HESI Questions_Aug29
A depressed client tells a nurse, "I want to die." What is the most therapeutic response by the nurse? 1. "You would rather not live." 2. "You're not alone in feeling this way." 3. "When was the last time you felt this way?" 4. "Do you believe that there's life after death?"
1. "You would rather not live." The response "You would rather not live" uses paraphrasing to demonstrate to the client that it is all right to talk about these feelings; it recognizes the client's sense of hopelessness without intensifying the feeling while providing an opportunity for the client to verbalize further. Although it may be true that others feel the same way, this statement takes the focus away from the client. Finding out when the client last felt this way is insignificant at this time; this question might be appropriate after the client's feelings have been validated and discussed. Asking the client about a belief in life after death takes the focus off the client's feelings and places it on a philosophical level.
A hyperactive client with bipolar I disorder becomes loud and insulting and says to a staff member, "Get lost, you old buzzard!" The nurse can best handle this situation by: 1. Asking the client to come with her for a walk 2. Asking the client to explain why he is so angry 3. Pointing out that the staff member is neither old nor a buzzard 4. Telling the client that if the rude behavior does not change there will be consequences
1. Asking the client to come with her for a walk Rather than placing emphasis on their behavior, staff members should use the easy distractibility of these clients to redirect manic behavior to more constructive channels. A walk with the nurse provides structure and a way to expend energy safely. The client will be unable to explain the basis for the expressed anger to the nurse. Pointing out that the staff member is neither old nor a buzzard encourages the client to defend the statement; it does not foster communication about feelings. Telling the client that if the rude behavior does not change there will be consequences focuses on the behavior; it is a punitive response that does not foster communication.
The nurse is acting as group leader for the weekly gathering of clients with bipolar disorder and their families. When the wife of one client expresses concern that, "he's not taking the medications right and will never get better," other family members begin to express their concerns about medication effectiveness. Several clients respond that the family members just don't understand what they are dealing with. Place the following nursing interventions in the appropriate order to best address the issues being expressed. 1. Assuring the entire group that everyone's opinions and concerns will be respected 2. Exploring the specific concern regarding medication compliance and effectiveness 3. Assisting the family and the clients in identifying positive outcomes of the therapies so far 4. Providing the group with education regarding both the condition and the various treatment modalities 5. Providing each member with ample time to express his or her concerns
1. Assuring the entire group that everyone's opinions and concerns will be respected 5. Providing each member with ample time to express his or her concerns 2. Exploring the specific concern regarding medication compliance and effectiveness 3. Assisting the family and the clients in identifying positive outcomes of the therapies so far 4. Providing the group with education regarding both the condition and the various treatment modalities The nurse needs to reestablish a tone of mutual respect, trust, and confidentiality among the group's members. Restating expectations and guidelines will assist in achieving that goal. Identifying concerns in a manner that allows all members to be involved will help eliminate misconceptions and flawed assumptions. The nurse can them accurately assess the problems and concerns. Providing time for the discussion of specific concerns by both family and clients supports effective discussion of the problems and concerns. Identifying positive outcomes facilitates hope and focuses attention on the plan of care. Once communication and specific concerns are addressed, the members can turn their attention to the task of refocusing on the plan of care.
When determining whether a client has anorexia nervosa or bulimia nervosa, the nurse should identify those characteristics that relate only to anorexia nervosa. Select all that apply. 1. Cachexia 2. Binge eating 3. Constipation 4. Decreased blood pressure 5. Delayed psychosexual development
1. Cachexia 4. Decreased blood pressure 5. Delayed psychosexual development A state of malnutrition with muscle wasting, weakness, and emaciation (cachexia) occurs with anorexia nervosa; clients usually are 15% to 30% below ideal body weight. Many clients with anorexia nervosa exhibit psychological symptoms, including a lack of age-appropriate interest in sex and relationships. Recurrent episodes of the rapid consumption of a large amount of food in a discrete period (binge eating) are associated with bulimia nervosa. Constipation can occur with both anorexia nervosa and bulimia nervosa, usually because of a lack of adequate fluids and intestinally stimulating foods. Hypotension can occur with both anorexia nervosa and bulimia nervosa, usually because of dehydration.
