Week 7 HESI QUIZ

The mother of a 7-month-old infant who is to be catheterized to obtain a sterile urine specimen expresses fear that this procedure may emotionally traumatize her baby. How should the nurse respond?

A 7-month-old infant is used to having the perineal area exposed and cared for and is not in a developmental stage in which fears related to sexuality are present, thus the procedure will not be emotionally traumatic for the child. A clean-catch specimen at this age may be contaminated. The order is for a catheterized specimen. Although the mother does have the right to refuse, her concern is not realistic for an infant at this age. The mother needs to be educated. The priority is assuring the mother that a catheterization will not result in an emotional problem for her infant.

What is a priority nursing intervention in the care of a drug-dependent mother and infant?

A nurse should attempt to support the mother-child relationship; the mother is experiencing a developmental crisis while coping with drug addiction and possibly guilt. It is the client's right to decide who will share in the care of her child. The client needs contact with her new infant to facilitate bonding.

According to Erikson, what will happen to an individual who fails to master the maturational crisis of adolescence?

According to Erikson, adolescents are struggling with identity versus role confusion, struggling to find out who they are. If an adolescent is unsuccessful in this regard, role confusion may result. Industry versus inferiority is the developmental struggle of the school-aged child. This reflects part of the struggle for autonomy; it does not indicate failure to achieve the developmental task of adolescence. Adolescents tend to be group oriented, not isolated; they struggle to belong, not to escape. Developing intimacy is the developmental task for the young adult.

A depressed client arrives at the mental health unit with mild suicidal ideation but no plan of action. Assessment data reveal that the client has many family responsibilities and adequate family support and attends church regularly. What does the nurse determine about this client?

Although this client is at risk for suicide and should be reassessed frequently, because the client has a support system and no plan the risk is not as great as for someone with no support and a plan. Any client who has suicidal ideas is at risk for suicide, whether or not there is a plan, but a person with a plan is at a higher risk than a person without a plan. This client has no immediate plan and no history of suicide attempts; therefore one-on-one observation is not indicated. A seclusion room is a last resort when a client is out of control and at risk for injuring others.

A nurse is caring for a client with an endotracheal tube. Which is the most effective way for the nurse to loosen respiratory secretions?

Because the client has an endotracheal tube in place, secretions can be loosened by administration of humidified oxygen and by frequent turning. A client with an endotracheal tube in place is not permitted fluids by mouth. Providing chest physiotherapy is too vigorous for a client with an endotracheal tube. Potassium is never instilled into the lungs.

Which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning?

Blowing forcefully through the mouth controls the strong urge to push and allows for a controlled birth of the head. A shallow breathing pattern does not help control expulsion of the fetus. Slow chest breathing is used during the latent phase of the first stage of labor; it is not helpful in overcoming the urge to push. Modified paced breathing is used during active labor when the cervix is dilated 3 to 7 cm; it is not helpful in overcoming the urge to push.

What should the nurse include in a teaching plan to help reduce the side effects associated with diltiazem?

Changing positions slowly will help prevent the side effect of orthostatic hypotension. Lying down after meals can relax the esophagus and lead to acid reflux. Avoiding dairy products and taking the drug with an antacid are not necessary.

Which drug worsens uncontrolled angle-closure glaucoma when used for the treatment of generalized anxiety disorder?

Duloxetine is an antidepressant drug used in the treatment of generalized anxiety disorder. A contraindication is that it can worsen uncontrolled angle-closure glaucoma.

Which are the most important assessment data for a nurse to gather from the client in crisis?

Knowing the client's perception of the circumstances surrounding the crisis helps the nurse determine what the situation means to the client.

A pregnant woman is administered medication to treat preterm labor that requires a prescription for calcium gluconate to counter the effects of the drug. Which drug was administered?

Magnesium sulfate is used to prevent preterm labor in pregnant women with hypertension. To reduce magnesium toxicity caused, calcium gluconate should also be prescribed to counter the effects of this drug.

The registered nurse teaches the student nurse regarding the priority of care provided to clients with eye injuries due to chemical exposure. Which activity performed by the student nurse indicates effective learning?

Ocular irrigation with saline solution should be performed immediately in the client with eye injuries due to chemical exposure. Visual acuity tests can be performed after the client's condition is stabilized. Analgesics should be administered after assessing the client's medical records. The client's eyes should be covered with sterile patches after performing ocular irrigation.

An 8-year-old girl who is hospitalized for intravenous antibiotic therapy tells the nurse that she is bored. The nurse has a discussion with the father about appropriate activities. Which activity suggested by the father indicates a need for further teaching?

Playing with a bat and ball is an unsafe activity in a hospital setting; the IV catheter could be dislodged, and boisterous activity is dangerous to the other children on the unit. A radio and CD player, homework and school supplies, and rubber stamps and a collection box are all appropriate for the school-aged child.

A client who has become a mother for the first time appears anxious about her new parenting role. The nurse recommends that she join a support group for new mothers at the local YWCA. Which type of prevention is this?

Primary prevention is focused on health promotion and illness prevention. Tertiary prevention is focused on rehabilitation and the reduction of residual effects. Secondary prevention is focused on early detection and treatment. No type of prevention is specifically known as therapeutic; however, all types of prevention should be therapeutic.

A 6-year-old child has been wetting the bed at night since the birth of a baby brother. What defense mechanism is the child using to cope with the stress of accepting a new family member?

