HESI Review

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. 1. Rye 2. Oats 3. Rice 4. Corn 5. Wheat

1, 2, 5 Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided.

A nurse is teaching a parent about the different temperaments that a child may display. What characteristics does a slow-to-warm up child display? Select all that apply. 1. The child adapts slowly to frequent communication 2. This child is regular and predictable in his or her habits 3. The child is highly active, irritable, and irregular in his or her habits 4. The child reacts with mild but passive resistance to novelty 5. The child reacts negatively and with mild intensity to new stimuli

1, 4, 5 A slow-to-warm up child adapts slowly with frequent communication and reacts to novelty with mild but passive resistance. A slow-to-warm up child also reacts negatively and with mild intensity to new stimuli. An easy child is regular and predictable in his or her habits. A difficult child is highly active, irritable, and irregular in his or her habits.

The nurse is gathering a client's health history. Which information does should the nurse classify as biographical information? Select all that apply. 1. Symptoms 2. Clients age 3. Family structure 4. Type of Insurance 5. Occupation status

2, 4, 5 Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client's age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.

A registered nurse is teaching a nursing student about Piaget's theory of cognitive development that includes four periods, which are related to age. Which age group corresponds with concrete operations? 1. 2-7 years 2. 7-11 years 3. Birth-2 years 4. 11-adulthood

7-11 years According to Piaget's theory of cognitive development, the concrete operations period applies to the age group of 7 to 11 years of age. The preoperational period is during the age group of 2 to 7 years. The sensorimotor period applies to the age group of birth to 2 years. The formal operations period applies to the age group of 11 years to adulthood.

A nursing student is listing the professional responsibilities and roles of the nurse. Who is the most independently functioning nurse? 1. Nurse educator 2. Nurse researcher 3. Nurse administrator 4. Advanced practice registered nurse

Advanced practice registered nurse The advanced practice registered nurse is the most independently functioning nurse. The nurse educator, nurse researcher, and nurse administrator all must be associated with an organization to pursue their professional prospects.

The nurse is verbally interviewing and taking a history of a client who was admitted to the hospital. Which phase of the nursing process is being used in this situation?

Assessment

The nurse interviews a client about a current health problem. The nurse then obtains and documents the client's temperature, blood pressure, and heart rate. Which step of the nursing process is involved in this situation? 1. Planning 2. Diagnosis 3. Assessment 4. Implementation

Assessment The scenario is an example of the assessment phase of the nursing process. Assessment involves the collection of comprehensive data pertinent to the client's health. During the planning level of nursing care, the nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. The nurse analyzes the assessment data to determine the diagnoses during the diagnosis level of nursing practice. The nurse implements the health care plan identified for the client during the implementation level of the standards of nursing practice. This level may include administering prescribed medications or healthcare procedures.

A nurse is hired to work in a healthcare facility that has a completely computer-based client information system. The nurse in charge knows that the newly hired nurse is knowledgeable about this system when the nurse says what?

Client information is immediately available while using this system

A client on a 2-gram sodium diet states, "I never add salt to my food when I cook. I just need help selecting low-sodium foods." After receiving dietary education, the client creates sample menus. Which meal selection will cause the nurse to intervene?

Cottage cheese, crackers, relish dish (celery, olives, sweet pickles)

The nurse is caring for a client who requires an intravenous infusion. The nurse explains the reason for the procedure while assembling the kit for the infusion. What is the role of the nurse in this situation? 1. Educator 2. Manager 3. Advocate 4. Caregiver

Educator The nurse assumes the role of educator when explaining to the client the need for an intravenous infusion. The nurse as a manager oversees the budget of a specific nursing unit or agency and is also responsible for coordinating the activities of the staff providing nursing care. As an advocate, the nurse protects the human and legal rights of the client. The nurse empowers the client with information required to make important health care decisions. The nurse is a caregiver when helping the client maintain and regain health, manage disease symptoms, and achieve a maximum level of functioning.

Which type of theory is the Neuman systems model?

