hesi next gen case studies for med surg

Select the 5 assessment findings that are consistent with acute rheumatic fever.

murmur opening snap joint pain painless nodules over elbows previous sore throat and upper respiratory infection

A primary health care provider schedules a bone scan for a client with osteoporosis. Which nursing action is beneficial for the client? Select all that apply. One, some, or all responses may be correct.

placing the client in the supine position informing the client a mild sedative may be used instructing the client to push fluids after the test instructing the client. to empty the bladder before the test

When assessing a client with varicose veins, which clinical manifestation would the nurse expect to find? Select all that apply. One, some, or all responses may be correct.

presence of ankle edema increased leg fatigue report of leg fullness and pruritus

Which neurovascular assessment would the nurse plan to perform immediately after a client has rotator cuff surgery? Select all that apply. One, some, or all responses may be correct.

skin color disproportionate pain presence of edema movement of the hand sensation of the extremities

The nurse plans to help a client get out of bed for the first time following a surgery on the right humerus. Which assessment would the nurse make before having the client sit on the side of the bed? Select all that apply. One, some, or all responses may be correct.

the presence of safe footwear status of comfort and pain appearance of wound and skin presence of tubes and lines

When a client develops internal bleeding after abdominal surgery, which clinical manifestation would the nurse expect the client to exhibit? Select all that apply. One, some, or all responses may be correct.

pallor decreased MAP tachycardia

A client who has recently moved to the country attends the prenatal clinic at 30 weeks gestation for the first time. Although she states that she has had immunizations, she does not know which ones. Which immunization would the nurse recommend? Select the 3 correct immunizations.

influenza TDAP hepatitis B

When a client with heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factor that may have contributed to the ankle swelling? Select all that apply. One, some, or all responses may be correct.

intake of salty foods increased fluid consumption medication compliance recent travel alcohol intake

The nurse provides discharge teaching to a client with acquired immunodeficiency syndrome (AIDS) and a low white blood cell (WBC) count. Which client statement indicates understanding of the content? Select all that apply. One, some, or all responses may be correct.

"my roommate will take care of our cats litter box" "I will rinse my toothbrush in bleach once a week" "each time I get a drink, I will use a different cup" " I will wash my hands thoroughly after shaking hands with anyone" "I will wash my armpits and peri area twice daily if I can't shower"

Which action would the nurse include in the plan of care at this time? Select all that apply. (case study is implying client has lupus) -

advise the client to have eyes checked every 6 months suggest use of moist heat on joints teach the client to complete priority activities first inform the client to fold the Childs clothes sitting down reassure client she did not cause this disease monitor for depression

Which interventions would the nurse anticipate at this time? Select all that apply patient has femur fracture now has decreased o2 sat)

apply oxygen place on bed rest start iv fluids

Which factor would the nurse identify as increasing the risk of human immunodeficiency virus (HIV) transmission? Select all that apply. One, some, or all responses may be correct

childbirth breast feeding anal sex needle sharing oral sexual contact

Which clinical manifestations will the nurse expect when caring for a client with a diagnosis of pulmonary edema? Select all that apply. One, some, or all responses may be correct.

crackles coughing orthopnea anxiety restlessness lethargy

Which finding would the nurse associate with chronic osteomyelitis? Select all that apply. One, some, or all responses may be correct.

elevated WBC count presence of avascular scar tissue elevated ESR

A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) receives pentamidine for a protozoal infection. The nurse will monitor the client for which common side effect? Select all that apply. One, some, or all responses may be correct.

hypoglycemia decreased blood pressure oliguria sore throat fever

After initiating antibiotic therapy on a client with syphilis, the nurse suspects a Jarisch-Herxheimer reaction (JHR). Which clinical manifestation supports the nurse's suspicion? Select all that apply. One, some, or all responses may be correct.

fever with shaking chills generalized aches worsening of skin rash

Select the 4 assessment findings that would indicate the client was not progressing as expected and another epinephrine injection is needed.

o2 sat of 85% development of stridor decreased LOC cyanotic lips and fingers

Which finding would the nurse expect when assessing a client with peripheral arterial disease (PAD)? Select all that apply. One, some, or all responses may be correct.

pallor of the feet ulcers on the toes delayed cap refill hair loss to lower extremities muscle atrophy intermittent claudication

Which nursing intervention would the nurse include in the plan of care for a client after a hip replacement? Select all that apply. One, some, or all responses may be correct.

place a pillow between the clients legs require the client to use an elevated toilet seat keep the clients hips in a neutral straight position use a fracture bedpan for urinary relief

Select the 3 findings that require immediate follow-up. (pt fell of ladder increasing acute right leg pain)

reports numbness and tingling in right toes reports 9/10 pain in right leg right leg externally rotated