Regression is the return to an earlier and more comfortable developmental level. Repression is the unconscious and involuntary forgetting of painful ideas, events, or conflicts. Dissociation is the unconscious separation of painful feelings and emotions from an unacceptable idea, situation, or object. Displacement is discharging pent-up feelings to a less threatening object or person.

A client is scheduled for several diagnostic studies. Which behavior best indicates to the nurse that the client has received adequate preparation?

The client's early arrival indicates an expected degree of anxiety; the quiet waiting indicates that the client has been told what to expect. A request for the tests to be explained again indicates an inadequate explanation or the inability of the client to remember the explanation that has been given. Checking the appointment card repeatedly and pacing up and down the hallway on the morning of the tests indicate a high degree of anxiety that may denote a fear of the tests because they have not been adequately explained.

As the nurse is teaching a child's parents about celiac disease, the mother sighs and says, "My neighbor told me that I'll only need to monitor the diet until our child is 8 years old. I'm so relieved. You know how kids are about eating!" On what fact should the nurse's response be based?

The diet must continue to be followed because the child will always have an absence of peptidase; some variations in the diet may be allowed, but this should not be promised. Each phase of child development may have problems related to dietary management; follow-up care is needed to prevent crises. A restricted diet is never easy to follow, especially for a growing child. Gluten must be avoided for a prolonged period and perhaps indefinitely.

A client is to have gastric lavage following an overdose of acetaminophen. In which position should the nurse place the client when the nasogastric tube is being inserted?

The high-Fowler position promotes optimal entry into the esophagus aided by gravity. Supine position does not take full advantage of the effect of gravity. Mid-Fowler and Trendelenburg positions will contribute to aspiration. The head of the bed should be raised, not lowered.

A 3-year-old child feels a sense of rivalry with his father and wants him to die. Shortly after these feelings emerge, the child's father dies in a road accident. The child then begins to feel intense guilt, believing that he caused the death. What is the best nursing intervention in this situation?

The nurse should clarify the child's thoughts and help reduce feelings of guilt by explaining that wishes do not make events occur. Relaxation techniques help to reduce anxiety but do not reduce the feeling of guilt. Playing with siblings or spending time with an uncle may help relieve the child's stress, but they do not address the feelings of guilt.

An 8-year-old child who is experiencing a sickle cell pain episode is admitted to the child health unit. What is the most appropriate nursing care during this acute period?

The priority is pain management; severe pain requires analgesics. Increased hydration is necessary to promote hemodilution, improve circulation, and prevent more sickling. Cold will constrict blood vessels, further depleting oxygenation to affected parts; warmth is preferable. There is too much swelling and pain in the joints during a crisis for the implementation of range-of-motion exercises.

After being medicated for anxiety, a client says to a nurse, "I guess you are too busy to stay with me." How should the nurse respond?

The response "I have to go now, but I will come back in 10 minutes" demonstrates that the nurse cares about the client and will have time for the client's special emotional needs. This approach allays anxiety and reduces emotional stress.

A nursing student is listing the characteristics of an ethical issue. Which point listed by the nursing student requires correction?

The utilitarianism system of ethics decides on the right action based on the greatest good for the greatest number of people. This is not a characteristic feature of an ethical dilemma. A situation can be called an ethical dilemma if it fulfills one of three conditions. An ethical issue is challenging and generally cannot be solved through logical decision-making. An ethical issue cannot be solved solely through a review of scientific data. If the answer to a specific problem has a profound relevance for areas of human concern, then it is an ethical issue.

A client attending a prenatal class about nutrition tells the nurse that she is a strict vegetarian (vegan). What should the nurse encourage the client to eat that includes all of the essential amino acids?

This combination provides a complete protein for vegans because they do not eat foods from animal sources, which contain all of the essential amino acids. Macaroni and cheese provides a complete protein and is acceptable to ovo-lacto-vegetarians, who eat milk, eggs, and cheese, but is not acceptable to vegans. Eggs are a complete protein, but are not acceptable to vegans, only to ovo-lacto-vegetarians, who eat milk, eggs, and cheese. Brown rice and whole-wheat bread are both unrefined grains, but together they do not provide a complete protein.

The nurse is inspecting the abdomen of an 18-month-old child. Which methods should the nurse adopt to inspect for inguinal hernia? Select all that apply.

Typically, to locate an inguinal hernia, the nurse positions his or her finger at the proper site and asks the child to cough. However, if the child is too young to cough, such as at 18 months of age, the nurse can have the child blow up a balloon or laugh to raise the intraabdominal pressure sufficiently to demonstrate the presence of an inguinal hernia. In case of umbilical hernias, the nurse palpates the sac for abdominal contents and estimates the approximate size of the opening. In case of a femoral hernia, is felt or seen as a small mass on the anterior surface of the thigh just below the inguinal ligament in the femoral canal, the nurse should feel for a hernia by placing the index finger of the right hand on the child's right femoral pulse and the middle finger flat against the skin toward the midline.

The nurse is instructing a primigravid client how to identify the onset of labor. Which clinical indicator of labor would necessitate the client to call her healthcare provider?

When the membranes rupture the potential for infection is increased, and when the contractions are 5 to 8 minutes apart they are usually of sufficient force to warrant professional supervision. Bloody show and back pressure may be early signs of labor or signs of posterior fetal position; however, it is too early to notify the healthcare provider. Irregular contractions coming 10 minutes apart and contractions 12 minutes apart and lasting about 30 seconds indicate that it is too soon in the labor process to call the healthcare provider; the client should remain with her family and keep moving around at home.