Grand Theory Neuman systems model is an example of a grand theory that provides a comprehensive foundation for scientific nursing practice, education, and research. Theories related to growth and development are descriptive theories. Prescriptive theories address nursing interventions for a phenomenon, describe the condition under which the prescription occurs, and predict the consequences. Mishel's theory of uncertainty is a prescriptive theory. Middle-range theories tend to focus on a specific field of nursing. Mishel's theory of uncertainty in illness is a middle-range theory.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client? 1. Heat stroke 2. Heat exhaustion 3. Accidental hypothermia 4. Malignant hyperthermia

Heat stroke Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95° F, the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalational anesthesia that is indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

A teenager with a diagnosis of osteosarcoma is to have the affected leg amputated. What should the nurse do to promote psychologic adjustment and early function immediately after surgery? 1. Allow client to change the first dressing 2. Help the client adjust to temporary prosthesis 3. Assign the client to a room with another adolescent 4. Have the client meet with a member of the cancer survivor organization

Help the client adjust to a temporary prosthesis A temporary prosthesis attached to a cast with a metal extension can be applied immediately after surgery. This will allow the adolescent to walk within several hours and helps start the adjustment process. The first dressing change is usually done by a member of the surgical team; also, this is too early to expect the adolescent to be ready to look at the surgical site. Assigning the adolescent to a particular room is usually done out of necessity rather than to promote psychologic adjustment. It is too early to have another cancer survivor visit, but this may be done later in the recovery process.

How can a nurse best soothe a hospitalized infant who appears to be in pain? 1. Feeding the infant 2. Holding the infant 3. Playing soft music in the room 4. Providing a quiet environment

Holding the infant Physical contact provides security for a distressed infant. Feeding to provide comfort is not always an option because the infant may have been fed recently, may be anorexic, or may be on nothing-by-mouth status. Music or a quiet environment may not always have a calming influence; often infants are not aware of the environment.

A nurse has made a nursing diagnosis without validating the data obtained from the client. Into what category does this error fall? 1. Labeling 2. Collecting 3. Clustering 4. Interpreting

Labeling The nurse's error of failure to validate the data is categorized as labeling. Errors at the collecting level include inaccurate data, missing data, and disorganization. Errors at the clustering level include insufficient clusters of cues, premature or early closure, and incorrect clustering. At the interpreting level, errors include failure to consider conflicting cues and failure to consider cultural influences or developmental stage.

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? 1. Presence of distention 2. Extent of weight gained 3. Amount of high fiber consumed 4. Length of time this problem has existed

Length of time this problem has existed First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time.

A nurse is assessing a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition does the nurse suspect?

Normal finding

A new mother said to the nurse, "I would like to care for my baby independently rather than depending on the baby's grandparents." What does the nurse infer from this information? 1. The client is of Asian culture 2. The client is of African culture 3. The client is of North American culture 4. The client is of latin american culture

North American culture The people who belong to United States and Western Europe culture possess individualistic characteristics. The people who belong to Asia, Africa, and Latin America do not possess individualistic characteristics; instead, they have a collectivistic approach. The new mother who belongs to any of these cultures other than the North American culture may depend on elder family members for child-rearing.

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present?

Paresthesias Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

Which nursing action would be considered a part of self-regulation in the decision-making process? 1. Reflecting on ones own experiences 2. Looking at all situations objectively 3. Supporting findings and conclusions 4. Making careful assumptions about a clients info

Reflecting on one's own experiences Self-regulation requires the nurse to reflect on his or her own experiences. Explanation requires looking at all situations objectively. Findings and conclusions are supported by explanation. Analysis requires the nurse to not make any careless assumptions.

An 8-year-old child who is cognitively impaired and blind does not speak or respond to the nurse. What should the nurse do when entering the child's room?

Say the child's name and touch arm before giving care

A nurse is teaching a school-aged child with juvenile idiopathic arthritis (JIA) activities to prevent the loss of joint function. What should the nurse caution the child to avoid?

Sedentary activities

The student nurse is reviewing the electronic health record for clients in a health care facility. Which action by the student nurse may inhibit clients from disclosing personal information? 1. Using the clients data for nursing research 2. Use of client data for medicaid payment 2. Discussing clients illness with the client 4. Sharing clients data with family members

Sharing clients data with family members Clients may not want their health information shared with others and may want to maintain their privacy. If the nurse retrieves client data from the electronic health records and shares it with family members, it may lead to clients not sharing information. The nurse can use client data for research without mentioning a client's personal details. The nurse can use client data for filing insurance to receive Medicaid payments. The nurse can discuss the client's illness with the client; doing so helps to understand the client's perspective and to provide effective care.

