MedSurg HESI Preparation Questions

Which insect bites cause pain and swelling at the site? Select all that apply. One, some, or all responses may be correct. 1 Bees 2 Ticks 3 Wasps 4 Bed bugs 5 Pediculosis

1 3, Bee and wasp stings cause burning and localized pain in addition to swelling and itching at the site. A tick's bite spreads a ringlike rash 3 to 4 weeks after being bitten. A bedbug's bite appears as a wheal surrounded by vivid flare with severe itching and firm urticaria transforming into the persistent lesion. A pediculosis bite causes minute, red, noninflammatory lesions.

Which joint is an example of a gliding joint? 1 Wrist 2 Elbow 3 Shoulder 4 Sacroiliac The sacroiliac joint connects the sacrum with the pelvis. It is a type of gliding joint, because one surface of the bone moves over another surface. The wrist joint is an example of a condyloid joint. The elbow joint is an example of a hinge joint. The shoulder joint is an example of a ball-and-socket joint.

4, The sacroiliac joint connects the sacrum with the pelvis. It is a type of gliding joint, because one surface of the bone moves over another surface. The wrist joint is an example of a condyloid joint. The elbow joint is an example of a hinge joint. The shoulder joint is an example of a ball-and-socket joint.

Which clinical manifestations would the nurse expect to identify in a client experiencing spinal shock client immediately after sustaining a functional transection of the spinal cord at C7-C8? Select all that apply. One, some, or all responses may be correct. 1 Spasticity 2 Incontinence 3 Flaccid paralysis 4 Respiratory failure 5 Lack of reflexes below the injury

3, 5, Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Transection of the spinal cord caused the spinal shock and resulted in a loss of reflex activity below the level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs because of decreased tone of the bladder and bowel; thus incontinence is unusual. Respirations are labored, but spontaneous breathing continues, indicating the level of injury is below C4 and respirations are not affected.

Which action would the nurse implement for a client who has a portable wound drainage system in place after surgery? 1 Irrigate the drainage tube with saline. 2 Apply warm compresses to the involved site. 3 Maintain compression of the drainage system. 4 Keep the involved area in a dependent position.

3, Self-contained suction devices for wound drainage must be compressed for suction to work. Drainage tubes generally are not irrigated by nurses. Application of heat may increase inflammatory edema. These drains work via negative pressure, not gravity.

Which is the middle layer of the eyeball? 1 Sclera 2 Retina 3 Uveal tract 4 Transparent cornea

3, The uveal tract (which consists of the iris, choroid, and ciliary body) is considered the middle layer of the eyeball. The sclera is a part of the tough outer layer of the eyeball. The retina is the innermost layer of the eyeball. The outermost layer of the eyeball consists of the transparent cornea.

Which cranial nerve is responsible for the client's equilibrium? 1 Vagus 2 Trochlear 3 Vestibulocochlear 4 Glossopharyngeal

3, The vestibulocochlear nerve located in the pons-medulla junction is responsible for equilibrium of the body. The vagus nerve located in the medulla is responsible for sensations from the pharynx, larynx, thoracic, and abdominal viscera. The trochlear nerve located in the lower midbrain is responsible for eye movement with superior oblique muscles. The glossopharyngeal nerve located in the medulla is responsible for taste and sensations from the posterior one third of the tongue and the pharynx.

Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing? 1 Glottis 2 Paranasal sinus 3 Palatine tonsils 4 Eustachian tubes

4 Eustachian tubes The Eustachian tubes connect the nasopharynx to the middle ears; these tubes open during swallowing to equalize pressure within the middle ear. The glottis is the opening between true vocal cords. The paranasal sinuses are air-filled cavities within the bones that surround the nasal passages. Palatine tonsils are a part of the immune system and are located on the sides of the oropharynx. These tonsils protect against invading organisms.

Which type of brain tumor can originate from cells that form the myelin sheath around nerves? 1 Meningioma 2 Astrocytoma 3 Ependymoma 4 Acoustic neuroma

4, Acoustic neuromas can originate from cells that form the myelin sheath around the nerves. Meningiomas originate from the meninges; they can be benign or malignant. Astrocytomas can originate from supportive tissues, glial cells, and astrocytes. Ependymomas can originate from the ependymal epithelium and can range from benign to highly malignant.

In which order will the nurse perform these prescribed actions for a client who is in the emergency department with sudden onset of dyspnea and possible pulmonary embolism? 1. Administer unfractionated heparin. 2. Obtain blood for coagulation studies. 3. Place client on cardiac monitor. 4. Check oxygen saturation using pulse oximetry. 5. Administer oxygen to keep saturation higher than 93%.

4. Check oxygen saturation using pulse oximetry. 5. Administer oxygen to keep saturation higher than 93%. 3. Place client on cardiac monitor. 2. Obtain blood for coagulation studies. 1. Administer unfractionated heparin. The initial action for a client with dyspnea and chest pain will be obtain a baseline oxygen saturation and then start oxygen administration. Because dysrhythmias can occur because of hypoxemia secondary to pulmonary embolus, the nurse will start cardiac monitoring. Rapid administration of anticoagulants is needed, but baseline coagulation studies are needed prior to starting anticoagulation.

The nurse is caring for a client who has a burn in the emergent stage. Which assessment is the highest priority? 1 Extent of burn 2 Cause of burn 3 Where it occurred 4 Type of first aid given

1, During the emergent stage of a burn, the nurse first assesses the extent and then the cause of the burn, then where it occurred, and then determines first aid measures that were used. For immediate treatment of the burn, the nurse would be concerned with the body location and extent of the burn.

Which finding would be most important to communicate to the health care provider after the nurse assesses a client's head and neck for respiratory problems? 1 Polyps on the nasal mucosa 2 Nasal septum deviated to left 3 Small mobile nodes at the mandible 4 Gagging with touch to posterior pharynx

1, Nasal polyps are an abnormal finding and indicate the need for treatment with corticosteroid medications or surgery. Many adults have slight deviation of the nasal septum. Small and mobile lymph nodes are normal; the nurse would be concerned about larger or tender nodes. Gagging when the posterior pharynx is touched indicates that the glossopharyngeal and vagus nerves are intact and that the client's airway is protected.