A nurse is caring for a client with the diagnosis of somatoform disorder, conversion type. What type of affect does the nurse expect this client to exhibit? Select all that apply. 1. Calm 2. Cheerful 3. Depressed 4. Frightened 5. Matter-of-fact
1. Calm 5. Matter-of-fact The symptoms prevent the individual from being forced to act in relation to a conflict or stressor; the client's symptoms thus reduce anxiety and remove the conflict. The individual demonstrates a lack of concern about the symptoms (la belle indifférence). The individual will not be happy and cheerful, sad and depressed, or frightened.
A client presents to the emergency department with a fever, headache, loss of appetite, and malaise. The nurse identifies raised red bumps on the client's arms and legs. A diagnosis of chickenpox is made. The client should be placed in a private room with what kind of precautions? Select all that apply. 1. Contact precautions 2. Droplet precautions 3. Airborne precautions 4. No additional precautions other than standard precautions 5. Hand hygiene only
1. Contact precautions 3. Airborne precautions According to The Centers for Disease Control and Prevention guidelines, airborne precautions apply to patients known or suspected to be infected with a pathogen that can be transmitted by airborne route, including chickenpox. Chickenpox is transmitted from person to person by directly touching the blisters, saliva, or mucus of an infected person. The virus can also be transmitted through the air. Chickenpox can be spread indirectly by touching contaminated items freshly soiled, such as clothing, from an infected person.
A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? Select all that apply. 1. Eat foods high in vitamin C. 2. Take your temperature daily. 3. Balance periods of rest and activity. 4. Use a strong soap when washing the skin. 5. Expose the skin to the sun as often as possible.
1. Eat foods high in vitamin C. 2. Take your temperature daily. 3. Balance periods of rest and activity. Vitamin C should be encouraged because it is essential for the biosynthesis of collagen. A fever is the major sign of an exacerbation. A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion should be applied. Exposing the skin to the sun as often as possible is not necessary. Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.
A nurse is performing a physical assessment of a client with gout. What parts of the client's body should the nurse assess for the presence of tophi (urate deposits)? Select all that apply. 1. Feet 2. Ears 3. Chin 4. Buttocks 5. Abdomen
1. Feet 2. Ears Clients with gout may develop deposits of monosodium urate in their tissues (tophi); these consist of a core of monosodium urate with a surrounding inflammatory reaction. Also, urate crystals form in the synovial tissue, typically the metatarsophalangeal joint of the great toe of a foot. Uric acid has a low solubility; it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears. Urate deposits will not form at the chin, buttocks, and abdomen because the blood flow is ample, and it is not cartilaginous tissue.
The nurse is examining a teenage patient who has a gawky, long-legged appearance. What is the sequence of growth changes that lead to this characteristic early adolescent appearance? 1. Growth of the neck, hands, and legs in length 2. Increase in the length of the trunk 3. Increase in the width of the shoulders 4. Increase in the depth of the chest 5. Increase in the breadth of the hips and chest
1. Growth of the neck, hands, and legs in length 5. Increase in the breadth of the hips and chest 3. Increase in the width of the shoulders 2. Increase in the length of the trunk 4. Increase in the depth of the chest There is a characteristic sequence in the growth changes that occur during adolescence. The lengthwise growth of the neck and extremities occurs before growth in other areas of the body. This is followed by an increase in the breadth of the hips and chest. Months later there is an increase in shoulder width. Then the trunk increases in length. Finally there is an increase in the depth of the chest. This sequential growth pattern results in the characteristic gawky, long-legged appearance of early adolescence.
