole
During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Place the first action on top and last action on the bottom.)
Reposition the client. Increase IV fluid. Provide oxygen via face mask. Call the healthcare provider. To stabilize the fetus, intrauterine resuscitation becomes the first priority. In order to enhance the fetal blood supply, the laboring client should be repositioned to displace the gravid uterus and improve fetal perfusion. Secondly, the IV fluids should be increased to expand the maternal circulating blood volume. The next step to optimize oxygenation of the circulatory blood volume is to apply oxygen via face to the mother. Finally, the last step is to notify the primary healthcare provider for additional interventions to resolve the fetal stress.
Which client should the nurse report to the healthcare provider as needing a prescription for Rh Immune Globulin (RhoGAM)? Woman whose blood group is AB Rh-positive. Newborn with rising serum bilirubin level. Newborn whose Coombs test is negative. Primigravida mother who is Rh-negative.
RhoGAM is indicated during pregnancy for a woman who is Rh-negative or within 72 hours of birth of a Rh-positive infant (D). RhoGAM is not indicated for (A, B,and C).
The mother of a 13-year-old female adolescent tells the nurse that her daughter has not started her menstral cycle. Which finding should the nurse report to the healthcare provider? Absence of pubic hair Plays make-believe with dolls. Does not have a boyfriend. History of urinary tract infections.
Secondary sex characteristics that occur with pubescence typically begin occurring by age 12. The absence of pubic hair may indicate a delay in maturation and development and should be reported to the healthcare provider.
A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. What content is most important for the nurse to include in the discharge teaching for this client? Information about smoking cessation. Diet instructions for a low-residue diet. Instructions on a weight-loss program. The importance of increasing milk in the diet.
Smoking has been associated with ulcer formation, and stopping or decreasing the number of cigarettes smoked per day is an important aspect of ulcer management.
Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate? Tactile stimulation. Commercial warm packs. Skin-to-skin contact with parent. Oral sucrose and nonnutritive sucking.
Studies of nonpharmacologic interventions for pain in the newborn most frequently indicate that the administration of oral sucrose and nonnutritive sucking (D), such as the provision of a pacifier, are effective in reducing objective indicators of pain after an invasive procedure. Other interventions, such as tactile stimulation (A) during apnea and bradycardic episodes and warm packs (B) for thermoregulation, have not been shown to reduce pain responses. Skin-to-skin contact (C) fosters neurobehavioral development and supporting parent-infant intimacy and attachment, but sucking behaviors provide the most effective pain-comfort responses.
An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? Apply flannel pajamas to provide warmth. Administer a PRN dose of ibuprofen. Perform range of motion exercises in a warm tub. Drape the sheets over the footboard of the bed.
The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. (A, B, and C) may be components of the client's plan of care, but the nurse should first address the client's complaint.
An adult female client who has been taking antipsychotic neuroleptic medication for the past three days has a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate? Place the client on seizure precautions and monitor carefully. Immediately transfer the client to intensive care unit. Describe the symptoms to the charge nurse and record on the client's chart. No action is required at this time as these are known side effects of such drugs.
These symptoms are descriptive of a life threatening reaction to neuroleptic drugs, known as neuroleptic malignant syndrome (NMS) which is manifested by fever, rigidity, autonomic instability, and encephalopathy. This is an emergency reaction, and the client requires immediate critical care. The other actions do not address the potential of respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure that can result in death due to NMS.
A woman admitted to the Emergency Department is bleeding profusely from a patch where hair was lost from her scalp. She is accompanied by her husband who tells the nurse that his wife caught her hair on the railing and pulled it out when she fell down the stairs. The husband is solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his wife by saying to her, 'I am right here with you, dear. Nothing can keep us apart.' What is the priority nursing intervention? Notify the local police of a suspected spousal abuse situation. Ask the hospital security to remove the husband from the treatment room. Reassure the husband that his wife will be treated well while he is in the waiting area. Require the husband to leave the cubicle while the client is being treated.
This client should be questioned about the possibility of spousal abuse and cannot answer truthfully in the presence of the perpetrator, so separating the couple is a priority. The nurse should require the husband to leave the cubicle while the client is being treated. The other interventions are not the priority.
A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement? Encourage fluids to 3000 ml per day. Change the client's position every two hours. Keep the head of the bed elevated 30 degrees. Turn off the television and darken the room.
To decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimuli or rotational movement, such as sudden head movements or position changes, should be minimized. To effectively manage the client's symptoms, turn off the television, darken the room by minimizing fluorescent lights, flickering television lights, and distracting sounds
The nurse is providing dietary instructions to a client who had a partial gastrectomy and experienced dumping syndrome. Which statement by the client indicates that the instructions were understood? Fluids should be limited to eight ounces with meals. Rice should be eliminated from the client's diet. Sugar-free gelatin should be used with caution. Meat should consist of no more than 4 ounces per day.
To minimizes symptoms of dumping syndrome, the client should limit fluid consumption during meals. Complex carbohydrates, such as rice, are appropriate choices for a client with dumping syndrome as long as the food is consumed in small frequent meals throughout the day. Simple sugars should be avoided in this diet, so sugar-free gelatin may be consumed. Clients with dumping syndrome should increase protein in the diet.
A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first? Bathe the infant with an antimicrobial soap. Measure the head and chest circumference. Obtain the infant's footprints. Administer vitamin K (AquaMEPHYTON).
To reduce direct contact with the human immuno-virus in blood and body fluids on the newborn's skin, a bath with an antimicrobial soap should be administered first.
Older clients are at highest risk for abuse and neglect due to which factors? (Select all that apply.) Needs are greater than the caretaker's abilities. Client's declining strength. Fixed income. Longer life expectancy. Lack of exposure to technology and trends.
Whenever needs are not being met due to lack of ability of the caretaker, stress and feelings of failure of the care provider may be expressed through neglect and abuse. A decline in strength also increases the older client's vulnerability to resist or respond to elder abuse. So needs and declining strength.