Which finding by the nurse would be most important to report to the health care provider before a client undergoes a spiral computed tomography (CT) scan for possible pulmonary embolism? Select all that apply. One, some, or all responses may be correct. 1 Client reports anaphylactic reaction to penicillin. 2 Client has poor skin turgor and dry oral mucosa. 3 Client serum creatinine level is 0.6 mg/dL (53 µmol/L). 4 Client pulse oximetry readings range from 92% to 95%.

2 Client has poor skin turgor and dry oral mucosa. Because the contrast medium is hypertonic and causes diuresis, clients who are dehydrated may develop acute kidney injury after CT scans using contrast. The client would need to receive fluids before the spiral CT. The contrast medium is iodine-based and an iodine allergy would be reported to the health care provider, but a penicillin allergy is not a contraindication for spiral CT using contrast. The client's serum creatinine level is normal and would not be a contraindication for the procedure. Pulse oximetry readings of 92% to 95% are slightly low, but would be acceptable for a client with a possible pulmonary embolism.

Where are the central thermoreceptors located in the human body? Select all that apply. One, some, or all responses may be correct. 1 Skin 2 Spinal cord 3 Hypothalamus 4 Throughout the body 5 Abdominal organs

2, 3, 5, Central thermoreceptors in the body provide skin and core temperature information to the hypothalamus. The receptors are located in the spinal cord, hypothalamus, and abdominal organs. Central thermoreceptors are not present in the skin; peripheral thermoreceptors are present in the skin. Central thermoreceptors are not present throughout the body; multiple types of thermoreceptors are present throughout the body.

The nurse is planning personal protective equipment for a client who is homeless and who is hospitalized for alcohol withdrawal. The nurse recalls that this population is at risk for which condition? 1 Prostatitis 2 Tuberculosis 3 Osteoarthritis 4 Diverticulosis

2, Medically underserved clients such as the homeless, clients who are alcohol or drug dependent, and those who have human immunodeficiency virus (HIV) infections are at risk for developing tuberculosis. Being homeless does not increase a person's risk for developing prostatitis, osteoarthritis, or diverticulosis.

Which role does vitamin C have in wound healing? 1 It aids in the process of epithelialization. 2 Vitamin C helps in the synthesis of immune factors. 3 It increases the metabolic energy required for inflammation. 4 Vitamin C is required for collagen production by fibroblasts.

4, Vitamin C aids in capillary synthesis and collagen production by fibroblasts. Vitamin A aids in the process of epithelialization. Protein helps in the synthesis of immune factors. Carbohydrates increase the metabolic energy required for inflammation.

Which is the first-line treatment for Paget's disease? 1 Oral alendronate 2 Oral calcium 3 Intravenous pamidronate 4 Intravenous zoledronic acid

1, Oral alendronate, a bisphosphonate, is the first-line treatment for Paget's disease. Clients with Paget's disease also are given 1500 mg of calcium daily as a supplement to reduce the risk for hypocalcemia. When oral medications are ineffective, pamidronate and zoledronic acid are administered intravenously.

Which carcinoma is the most common type of thyroid cancer and is most often found in younger women? 1 Papillary carcinoma 2 Follicular carcinoma 3 Medullary carcinoma 4 Anaplastic carcinoma

1, Papillary carcinoma is the most common type of thyroid cancer; it is most often seen in younger women. Follicular carcinoma occurs most often in older adults. Medullary carcinoma is seen mostly in clients older than 50 years. Anaplastic carcinoma is a rapid-growing, aggressive tumor.

While conducting an eye examination, the ophthalmologist shines a light into the client's pupil and observes that there is a slow recovery of the pupil size. Which muscular atrophy is responsible for this condition? 1 The iris dilator muscle 2 The iris sphincter muscle 3 The medial rectus muscle 4 The lateral rectus muscle

1, The iris dilator muscle is involved in the dilation of the pupil. Atrophy of the iris dilator muscle is responsible for slow recovery of the pupil size after a light is shone in the client's pupil. The iris sphincter muscle is involved in pupil constriction. Atrophy of this muscle may cause a failure to constrict the pupil when a light is shone on it. The medial rectus muscle is an extraocular muscle that helps in the movement of the eye. The lateral rectus muscle is also an extraocular muscle that is unassociated with pupil dilation.

Which action by an unlicensed assistive personnel (UAP) who is assisting with the care of a client who just returned to the nursing unit after laryngoscopy indicates that the nurse needs to intervene? 1 Raises the head of the client's bed 2 Offers a breakfast tray to the client 3 Asks whether the client's throat is painful 4 Checks the client's oxygen (O2) saturation using pulse oximetry

2 Offers a breakfast tray to the client Because the gag reflex is diminished by the anesthesia used for laryngoscopy, oral intake should not be offered until the nurse has assessed for return of the gag reflex. Elevation of the head will improve ventilation and decrease aspiration risk. Asking about client discomfort is appropriate for all staff members. Checking oxygen saturation is needed after laryngoscopy and is within the scope of UAP practice.

When the nurse educator is observing a student performing tracheal suctioning of a client with thick secretions, which student action requires intervention? 1 Maintains a sterile field 2 Applies suction during insertion of the catheter 3 Preoxygenates with 100% oxygen for 1 minute 4 Tests suction pressure at 100 mm Hg before inserting catheter

2, Suction should be applied during withdrawal, not insertion, of the catheter. A sterile field is required for tracheal suctioning, but not oral suctioning. Preoxygenation will be completed for 30 seconds to 3 minutes. Pressure must be tested before suctioning and be within the range of 80 to 120 mm Hg.