The nursing instructor determines that the student nurse understands the type(s) of hepatitis that most commonly are spread by consuming contaminated food and water or by fecal contamination if the student identifies which of the following? Select all that apply. 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D 5. Hepatitis E
1. Hepatitis A 5. Hepatitis E Hepatitis A and E most commonly are spread through the fecal-oral route. Hepatitis B most commonly is spread through the sharing of needles and through unprotected sex. Hepatitis C and D most commonly are spread through intravenous (IV) drug needle sharing.
An older adult, who alternately lives in a homeless shelter and on the street, is brought to the emergency department by friends. The client has a fever, night sweats, and a blood-tinged productive cough. The health care provider suspects that the client has tuberculosis and prescribes a purified protein derivate (PPD) test, chest x-ray, and sputum culture. Place these interventions in the order that they should be performed. 1. Institute airborne precautions. 2. Perform a PPD intradermal skin test. 3. Obtain a sputum specimen. 4. Have a chest x-ray performed. 5. Notify the Department of Health.
1. Institute airborne precautions. 4. Have a chest x-ray performed. 2. Perform a PPD intradermal skin test. 3. Obtain a sputum specimen. 5. Notify the Department of Health.
The significant other of a client who is dying of AIDS tells the nurse, "Life is not worth living without my partner." What should the nurse plan to do to help the significant other cope with the impending death? 1. Involve the significant other's support system. 2. Explore the significant other's psychotic thoughts. 3. Suggest a bereavement group to the significant other. 4. Reinforce the current self-image of the significant other.
1. Involve the significant other's support system. Involving the support system will decrease the person's feelings of isolation. Anticipatory grieving does not involve psychotic thoughts. Suggesting a bereavement group to the significant other is premature. The concern is about loss and loneliness, not self-image.
A client with a personality disorder tells a nurse, "I want to tell you something, but you have to promise to keep it a secret." Which response could lead to splitting among the staff? 1. "I'm part of a team that shares important information about clients." 2. "I'll keep your comments confidential because I'm your advocate." 3. "I can't promise to keep what you say confidential from the rest of the staff." 4. "Trust me to do what is in your best interests with the information, which includes discussing it with the team."
2. "I'll keep your comments confidential because I'm your advocate." To gain control, clients often try to split the staff apart, separating the nurse from the rest of the treatment team; confidentiality is not expected to be maintained among professionals caring for a client, because it is detrimental to the client's therapy. The response "I am part of a team that shares important information about clients" reinforces the team approach to care. The response "I cannot promise to keep what you say confidential from the rest of the staff" both reinforces the team approach and avoids providing false assurance that the information will be kept secret. The response "Trust me to do what is in your best interests with the information, which includes discussing it with the team" does not provide false assurance that the information will be kept secret.
A 25-year-old male client is being treated for an anxiety disorder and issues related to impaired social interaction. The client accuses the health care providers of being homosexuals. This behavior indicates that the client is most likely: 1. Attempting to keep the focus off his problems 2. Having difficulty handling unacceptable feelings about himself 3. Exploring emotionally charged reactions to threatening situations 4. Trying to embarrass those people he perceives as authority figures
2. Having difficulty handling unacceptable feelings about himself By using the defense mechanism of projection, the client is attributing to others those personal feelings that are objectionable to himself. No evidence is given to indicate that redirection is being used. The client is not exploring emotionally charged reactions. There is no evidence to indicate that the client is trying to embarrass those people he perceives as authority figures.
A nurse is caring for a client with bipolar I disorder. What should the plan of care for this client include? Select all that apply. 1. Touching the client to provide reassurance 2. Providing a structured environment for the client 3. Ensuring that the client's nutritional needs are met 4. Engaging the client in conversation about current affairs 5. Designing activities that require the client to maintain contact with reality Structure tends to decrease agitation and anxiety and to increase the client's feelings of security. Whether the individual is experiencing mania or depression, nutritional needs must be met. The hyperactivity associated with mania interferes with the ability to sit still long enough to eat; hyperactivity requires an increase in the intake of calories for the energy expended. Touching can be threatening for many clients and should not be used indiscriminately. Conversations should be kept simple. The client with a bipolar disorder, either depressed or manic phase, may have difficulty following involved conversations about current affairs. Clients with bipolar disorders are in contact with reality, so designing activities that require the client to maintain such contact will serve little purpose.