The nurse is caring for a client who reports dizziness, excessive thirst, and nausea. Which assessment parameter should make the nurse suspect this client may be suffering from heat stroke? 1. Skin that is hot and dry to touch 2. Increased blood pressure 3. Decreased respiratory rate 4. Edema in bilateral lower extremities

Skin that is hot and dry to touch Prolonged exposure to a high environmental temperature can overwhelm the body's heat-loss mechanisms. These conditions initially cause heat exhaustion which progresses to heat stroke if left untreated, which manifests as dizziness, excessive thirst, nausea, and skin that is hot and dry to the touch. A decreased (not increased) blood pressure characterizes a heat stroke due to low blood volume from dehydration. An increased (not decreased) respiratory rate is a nonspecific sign of heat stroke; tachypnea (increased respiratory rate) occurs in response to increased oxygen demand and reduced blood volume. Edema in the bilateral lower extremities is an indicator of right sided heart failure and not heat stroke.

A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? 1. Milk 2. Tea 3. Orange juice 4. Tomato juice

Tea The client is hyperkalemic, and potassium intake should be limited; tea is very low in potassium. Milk, orange juice, and tomato juice are all high-potassium foods and should be avoided.

The parents of a preschooler inform the nurse that their child often develops diarrhea and ask whether there might be anything wrong with the child's stomach. Upon assessment, the nurse also finds that the child has poor oral care and is at risk for dental caries. What is the most probable cause for the child's health issues? 1. The family often consumes fast foods 2. The parents neglect the child's dietary needs 3. The family does not follow hygienic practices 4. The child consumes excessive amounts of fruit juice

The child consumes excessive amounts of fruit juice If the child consumes excessive fruit juice or sweetened beverages, it increases the risk for dental caries and gastrointestinal conditions, such as chronic diarrhea. Consuming fast foods often result in childhood obesity, because fast foods are high in fats and starches. Neglecting the dietary needs or not following hygienic practices may cause gastrointestinal problems or make the child susceptible to infections.

Which activity would the nurse explain can be performed by infants of aged 6 to 8 months? 1. Holding a pencil 2. Showing hand preference 3. Placing objects into containers 4. Transferring objects from hand to hand

Transferring objects from hand to hand Infants of aged 6 to 8 months may be able to transfer objects from hand to hand. Infants of aged 10 to 12 months may be able to hold a pencil. Infants of aged 8 to 10 months may show a hand preference. Infants of aged 10 to 12 months may be able to place objects into a container.

Which organization's 2010 publication did not include a call to improve health care for lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) clients?

U.S. Department of Health and Human Services The U.S. Department of Health and Human Services published Healthy People 2010, which did not include any information related to the need to improve the health care for LGBTQ people. The Institute of Medicine's (IOM) report on LGBT health, The Joint Commission field guide for care of LGBT clients, and the World Professional Association for Transgender Health standards of care all included an emphasis on the need to improve health care for LGBTQ clients.

Which food should the nurse recommend for a toddler-age client who is at risk for developing rickets? 1. Yogurt 2. Carrots 3. Fruit juice 4. Dried fruit

Yogurt A calcium and vitamin D deficiency causes rickets; therefore, the nurse should recommend yogurt for the toddler who is at risk. Carrots, fruit juice, and dried fruits are not food items that are rich in calcium and vitamin D.

Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply. 1. Interventions to restore tissue integrity 2. Interventions to optimize neurological functions 3. Interventions to manage restricted body movements 4. Interventions to promote comfort using psychosocial techniques 5. Interventions to provide care before, during, and immediately after surgery

1, 2, 5 Interventions such as restoring tissue integrity, optimizing neurologic functions, and providing care before, during, and immediately after surgery are classified under physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy [1] [2]. Interventions to manage restricted body movements are classified under the simple physiologic domain. Interventions to promote comfort using psychosocial techniques are classified under the behavioral domain.