When a client is scheduled for an emergency splenectomy after a traumatic injury, which topic would the nurse include in preoperative teaching? 1 Probability of wound dehiscence 2 Safety aspects of this type of surgery 3 Expectation of postoperative bleeding 4 Presence of abdominal drains for several days

4, Drains usually are inserted into the splenic bed to facilitate removal of fluid that can lead to abscess formation. The risk for wound dehiscence is no greater than for any other abdominal surgery. Discussion of safety aspects of this type of surgery is the role of the health care provider. Bleeding may occur after splenectomy, but the nurse would not teach that bleeding is "expected."

Which activities might cause chest pain in a client with stable angina? Select all that apply. One, some, or all responses may be correct. 1 Deep breathing during meditation 2 Walking outside on a cold day 3 Sexual activity 4 Taking an afternoon nap 5 Smoking a cigarette 6 Use of an oral decongestant

2 3 5, Clients with stable angina experience chest pain (or other angina equivalents) in response to activities that increase cardiac workload or decrease blood flow and oxygen availability to the heart. Cold temperatures cause vasoconstriction, increasing the cardiac workload during systole. Sexual activity increases heart rate and force of contraction, leading to increased cardiac workload. Tobacco use stimulates catecholamine release, increasing heart rate and causing vasoconstriction, and resulting in increased cardiac workload. In addition, tobacco use transiently increases carbon monoxide levels, resulting in a decrease in available oxygen for cardiac tissues. Oral decongestants are sympathetic nervous system stimulants, which increase heart rate and force of contraction and cause vasoconstriction, leading to increased cardiac workload. Deep breathing will increase oxygen availability and tends to lead to relaxation, resulting in reduced heart rate and force of contraction. Taking an afternoon nap will reduce cardiac workload.

A client with heart block who requires implantation of a permanent pacemaker expresses concern about having an increased risk of accidental electrocution. How would the nurse respond? 1 "No one has been electrocuted yet by a pacemaker." 2 "New technology prevents electrocution from occurring." 3 "The pacemaker is pretested for safety before it is inserted." 4 "The voltage emitted is not strong enough to electrocute."

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The nurse is teaching a client who has decreased production of estrogen because of menopause about self-management and prevention of complications. Which actions performed by the client would help reduce the complications? Select all that apply. One, some, or all responses may be correct. 1 Walking for 30 minutes per day 2 Performing weight-bearing activities 3 Dressing warmly in cool or cold weather 4 Urinating immediately after sexual intercourse 5 Keeping within 10 pounds of ideal body weight

1 2 4, Because decreased ovarian production of estrogen leads to low bone density, regular exercises are advised, such as walking for 30 minutes per day and performing weight-bearing activities. Decreased ovarian production of estrogen increases the risk of cystitis; therefore, female clients are advised to reduce the risk by urinating immediately after sexual intercourse. Dressing warmly in cool weather would be beneficial to a client with decreased general metabolism because they may have less tolerance to cold. Maintaining body weight within 10 pounds of ideal would be beneficial to a client with decreased glucose tolerance.

Which actions will the nurse take after noticing bibasilar crackles in a client who had an open cholecystectomy on the previous day? Select all that apply. One, some, or all responses may be correct. 1 Encourage turning, coughing, and deep-breathing exercises. 2 Perform frequent breath sounds assessment. 3 Decrease by mouth fluid intake. 4 Offer a high-potassium diet. 5 Ask the health care provider to prescribe a chest x-ray.

1 2, This client likely has postoperative atelectasis and requires frequent breath sounds assessment because of the presence of adventitious breath sounds. Also, the client should turn, cough, and deep breathe to improve ventilation and resolve atelectasis. The client may be encouraged to increase intake to facilitate thinning of any secretions that may be present. High-potassium diet will have no effect on the resolution of atelectasis. A chest x-ray is not indicated for atelectasis, which is a common postoperative complication.

Which intervention(s) will the nurse include in a care plan for a client with Alzheimer disease? Select all that apply. One, some, or all responses may be correct. 1 Limit choices. 2 Use all side rails. 3 Toilet every 2 hours. 4 Ask open-ended questions. 5 Encourage participation in self-care.

1 3 5, Clients with Alzheimer disease need limited choices; having too many choices can increase confusion and frustration. Toileting every 2 hours supports bladder and bowel training and continence. Encouraging participation in self-care supports independence. The use of all side rails or any other form of restraints needs to be avoided in clients with dementia; trying to free themselves from the restraints can lead to injury. Simple "yes or no" questions are best. Open-ended questions can be confusing and overwhelming.

A client experiences a lateral crushing chest injury. Assessment findings include obvious right-sided paradoxical motion of the chest and multiple rib fractures, resulting in a flail chest. The nurse would monitor the client for which complication? 1 Mediastinal shift 2 Tracheal laceration 3 Open pneumothorax 4 Pericardial tamponade

1 Mediastinal shift Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return. Tracheal laceration is unlikely with a crushing injury to the chest. Flail chest is a closed chest injury; open pneumothorax results from a penetrating injury to the chest wall. Pericardial tamponade is associated with a cardiac contusion and usually occurs from a sternal, not lateral, compression injury.

Which assessment finding is consistent with bronchospasm? 1 Wheezing 2 Rhonchi 3 Pleural friction rub 4 Low-pitched crackles

1 Wheezing Wheezing, a high-pitched, musical, continuous sound that does not clear with coughing, is caused by airway narrowing, which occurs with bronchospasm, for example. Rhonchi are associated with obstruction by a foreign body or thick mucus. Pleural friction rub can be heard in cases of pleurisy. Pneumonia may be present in a client who exhibits low-pitched crackles.

Which intervention will the nurse include in a care plan for a client with dementia who wanders? Select all that apply. One, some, or all responses may be correct. 1 Assess and treat pain. 2 Avoid loud music, television, and glaring lights. 3 Have family members monitor client activity when possible. 4 Use chemical or physical restraint at night to keep the client in bed. 5 Place the client at the end of the hall to allow use of the hall for wandering.

1, 2, 3, Assessing and treating pain in clients with dementia promotes relaxation and prevents unsafe wandering. Avoiding loud music, television, and glaring lights helps decrease confusion and unsafe sensory overload. When possible, family members or volunteers can be "sitters" for clients by providing safe supervision. Chemical or physical restraint is only used as a last resort; it is generally avoided. Clients with dementia who are prone to wander need to be placed away from stairs and elevators, preferably close to the nurse's station to allow for close monitoring of their activity.