2. Providing a structured environment for the client 3. Ensuring that the client's nutritional needs are met Structure tends to decrease agitation and anxiety and to increase the client's feelings of security. Whether the individual is experiencing mania or depression, nutritional needs must be met. The hyperactivity associated with mania interferes with the ability to sit still long enough to eat; hyperactivity requires an increase in the intake of calories for the energy expended. Touching can be threatening for many clients and should not be used indiscriminately. Conversations should be kept simple. The client with a bipolar disorder, either depressed or manic phase, may have difficulty following involved conversations about current affairs. Clients with bipolar disorders are in contact with reality, so designing activities that require the client to maintain such contact will serve little purpose.
A client with the diagnosis of schizophrenia, paranoid type, is admitted to the hospital. The client says to the nurse, "I know they're spying on me in here, too. I'm not safe anywhere!" What is the most therapeutic response by the nurse? 1. "Nobody's spying on you in here." 2. "Why do you feel they'd want to follow you here?" 3. "You don't feel safe anywhere, not even in the hospital?" 4. "You're safe in the hospital; nothing can happen to you here."
3. "You don't feel safe anywhere, not even in the hospital?" Rephrasing facilitates further communication, helps the nurse express understanding, and does not belittle the client's feelings. Presenting reality to the client at this time will only increase the client's anxiety and lead the client to defend the delusion. "Why" questions make a client defensive, and the wording implies that the client's delusion is true. Telling the client that he is safe constitutes false reassurance; also, a suspicious client will not believe the nurse.
During assessment, the nurse asks a patient about developmental milestones such as the age at which thelarche and menarche occurred. The nurse determines that the patient experienced pubertal delay. Which finding in the patient supports the nurse's conclusion? 1. Weight increased by 8-12 kilograms. 2. Menarche occurred 2 years after thelarche. 3. Breast development occurred by 15 years of age. 4. Growth in height stopped 2 years after menarche.
3. Breast development occurred by 15 years of age. When the development of breasts has not occurred by 13 years of age in girls, it is considered pubertal delay. An increase in weight between 7 and 25 kilograms is considered normal during the growth spurt period. The occurrence of menarche within 2 years of onset of breast development or thelarche is a normal finding. Generally in girls, growth in height stops 2 to 2 1/2 years after menarche.
A nurse is caring for a group of children with the diagnosis of autism. Which signs and symptoms are associated with this disorder? Select all that apply. 1. Lack of appetite 2. Depressed mood 3. Repetitive activities 4. Self-injurious behaviors 5. Lack of communication with others
3. Repetitive activities 4. Self-injurious behaviors 5. Lack of communication with others Perseveration (repetition of a behavior pattern) is commonly demonstrated by children with autism; this behavior provides comfort. Self-stimulation through injurious behavior is associated with autism. Children with autism have difficulty communicating or do not communicate at all with others. There may be unusual eating habits and food preferences, but lack of appetite is not associated with autism. Mood disorders are usually not associated with autism.
A nurse is caring for a group of clients who are being considered for treatment with a negative pressure wound treatment device. The nurse should discuss this prescription with the primary health care provider when the client has which condition? 1. Neuropathic ulcer 2. Abdominal dehiscence 3. Stage IV pressure ulcer with eschar 4. Treated osteomyelitis within the vicinity of the wound
3. Stage IV pressure ulcer with eschar The nurse should discuss this treatment option with the practitioner because eschar should be removed down to a rich vascular bed before treatment with a negative pressure wound treatment device. Research demonstrates that a neuropathic ulcer responds well to negative pressure wound treatment. Research demonstrates that a wound with dehiscence responds well to negative pressure wound treatment. A negative pressure wound treatment device is contraindicated with untreated, not treated, osteomyelitis.