Which instruction(s) would the nurse provide for a cervical spine injury client with a halo in place? Select all that apply. One, some, or all responses may be correct. 1 "Attach the vest wrench to the jacket for emergency access." 2 "Observe the pin sites and report purulent drainage to your doctor." 3 "Check to make sure one finger fits between the device and your skin." 4 "Perform neck range of motion by holding and pulling on the halo device." 5 "Use a long, pointed object to reach any spots that are itchy while wearing the halo."

1, 2, 3, Clients will be instructed to attach the wrench device to the jacket for quick access in the event emergency removal is needed. The pin site requires care per policy as ordered by the client's health care provider; any signs of infection such as purulent drainage need to be reported immediately. The halo should be snug but not cause skin breakdown; clients will need to ensure one finger can fit between the skin and the device at pressure points. Sharp objects should not be stuck under the vest to scratch the skin because this can impair the skin, introduce infection, and delay healing. Clients should not grab or pull on the halo because its purpose is to immobilize the neck.

Which clinical manifestations are more likely to occur in women with coronary artery disease compared with men? Select all that apply. One, some, or all responses may be correct. 1 Severe fatigue 2 Sense of unease 3 Substernal chest pain 4 Shortness of breath 5 Pain radiating down the left arm

1, 2, 4

When assessing a client with varicose veins, which clinical manifestations would the nurse expect to find? Select all that apply. One, some, or all responses may be correct. 1 Presence of ankle edema 2 Increased leg fatigue 3 Diminished peripheral pulses 4 Report of leg fullness and pruritus 5 Leg pain with activity that resolves with r

1, 2, 4, Presence of ankle edema, increased leg fatigue, and a report of leg fullness and pruritus are signs of varicose veins, due to poor venous return and increased venous pressure. Diminished peripheral pulses occur with decreased arterial blood flow. Intermittent claudication (as evidenced by leg pain with activity that resolves with rest) occurs with decreased arterial, not venous, perfusion.

Which symptoms would the nurse include when teaching a client to recognize symptoms of hypoglycemia? Select all that apply. One, some, or all responses may be correct. 1 Rapid heartbeat 2 Emotional changes 3 Abdominal cramping 4 Nausea and vomiting 5 Weakness and fatigue 6 Numbness of fingers, toes, or mouth

1, 2, 6, A rapid heartbeat, emotional changes, and numbness of the fingers, toes, or mouth are all signs of hypoglycemia. Abdominal cramping, nausea and vomiting, and weakness and fatigue are indicative of hyperglycemia.

Which actions will the nurse take when preparing a client before thoracentesis? Select all that apply. One, some, or all responses may be correct. 1 Assist the client to sit up on the edge of the bed. 2 Remind the client not to eat before the procedure. 3 Instruct the client to rest the arms on the bedside table. 4 Verify that the client has signed the informed consent form. 5 Educate the client about when to cough during the procedure.

1, 3, 4 The client is usually positioned sitting up at the side of the bed or seated facing backward on a chair so that the posterior thorax is exposed. The client will rest the arms on the bedside table, which increases the size of the intercostal spaces. Informed consent is needed before thoracentesis. Because no sedation or general anesthesia is needed for thoracentesis, the client does not need to refrain from eating before the procedure. The client should be instructed to avoid coughing or moving during the procedure to decrease risk for pneumothorax.

An in-home babysitter phones a health clinic, stating that a child swallowed dish soap. Which advice would the nurse give? 1 Call a Poison Control Center. 2 Induce vomiting immediately. 3 Give syrup of ipecac, 1 tablespoon. 4 Give activated charcoal and expect black stools for 24 hours.

1, Advise the babysitter to call a Poison Control Center immediately. Information as to what needs to be done for virtually every product is available. This also would be the fastest source for obtaining details for treatment. Inducing vomiting may cause further damage if the substance is caustic, such as drain cleaner, or contains lye. Giving syrup of ipecac is no longer advised, and the substance is not in most homes. Activated charcoal is given in an emergency facility.

After the nurse has taught a client about how to use a dry powder inhaler, which statement by the client indicates understanding of how to use the medication safely and effectively? 1 "I will forcefully inhale the powder." 2 "I will exhale into the delivery device." 3 "I will shake the inhaler before using it." 4 "I will submerge the inhaler in water to wash it."

1, Dry powder inhalers do not contain a propellant; clients will forcefully inhale the powder. Clients should never exhale into the device because their breath will moisten the powder. Dry powder inhalers should be held still and steady, not shaken; to do so would disperse the powder. Dry powder inhalers should not be used with water or submerged in water, to prevent the powder from becoming moistened.

A client is admitted to the hospital with a history of cancer of the liver and jaundice. In relation to the jaundice, which symptom does the nurse expect the client to report? 1 Pruritus 2 Diarrhea 3 Blurred vision 4 Bleeding gums

1, Itching associated with jaundice is believed to be caused by accumulating bile salts in the skin. Diarrhea, blurred vision, and bleeding gums are not related to jaundice.

Which action would the nurse take next after observing this rhythm in a client who came to the emergency department after experiencing "skipped heartbeats"? 1 Obtain the client's blood pressure. 2 Ask the client about caffeine intake. 3 Review the client's home medications. 4 Question the client about alcohol use

1, The cardiac monitor shows sinus rhythm with unifocal premature ventricular contractions (PVCs). The nurse's first action would be to determine whether the client is hemodynamically stable by assessing blood pressure. Stimulants such as caffeine can cause PVCs, and the nurse would ask about caffeine use after determining that the client is hemodynamically stable and does not need immediate treatment for the PVCs. The client's home medications may provide information about possible causes of the PVCs, but these will be reviewed by the nurse after assessing for hemodynamic effects of the PVCs. Alcohol use can cause PVCs, so the nurse will ask the client about alcohol use after assessing for hemodynamic stability.

The nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in the client's diet? Select all that apply. One, some, or all responses may be correct. 1 High fat 2 Low sodium 3 High vitamins 4 Moderate protein 5 Low carbohydrates

2, 3, 4 Low sodium intake controls fluid retention and edema and, consequently, ascites. Vitamins help repair long-standing nutritional deficits associated with cirrhosis of the liver. A moderate protein diet reduces formation of ammonia, which must be degraded by the liver. High fat intake should be avoided because of related cardiovascular risks and a demand for bile that the liver may not be capable of meeting. High, not low, carbohydrate intake is necessary to meet energy requirements for tissue regeneration.

Which would the nurse assess using the PASS acronym to prevent aspiration pneumonia in a client with stomatitis? Select all that apply. One, some, or all responses may be correct. 1 Is the client's airway open? 2 Does the client have any difficulty swallowing? 3 Does the client have a history of trouble swallowing? 4 Has a speech language-pathologist been consulted? 5 Does the client have any signs or symptoms of dysphagia? 6 What have been the client's dietary intake patterns?

2, 3, 4, 5 The acronym PASS is used for a fast assessment of a client's swallowing ability. The acronym stands for Probability of difficulty swallowing, Account for prior swallowing issues, Screen for signs and symptoms of dysphagia, and Speech-language pathologist referral. The acronym does not include the physical assessment of the airway nor dietary intake patterns.

Which findings would the nurse expect when caring for a client with cor pulmonale? Select all that apply. One, some, or all responses may be correct. 1 Weight loss 2 Neck vein distension 3 Lower extremity edema 4 Right upper quadrant abdominal tenderness 5 Lower than normal hemoglobin and hematocrit 6 Elevated B-type natriuretic peptide (BNP) levels

2, 3, 4, 6 Cor pulmonale is right-sided heart failure caused by pulmonary hypertension secondary to chronic obstructive pulmonary disease. The client will have clinical manifestations of right-sided heart failure such as neck vein distension, peripheral edema, hepatomegaly with right upper quadrant tenderness and elevated BNP due to atrial enlargement. Weight gain would be expected because of fluid retention. Chronic hypoxemia in cor pulmonale leads to polycythemia with increases in hemoglobin and hematocrit and increased blood viscosity.

Which clinical manifestations are found in the client diagnosed with stage 3 of Parkinson disease? Select all that apply. One, some, or all responses may be correct. 1 Akinesia 2 Masklike face 3 Postural instability 4 Unilateral limb involvement 5 Increased gait disturbances

2, 3, 5, Parkinson disease is a progressive neurodegenerative disease that is one of the most common neurological disorders of older adults. Stage 3 of Parkinson disease is characterized by postural instability and increased gait disturbances. The "masklike" face begins in stage 2 and continues in stage 3. Akinesia is manifested in stage 4 of the disease. In stage 1 of Parkinson disease, only unilateral limb involvement is seen, but it progresses to bilateral in later stages.

Which foods will the nurse include when suggesting dietary sources of iron to a client with anemia? Select all that apply. One, some, or all responses may be correct. 1 Raw carrots 2 Boiled spinach 3 Dried prunes 4 Brussel sprouts 5 Asparagus spears

2, 3, Food sources highest in iron are liver and beef, dried fruits (such as prunes), legumes, dark green leafy vegetables (which would include spinach), whole-grain and enriched bread and cereals, and beans. Carrots are not a high source of iron. Asparagus is not high in iron. Brussels sprouts are not high in iron.

Which medications inhibit purine synthesis and suppress cell-mediated and humoral immune responses? Select all that apply. One, some, or all responses may be correct. 1 Sirolimus 2 Azathioprine 3 Cyclophosphamide 4 Methylprednisolone 5 Mycophenolate mofetil

2, 5, Azathioprine and mycophenolate mofetil are administered to inhibit purine synthesis and suppress cell-mediated and humoral immunity. Sirolimus binds to a mammalian target of rapamycin (mTOR), which suppresses T-cell activation and proliferation. Cyclophosphamide is administered to treat cancers, autoimmune disorders, and amyloidosis. Methylprednisolone is a corticosteroid that inhibits cytokine production.

When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia? 1 Giving influenza vaccine to the client 2 Having suction available during meals 3 Assisting the client to take deep breaths 4 Teaching about incentive spirometer use

2, Because a client with difficulty swallowing is at risk for aspiration, having suction available will be the most effective intervention in preventing aspiration pneumonia. Giving the influenza vaccine is important in preventing viral pneumonia, but would not help prevent aspiration. Deep breathing is important to prevent atelectasis, but would not prevent aspiration pneumonia. Incentive spirometer use is important in preventing atelectasis, but not helpful in preventing aspiration.

When a client reports a sudden onset of chest pain that feels like a pressure or weight on the chest, which action would the nurse take first? 1 Call the rapid response team. 2 Check blood pressure and heart rate. 3 Administer the prescribed as-needed nitroglycerin 0.4 mg. 4 Ask whether there have been previous episodes of similar pain.

2, Because there are multiple diagnoses that might cause chest pain, the nurse would first assess for cardiovascular symptoms such as changes in blood pressure or heart rate. Activation of the rapid response team may be needed, but this will depend on vital signs and other assessments. Administration of nitroglycerin may be needed, but blood pressure should be taken before giving nitroglycerin to avoid hypotension. More information about the client's past cardiac history will be helpful, but the priority action is to check the client's current physiologic status.

Which nursing interventions would the nurse implement when providing postoperative care for a client who had a below-the-knee amputation? 1 Maintain strict bed rest for 2 days postprocedure to reduce dependent edema. 2 Elevate residual leg slightly while keeping the knee joint straight for first 24 hours. 3 Hemorrhage rarely occurs during the early postoperative period. 4 The surgeon will change the dressing within 48 hours after the procedure.

2, Elevation of the residual limb helps prevent edema; however, slight elevation during the first 24 hours as continued elevation may lead to hip contractures. The knee joint is kept extended, not flexed during this time. The client usually is out of bed on the second postoperative day. Hemorrhage and infection are the two most common complications. The dressing usually is a pressure dressing, and the surgeon does not change the pressure dressing this soon postoperatively. Sometimes the pressure dressing has a cast in place to shape the residual leg for a prosthesis.