A client is admitted to the hospital with a history of increasingly bizarre behavior. The client says, "I'm wired to the TV, and it told me that my family is out to kill me." What is the best initial action by the admitting nurse? 1. Taking the client to the dayroom and introducing the other clients on the unit 2. Reassuring the client that the unit is safe and that the client will be protected from the family 3. Telling the client that the door is locked and that no one will be permitted to enter the unit to harm anyone 4. Introducing the client to the primary nurse who will be assigned to work on a one-to-one basis with the client
4. Introducing the client to the primary nurse who will be assigned to work on a one-to-one basis with the client Introducing the client to the primary nurse who will be assigned to work on a one-to-one basis with the client is extremely important because the client can be assisted back to reality by a nurse who is interested in her and her feelings. It can also start to build the therapeutic relationship which will be the foundation of trust. Taking the client to the dayroom and introducing the other clients on the unit should come later. Reassuring the client that the unit is safe and that the client will be protected from the family is false reassurance that the client will not believe. Telling the client that the door is locked and that no one will be permitted to enter the unit to harm anyone will have no effect because the client is under a strong delusion.
A depressed client frequently expresses doubts about living and admits thinking about suicide while denying that he has developed a plan. During this period it is essential that the nurse: 1. Have a staff member stay with the client continuously 2. Plan to involve the client in activities that foster independence 3. Explain in detail to the client how the staff will protect him against self-harm 4. Make frequent unobtrusive observations of the client's moods and his activities
4. Make frequent unobtrusive observations of the client's moods and his activities It is necessary to assess behavior changes that indicate impending suicidal acting out. Because there is no overt acting out and there is no plan, continuous observation is not necessary. The depressed client has little energy and has difficulty making decisions. Activities that are more structured are needed. Detailed explanations are inappropriate and overwhelming for a depressed client.
What is a frequent finding in clients with paraphiliac disorders? 1. Other covert or overt emotional problems 2. Gonadal and pituitary hormone deficiencies 3. Overassociation with society's fringe groups 4. Inadequate development of the sexual organs
1. Other covert or overt emotional problems Clients with paraphiliac disorders usually have many other emotional problems, either overt or covert in nature. There is no proof of a deficiency of gonadal and pituitary hormones in connection with paraphiliac disorders. A link between overassociation with society's fringe groups and paraphiliac disorders has no basis in fact. Sexual organs in individuals with paraphiliac sexual disorders are not inadequately developed.
A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client? 1. Double bind 2. Ambivalence 3. Loose association 4. Inappropriate affect
Ambivalence is the existence of two conflicting emotions, impulses, or desires. Double bind is two conflicting messages, not emotions, in a single communication. Loose associations are not two conflicting emotions but instead the loosening of connections between thoughts. Inappropriate affect is not two conflicting emotions but instead the inappropriate expression of emotions.
A male client with the diagnosis of a bipolar disorder, depressed episode, is found lying on the floor in his room in the psychiatric unit. He states, "I don't deserve a comfortable bed; give it to someone else." The best response response by the nurse is: 1. "Everyone has a bed. This one is yours." 2. "You are not allowed to sleep on the floor." 3. "I don't understand why you're on the floor." 4. "You're a valuable person. You don't need to lie on the floor."
1. "Everyone has a bed. This one is yours." A matter-of-fact approach helps avoid a cycle in which the nurse expresses concern to a client who feels unworthy, which increases feelings of unworthiness. Citing a hospital policy focuses on rules and regulations, which may exacerbate the client's negative personal feelings because he is breaking the rules. "I don't understand why you're on the floor" is a statement that the client may not be able to respond to. Telling the client that he is a valuable person and doesn't need to lie on the floor may increase feelings of unworthiness because it creates a gap between the nurse's estimate of the client and what the client feels.