The nurse reviews the medical record of a client with a grade 2 goiter. Which assessment finding is consistent with this type of goiter? 1 It is impalpable. 2 It is asymmetrical. 3 It moves up when the client swallows. 4 It is invisible when the client's neck is in the normal position.

2, In a grade 2 goiter, the mass is usually asymmetrical and is easily palpable. The goiter is invisible or impalpable in grade 0. The goiter mass moves up while swallowing and is palpable in grade 1. The goiter mass is invisible in grade 1 while the neck is in a normal position.

Which condition would the nurse expect the client to develop if their parathyroid glands have become damaged during a thyroidectomy? 1 Goiter 2 Tetany 3 Globe lag 4 Photophobia

2, The parathyroid gland maintains calcium and phosphate levels in the body. When there is any damage to parathyroid glands, there would be improper functioning of these glands, which may cause conditions such as tetany. Tetany is a condition in which there is hyperexcitability of nerves and muscles that occurs as a result of low calcium in the body (hypocalcemia). A goiter is caused by an enlarged thyroid gland. Globe lag is a condition in which the upper eyelid pulls back faster than the eyeball; this occurs in hyperthyroidism. Photophobia is a visual problem that may be seen in clients with Graves disease.

Which action is promoted by vasopressin? 1 Sodium reabsorption 2 Reabsorption of water 3 Tubular secretion of sodium 4 Red blood cell production

2, Vasopressin is also known as an antidiuretic hormone. It helps in the reabsorption of water into the capillaries. Aldosterone promotes sodium reabsorption. Natriuretic hormones promote tubular secretion of sodium. Erythropoietin stimulates bone marrow to make red blood cells.

Which action by the nurse is the priority when admitting a client who has a productive cough, fever, and chills, and reports having children at home with whooping cough (pertussis)? 1 Auscultate client breath sounds. 2 Start prescribed antibiotic therapy. 3 Place client on droplet precautions. 4 Obtain sputum specimen for culture.

3 Place client on droplet precautions. Because the client data indicate possible pertussis, the priority action would be to prevent transmission to other clients, visitors, and staff through the use of droplet precautions. The client's lung sounds would be assessed, but this would be done after actions to prevent disease transmission. Prescribed antibiotics would be given as quickly as possible after sputum specimens were obtained, but prevention of disease transmission has higher priority. Sputum cultures are needed, but this can be done after initiation of droplet precautions.

Which clinical indicators would the nurse expect to identify when assessing a client who has trigeminal neuralgia (tic douloureux)? Select all that apply. One, some, or all responses may be correct. 1 Prolonged periods of sleep 2 Hyperactivity 3 Exhaustion and fatigue 4 Excessive talkativeness 5 Inadequate nutritional intake

3, 5, Severe, constant pain; emotional stress; muscle tensing; and diminished nutritional intake can lead to exhaustion and fatigue. The movements associated with chewing and swallowing may precipitate a painful attack. Because clients are apprehensive and have pain, prolonged periods of sleep usually do not occur. Pain medications do not normally cause hyperactivity. The client may speak less for fear of precipitating an attack.

Which prescribed intervention would the nurse question for a client who has just been diagnosed with influenza after having symptoms for 4 days? 1 Loratadine 2 Ibuprofen 3 Oseltamivir 4 Acetaminophen

3, Antiviral medications such as oseltamivir must be taken within 48 hours after onset of symptoms to be effective and the nurse would plan to discuss this medication with the health care provider before administration. Antihistamines such as loratadine are used in influenza to decrease rhinorrhea. Ibuprofen would be used to decrease generalized aches and fever associated with influenza. Acetaminophen would be used to decrease generalized aches and fever caused by influenza.

Which serum blood level would the nurse expect to be decreased in a client with a diagnosis of hyperparathyroidism? 1 Calcium 2 Chloride 3 Phosphorus 4 Parathyroid hormone

3, Because of its inverse relationship with calcium, when serum calcium levels increase, serum phosphorus levels decrease (greater than 3 mg/dL; greater than 0.17 mmol/L). Serum calcium levels will increase because of the action of elevated levels of serum parathormone; serum calcium levels usually exceed 10 mg/dL (2.50 mmol/L). Serum chloride levels will increase, not decrease, with hyperparathyroidism. Parathyroid hormone, produced in the parathyroid gland, will increase with hyperparathyroidism.

A client is diagnosed with pleural effusion. Which assessment finding would the nurse expect to identify? 1 Moist crackles at the posterior of the lungs 2 Deviation of the trachea toward the involved side 3 Reduced or absent breath sounds at the base of the lung 4 Increased resonance with percussion of the involved area

3, Compression of the lung by fluid that accumulates at the base of the lungs reduces lung expansion and air exchange. There is no fluid in the alveoli, so no crackles are produced. If there is tracheal deviation, it is away from the involved side. Dullness is produced on percussion of the involved area.

A client is hospitalized with emphysema. The nurse recognizes the importance of assessing for clinical indicators of hypoxia based on which condition associated with the disease? 1 Pleural effusion 2 Infectious obstructions 3 Loss of aerating surface 4 Respiratory muscle paralysis

3, Destruction of the alveolar walls leads to diminished surface area for gaseous exchange and to increased carbon dioxide levels in the blood. Pleural effusion occurs when there is seepage of fluid into the intrapleural space; this does not occur with emphysema. Infectious obstructions occur in conditions in which microorganisms invade lung tissue; emphysema is not an infectious disease. Muscle paralysis may occur in diseases affecting the neurological system. Emphysema does not affect the neurological system; therefore it is not a neurological disease.

Which element would the nurse focus on when teaching crutch-walking to a client who has a casted leg fracture? 1 Establishing a schedule for pain medication 2 Maintaining a fixed schedule of daily activities 3 Modifying the home environment to prevent accidents 4 Understanding that a more sedentary lifestyle is necessary

3, Modifications in the home may be needed to permit safe use of crutches. Pain medications should not be required on a regular basis. The client may vary the schedule of activities based on abilities and responses to activities. The client does not have to be sedentary; crutches are used for ambulation.

The registered nurse teaches a 70-year-old client with kyphosis about self-care measures. Which statement made by the client indicates effective learning? 1 "I should take warm baths." 2 "I should do isometric exercises." 3 "I should sit in supportive armchairs." 4 "I should position myself quickly."

3, Sitting in a supportive armchair provides support to the bony structures and prevents further deformity in a client with kyphosis. Cartilaginous degeneration is prevented by taking warm baths. Isometric exercises are indicated for clients with muscular atrophy. Clients with kyphosis have a shift in the center of gravity and should not move quickly.

After a fire, a client in the emergency department is diagnosed with smoke inhalation and has arterial blood gases that demonstrate an oxygen saturation (SaO2) of 91%, partial pressure of oxygen (PaO2) of 75 mm Hg, a partial pressure of carbon dioxide (PaCO2) of 45 mm Hg, and a pH of 7.35. Which intervention would the nurse anticipate implementing? 1 Oral and tracheal suctioning 2 Intubation and mechanical ventilation 3 Oxygen administration by nasal cannula 4 Discharge teaching and follow up instructions

3, The SaO2 and PaO2 indicate mild hypoxemia and need for oxygen administration, which would be done using a nasal cannula because that is the most comfortable means for oxygen administration. Oral and tracheal suctioning are not needed based on the client's data and would further traumatize the upper airway. Mild hypoxemia does not require intubation and mechanical ventilation. Because the client does have hypoxemia, continued observation is needed and discharge teaching is not indicated.

Before signing a consent form for a total laryngectomy, a client asks, "Because part of my throat will be taken out and I will breathe through a hole in my neck, will I be able to talk like I did before I had the surgery?" How would the nurse respond? 1 "Several clients have had this operation, and many of them can talk again." 2 "That's a good question. I will have the health care provider talk with you." 3 "You seem very concerned. Tell me what you know about your surgery." 4 "You will not be able to talk like before, but there is nothing to worry about."

3, The nurse should strive to clarify misconceptions and fears before a client signs a consent form; this response ("You seem very concerned. Tell me what you know about your surgery.") promotes further communication and begins where the client is. The fact that others have had the surgery provides little solace; the remainder of the response is false reassurance and does not truthfully answer the client's question. The response "That's a good question. I'll have the health care provider talk with you" avoids assuming the responsibility of answering the client's question; the client needs an immediate clarification. The response "You will not be able to talk like before, but there is nothing to worry about" denies the client's feelings and cuts off communication.

Which situation in a client with hyperthyroidism may precipitate thyroid crisis (thyroid storm)? 1 Increased iodine in the blood 2 Removal of the parathyroid glands 3 High levels of the hormone triiodothyronine 4 Rebound increase in metabolism after anesthesia

3, Thyroid trauma, thyroid surgery, or physiological stress in a client with hyperthyroidism may lead to a release of abnormally high levels of thyroid hormones. High levels of the hormone triiodothyronine (T3) intensify all the signs and symptoms of hyperthyroidism (thyroid storm or crisis), such as increased temperature, pulse, and respirations, restlessness, vomiting, and often death. Iodine binds with thyroxine, thus decreasing the potential for crisis. Tetany, not thyroid crisis, occurs from surgical excision of the parathyroid glands. Anesthesia will depress metabolism, not increase it.

Which finding by the nurse who is caring for a client with a nasal fracture is most important to communicate to the health care provider? 1 Extensive nasal swelling 2 Ecchymosis under both eyes 3 Client report of nasal pain of 9 (0-10 scale) 4 Dipstick testing of nasal drainage positive for glucose

4 Glucose in the nasal drainage indicates leakage of cerebrospinal fluid and possible skull fracture. The nurse will notify the health care provider and anticipate further diagnostic testing and treatment to prevent complications such as meningitis. Nasal swelling is common with nasal trauma. Ecchymosis under the eyes is common after nasal fracture because blood migrates through subcutaneous tissues. Client report of severe pain is common and indicates a need for actions such as analgesic administration and application of cool packs to the nose, but is not life-threatening.

When the nurse is caring for a diabetic client with a bacterial infection of the foot, which assessment finding indicates a need to activate the rapid response team? 1 Hypertonic bowel sounds in all 4 quadrants 2 Blood glucose level 145 mg/dL (8.1 mmol/L) 3 Client report of level 9 pain of the foot (0 to 10 scale) 4 Systolic blood pressure persistently 85 to 90 mm Hg

4, A systolic blood pressure less than 90 in a client who is at risk for sepsis (such as this client with a bacterial infection and diabetes) indicates possible sepsis and systemic inflammatory response syndrome (SIRS). The nurse would immediately activate the rapid response team and anticipate collaborative actions such as further diagnostic testing, massive fluid infusion, and administration of vasoconstrictive medications. Hypotonic bowel sounds may indicate sepsis or SIRS. Blood glucose levels higher than 140 mg/dL (7.7 mmol/L) might indicate sepsis or SIRS in a nondiabetic client, but would not be unusual in a client with diabetes. Level 9 out of 10 pain would require administration of analgesics, but is not as concerning as hypotension and does not require activation of the rapid response team.

Which client action would the nurse score as 3 on the muscle-strength scale? 1 Active movement against gravity and some resistance 2 Active movement of body part with elimination of gravity 3 Active movement against full resistance without evident fatigue 4 Active movement against gravity only and not against resistance

4, According to the muscle-strength scale, a score of 3 indicates active movement against gravity only and not against resistance. A score of 4 indicates active movement against gravity and some resistance. A score of 2 indicates active movement of a body part with elimination of gravity. A score of 5 indicates active movement against full resistance without evident fatigue.