A client with burns over 35% of the body complains of chilling. To promote client comfort, the nurse should: 1. Limit room drafts 2. Maintain an 80° F room temperature 3. Place a sterile top sheet over the client 4. Maintain the room humidity below 40%
1. Limit room drafts Limiting drafts minimizes body heat lost by convection; the loss of body heat increases when moistened skin is exposed to slightly moving air. The room temperature should be kept at approximately 85° F because heat is lost from burned areas. A sterile sheet is not necessary; some clients may be treated by the open method and have burns exposed.
The nurse is providing discharge teaching to a client with acquired immunodeficiency syndrome (AIDS) whose white blood cell count (WBC) is low. Which statement indicates a need for further education? Select all that apply. 1. "My roommate will take care of our cat's litter box." 2. "I will eat at least one piece of fresh fruit every day." 3. "I will use a different cup every time I have a drink." 4. "I will rinse my toothbrush in bleach once a week." 5. "I will walk at the mall twice a week to keep up my strength." 6. "I will wash my hands thoroughly after shaking hands with anyone."
2. "I will eat at least one piece of fresh fruit every day." 3. "I will use a different cup every time I have a drink." 4. "I will rinse my toothbrush in bleach once a week." 6. "I will wash my hands thoroughly after shaking hands with anyone." When a client with AIDS has a low WBC, it is necessary to avoid possible sources of infection. Raw fruit and vegetables should be avoided, as should large gatherings of people who might be ill. When the WBC is low, the client should avoid changing the litter box, and cups and glasses should not be reused. The client should rinse his/her toothbrush in bleach weekly and then rise out the bleach with hot water. Hands should be washed with an antimicrobial soap before eating and drinking, after touching a pet, after using the toilet, and after shaking hands with anyone.
A nurse is caring for a client who is addicted to opioids and who has undergone major surgery. The client is receiving methadone. What is the purpose of this medication? 1. Allows symptom-free termination of opioid addiction 2. Switches the user from illicit opioid use to use of a legal drug 3. Provides postoperative pain control without causing opioid dependence 4. Counteracts the depressive effects of long-term opioid use on thoracic muscles
2. Switches the user from illicit opioid use to use of a legal drug Methadone may legally be dispensed; the strength of this drug is controlled and remains constant from dose to dose, unlike illicit drugs. Methadone is used in the medically supervised withdrawal period to treat physical dependence on opiates; methadone therapy substitutes a legal for an illegal drug. Methadone may be administered over the long term to replace illegal opioid use. If methadone treatment is abruptly stopped, there will be withdrawal symptoms. Methadone is a synthetic opioid and can cause dependence; it is used in the treatment of heroin addiction but may be prescribed for people who have chronic pain syndromes. It is not used for acute postoperative pain. Methadone is not known to counteract the depressive effects of long-term opioid use on thoracic muscles.
While teaching parents about the developmental milestones of a 15-month-old child, the nurse informs the parents about various activities that their child should be able to do. Which statement of the parent indicates effective learning? 1. "My child can jump with both feet." 2. "My child can walk up stairs with one hand held." 3. "My child can creep up stairs and kneel without support." 4. "My child goes up and down stairs alone with two feet on each step."
3. "My child can creep up stairs and kneel without support." A 15-month-old child has the ability to creep up stairs and kneel without support due to the development of gross motor skills. The child starts jumping with both feet at the age of 30 months. The child will start walking up stairs with one hand held at the age of 18 months. The calf muscles develop sufficiently for the child to walk up and down stairs alone at the age of 24 months.
A client receiving chemotherapy for cancer develops sores in the mouth and asks the nurse why this happened. What is the nurse's best response? 1. "The sores occur because of the direct irritating effects of the drug." 2. "These tissues are poorly nourished because you have a decreased appetite." 3. "The rapidly dividing cells of the gastrointestinal tract are damaged by the drug." 4. "This side effect occurs because it targets the cells of the gastrointestinal system."