Which finding for a client with acute coronary syndrome who is walking in the hallway will be most important to communicate to the health care provider? 1 Client has a premature atrial contraction while ambulating. 2 Client expresses anxiety about ambulating alone at home. 3 Pulse rate increases from 68 beats/minute to 80 beats/minute with ambulation. 4 Blood pressure drops from 130/72 mm Hg to 122/60 mm Hg with ambulation.

4, An increase in blood pressure is expected with exercise, and this decrease may indicate ischemic myocardium that is unable to respond appropriately to mild exercise. The nurse will have the client decrease activity and notify the provider, anticipating a change in treatment. An isolated premature atrial contraction is a benign finding that does not require any change in treatment. Anxiety about self-care after discharge is a common finding after acute coronary syndrome and indicates a need for further assessment and client teaching, but does not indicate a need for a change in treatment by the health care provider. Pulse rate is expected to increase slightly with exercise.

Which condition results in visual distortion? 1 Myopia 2 Hyperopia 3 Presbyopia 4 Astigmatism

4, Astigmatism is caused by unevenness in the cornea; this condition results in visual distortion. Myopia (nearsightedness) results in the blurred vision of distant objects. Hyperopia (farsightedness) results in the clear vision of distant objects and the blurred vision of close objects. Presbyopia is a condition related to older adults; this condition results in an inability to focus on near objects.

Which description is common to zosteriform-type lesions? 1 Wide distribution 2 Diffuse distribution 3 Bilateral distribution 4 Band-like distribution

4, Band-like distribution of lesions would be termed as zosteriform-type lesions. Diffuse-type lesions are described as the wide distribution of the lesions. Generalized-type lesions are identified by the diffused distribution of the lesions. Symmetric-type lesions are the bilateral distribution of the lesions.

When teaching a group of older adults about differences between the common cold and influenza, the nurse would educate the clients that it is most important to communicate with the health care provider about which symptom? 1 Earache 2 Sneezing 3 Nasal stuffiness 4 Elevated temperature

4, Because influenza can lead to complications such as pneumonia and older adults are at higher risk for complications, the nurse would emphasize the need to contact the health care provider about symptoms typical of influenza. Fever or an elevated temperature is common in influenza but rare in viral rhinitis (common cold). Earache is a complication of viral rhinitis, but more severe complications such as pneumonia and respiratory failure occur with influenza. Sneezing is common with viral rhinitis but not as common with influenza. Nasal stuffiness is common with viral rhinitis but not typical of influenza.

When a client asks to be screened for human immunodeficiency virus (HIV) infection, which information will the nurse include in client teaching about the test? 1 Identifies the number of CD4 cells that are in the blood 2 Shows how much of the HIV virus is present in the blood 3 Takes several days for results to be complete and reported 4 Detects antibodies to HIV and may not detect acute infection

4, Because initial screening for HIV detects antibodies to HIV, which take several weeks to months to develop, the common screening tests may not detect early acute HIV infection. CD4 cell count is monitored to determine progression of HIV and effectiveness of treatment, but it is not used for screening. Viral load testing shows the amount of HIV virus in the blood and is used to detect disease progression and effectiveness of treatment. The screening test results are typically available in about 30 minutes, not several days.

The nurse provides teaching for a client with gastroesophageal reflux disease. The nurse should recommend that the client take which action after meals? 1 Drink 8 oz (240 mL) of water. 2 Take a walk for 30 minutes. 3 Lie down for at least 20 minutes. 4 Rest in a sitting position for 1 hour.

4, Gravity facilitates digestion and prevents reflux of stomach contents into the esophagus. Water should not be taken with or immediately after meals because it overly distends the stomach. Exercising immediately after eating may prolong the digestive process. Lying down immediately after eating facilitates reflux of the stomach contents into the esophagus.

Which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident (CVA, also known as a "brain attack")? 1 Glaucoma 2 Hypothyroidism 3 Continuous nervousness, stress 4 Transient ischemic attacks (TIAs)

4, TIAs are temporary neurological deficits related to cerebral hypoxia; about one third of the people who have TIAs will have a brain attack (CVA) within 2 to 5 years. Glaucoma, hypothyroidism, and continuous nervousness are not risk factors associated with a CVA.

The registered nurse (RN) is teaching a client about cholinergic crisis. Which statement by the client indicates a need for additional instruction? 1 "I will have limp paralysis." 2 "I will have abdominal cramps." 3 "I will have nausea and vomiting." 4 "I will have decreased urine output."

4, The client will not have decreased urine output because decreased output relates to a myasthenia gravis crisis, not a cholinergic crisis. Myasthenic crisis is an exacerbation of myasthenia gravis symptoms caused by insufficient anticholinergic medications and is characterized by decreased urine output. Myasthenia gravis is an acquired autoimmune disease characterized by muscle weakness. A cholinergic crisis is characterized by flaccid (limp) paralysis, abdominal cramps, nausea, and vomiting. A cholinergic crisis is an exacerbation of muscle weakness caused by too many anticholinesterase medications.

Which task regarding the care of a client with Buck's traction is appropriate to delegate to the unlicensed assistive personnel (UAP)? 1 Check body positioning. 2 Check the distal pulses and capillary refill. 3 Teach the client about potential complications. 4 Help the client with range-of-motion (ROM) exercises.

4, The nurse would delegate helping with ROM exercises to the UAP because this is an appropriate action for the UAP to take. It is not within the scope of practice for the UAP to perform any assessments, such as checking body positioning or distal pulses and capillary refill. The UAP also should not perform any client teaching.

The nurse teaches a client and the caregiver about pressure injury care. Which statement made by the caregiver indicates the need for further teaching? 1 "I will inspect the client's skin daily." 2 "I will manage the client's incontinence as quickly as possible." 3 "I will properly dispose of the client's contaminated dressings." 4 "I will not worry about what the client eats."

4, The nurse would teach the caregiver about the role that good nutrition plays in enhancing a client's healing to correct this misconception. All the other statements are correct and require no further teaching. The nurse would teach the caregiver to conduct daily skin inspections. The nurse would instruct the caregiver about how to manage a client's incontinence and how to properly dispose of contaminated dressings.