3. "The rapidly dividing cells of the gastrointestinal tract are damaged by the drug." Many chemotherapeutic agents function by interfering with DNA replication associated with cellular reproduction (mitosis). Rapid mitosis of the stratified squamous epithelium of the mouth and anus results in these areas being powerfully affected by the drugs. The response "The sores occur because of the direct irritating effects of the drug" is not caused by direct irritation; most agents are administered parenterally. A decreased appetite (anorexia) does not cause stomatitis. Chemotherapeutic agents affect most rapidly proliferating cells, which include not only the cells of the gastrointestinal epithelium but also those of the bone marrow and hair follicles.
client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Place the nurse's responsibilities in the order in which they should be performed. 1. Remove the client's clothing 2. Insert a venous access device in an unaffected arm Incorrect 3. Evaluate whether the client has inhaled smoke 4. Determine the extent of the burns, using the rule of nines 5. Apply sterile saline dressings to the burned surfaces
3. Evaluate whether the client has inhaled smoke 2. Insert a venous access device in an unaffected arm Incorrect 1. Remove the client's clothing 4. Determine the extent of the burns, using the rule of nines 5. Apply sterile saline dressings to the burned surfaces Smoke inhalation can cause edema of the respiratory lumen, interfering with oxygenation; evaluation of respiratory status is a priority assessment. Venous access facilitates administration of parenteral medications that may be urgently needed. Removing the client's clothing should be done after the client's respiratory status is evaluated and venous access is established so that the extent of the burns can be evaluated. Determining the extent of the burns, using the rule of nines, should be done after the client's respiratory status is evaluated and the clothes removed. Sterile saline dressings are applied after the health care provider has evaluated the wounds.
A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client? Select all that apply. 1. Polyuria 2. Leukopenia 3. Hyperthermia 4. Splenomegaly 5. Erythrocytosis
3. Hyperthermia 4. Splenomegaly A high fever (hyperthermia) results from the disease process. Parasites invade the erythrocytes, subsequently dividing and causing the cell to burst. The spleen enlarges from the sloughing of red blood cells. Oliguria, not polyuria, occurs in malaria-induced kidney failure. Leukopenia does not occur. Erythrocytosis does not occur.
Which feelings should a nurse anticipate a client with bulimia nervosa to report experiencing during an episode of binge eating? Select all that apply. 1. Happiness 2. Sleepiness 3. Loneliness 4. Hopelessness 5. Powerlessness
4. Hopelessness 5. Powerlessness When clients feel powerless and helpless, they often lose hope. They feel desperate, despondent, and dejected. Clients with bulimia nervosa have a sense of being out of control that accompanies the excessive or compulsive consumption of large amounts of food, resulting in feelings of powerlessness, helplessness, and hopelessness. They tend to feel depressed rather than happy. Sleepiness is not experienced during an episode of binge eating; however, severe electrolyte imbalances caused by binge eating may result in weakness and fatigue. Although people with bulimia nervosa tend to binge alone and in secret, loneliness is not the primary feeling experienced during binge eating.
A client with cellulitis of the leg asks why bed rest has been prescribed. The nurse explains that the primary purpose of bed rest for this client is to: 1. Decrease catabolism to promote healing at the site of injury 2. Lower the metabolic rate in an attempt to help reduce the fever 3. Reduce the energy demands on the body in the presence of infection 4. Limit muscle contractions that may force causative organisms into the bloodstream
4. Limit muscle contractions that may force causative organisms into the bloodstream Exercise will promote extension of the local infection from the leg into the circulation, causing septicemia. Decreasing catabolism to promote healing at the site of injury is not accomplished by bed rest. Although bed rest does decrease catabolism to promote healing at the site of injury, it is not the purpose for bed rest in this situation. Although bed rest does reduce the energy demands on the body in the presence of infection, it is not the purpose for bed rest in this situation.
A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke one year ago. What assessment is most important for the nurse to perform before beginning the irrigation? Neurological Skin Pain Wound
Pain Assessment of pain must be performed before beginning a potentially painful procedure such as a wound irrigation. A neurological check is not necessary unless the client's neurological status has worsened since the stroke. Both skin and wound checks can be assessed once client comfort has been determined and handled.
