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A Compilation of HESI Extra Credit Modules 1, 2, 3, 4, 5, 6, 7, 8, 9 & 10 Exams with Rationales UPDATED 2022 (multiple versions of each module) - with all 100% CORRECT ANSWERS SHOWN.
38 Items
HESI Extra Credit Module 1 Exam Developmental Stages and Transitions [NEW!!] 2022 (77 Pages)
1. A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's th... [Show More] eory of psychosocial development, what should the nurse tell the group about the infants? A. Rely on the fact that their needs will be met Correct B. Need to tolerate a great deal of frustration and discomfort to develop a healthy personality C. Must have needs ignored for short periods to develop a healthy personality D. Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs Rationale: According to Erikson’s theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore the other options are incorrect. Test-Taking Strategy: Eliminate the option that contains the closed-ended word "must." Eliminate the options that are comparable or alike and indicate that experiencing frustration is necessary. Review: Erikson’s theory of psychosocial development as it relates to the infant. Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternalchild nursing (4th ed., pp. 74-75). St. Louis: Elsevier. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Giddens Concepts: Development, Reproduction HESI Concepts: Developmental, Sexuality/Reproduction Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9476987754 A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz (2.9 kg). The nurse notes that the infant now weighs 13 lb (5.9 kg). Which action should the nurse take?A. Tell the mother that the infant's weight is increasing as expected Correct B. Tell the mother to decrease the daily number of feedings because the weight gain is excessive C. Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes D. Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate Rationale: Infants usually double their birth weight by 6 months and triple it by 1 year of age. If the infant is 6 lb 8 oz (2.9 kg), at birth, a weight of 13 lb (5.9 kg) at 6 months of age is to be expected. Semisolid foods are usually introduced between 4 and 6 months of age. Test-Taking Strategy: Focus on the subject in the question, the current weight of the infant. Recalling that infants double their weight by 6 months of age will direct you to the correct option. Review: the growth rate of an infant. Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 488-489). St. Louis: Elsevier. Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., p. 143). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Giddens Concepts: Development, Nutrition HESI Concepts: Developmental, Nutrition Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9476997157 A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. Based on this finding, what should the nurse do? A. Suspect the presence of hydrocephalus B. Suggest to the pediatrician that a skull x-ray be performed C. Tell the mother that the infant is growing faster than expected D. Document these measurements in the infant's health-care record Correct Rationale: The head circumference growth rate during the first year is approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the infant’s head and chest circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling the mother that the infant is growing faster than expected, and suggesting that a skull x-ray be performed are incorrect. Test-Taking Strategy: Eliminate the options that are comparable or alike andindicate that the infant has a physiological problem. Review: the expected growth rate of an infant. Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 69, 489-490). St. Louis: Elsevier. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Giddens Concepts: Clinical Judgment, Development HESI Concepts: Clinical Decision-Making/Clinical Judgment, Developmental Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9476985787 A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? A. "Yes, your infant is protected from all infections." B. "If you breastfeed, your infant is protected from infection." C. "The transfer of your antibodies protects your infant until the infant is 12 months old." D. "The immune system of an infant is immature, and the infant is at risk for infection." Correct Rationale: Transplacental transfer of maternal antibodies supplements the infant’s weak response to infection until approximately 3 to 4 months of age. Although the infant begins to produce immunoglobulin (Ig) soon after birth, by 1 year of age the infant has only approximately 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level. Breast milk transmits additional IgA protection. The activity of T-lymphocytes also increases after birth. Even though the immune system matures during infancy, maximal protection against infection is not achieved until early childhood. This immaturity places the infant at risk for infection. Test-Taking Strategy: Eliminate the option containing the closed-ended word "all." Recalling that breastfeeding alone does not protect the infant from infection will assist you in eliminating the option that suggests breastfeeding protects the infant. From the remaining options, use the strategy of selecting the umbrella option to answer correctly. Review: the physiological concepts related to the maturity of body systems in an infant. References: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 477-478). St. Louis: Elsevier. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/Implementation Content Area: Developmental Stages Giddens Concepts: Development, Immunity HESI Concepts: Developmental, Immunity Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 9476985720 A nurse is assessing the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age? A. The infant babbles. B. The infant says "Mama." Correct C. The infant smiles and coos. D. The infant babbles single consonants. Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as "Mama," "Daddy," "bye-bye," and "baby," begin to have meaning. A 1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single-consonant babbling occurs between 6 and 8 months of age. Test-Taking Strategy: Focus on the subject, the age of the infant. Recalling the language development that occurs during infancy will direct you to the correct option. Remember that an 8- to 9-month-old infant can string vowels and consonants together. Review: the developmental milestones related to language development in an infant. Reference:McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 94, 112). St. Louis: Elsevier. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Developmental Stages Giddens Concepts: Commuication, Development HESI Concepts: Communication, Developmental Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9476988639 The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. What should the nurse instruct the mother to do? A. Schedule an appointment with a dentist for a dental evaluation B. Rub the infant's gums with baby aspirin that has been dissolved in water C. Obtain an over-the-counter (OTC) topical medication for gumpain reliefD. Give the infant cool liquids or a Popsicle and hard foods such as dry toast Correct Rationale: Although sometimes asymptomatic, teething is often signaled by behavior such as nighttime awakening, daytime restlessness, an increase in nonnutritive sucking, excess drooling, and temporary loss of appetite. Some degree of discomfort is normal. It is unnecessary to obtain a dental evaluation, but a health-care professional should further investigate any incidence of increased temperature, irritability, ear-tugging, or diarrhea. The nurse may suggest that the mother provide cool liquids and hard foods such as dry toast, Popsicles, or a frozen bagel for chewing to relieve discomfort. Hard, cold teethers and ice wrapped in cloth may also provide comfort for inflamed gums. OTC medications for gum relief should only be used as directed by the healthcare provider. Home remedies such as rubbing the gums with aspirin should be discouraged, but acetaminophen (Tylenol), administered as directed for the child’s age, can relieve discomfort. Test-Taking Strategy: Focus on the subject, teething and relieving the infant’s discomfort. First recall that it is unnecessary to consult with a dentist. Next, eliminate the options that are comparable or alike and involve administering medication to the infant. Review: the measures that will relieve the discomfort of teething. Reference:McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 105). St. Louis: Elsevier. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Giddens Concepts: Comfort, Development HESI Concepts: Comfort—Pain, Developmental Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9476988697 A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. What should the nurse tell the mother to do? A. Use water and a cotton swab and rub the teeth Correct B. Use diluted fluoride and rub the teeth with a soft washcloth C. Use a small amount of toothpaste and a soft-bristle toothbrush D. Dip the infant's pacifier in maple syrup so that the infant will suck Rationale: Because the primary teeth are used for chewing until the permanent teeth erupt and because decay of the primary teeth often results in decay of the permanent teeth, dental care must be started in infancy. The mother can use cotton swabs or a soft washcloth to clean the teeth. Appropriate amounts offluoride are necessary for the development of healthy teeth, but infants usually receive fluoride when formula and cereal are mixed with fluoridated water or through fluoride supplementation. Toothpaste is not recommended because infants tend to swallow it, possibly ingesting excessive amounts of fluoride. Dipping the infant’s pacifier in maple syrup is unacceptable because of the risk of tooth decay. Test-Taking Strategy: Focus on the subject, cleaning the teeth. Recalling the risk associated with tooth decay will help eliminate the option that identifies the use of maple syrup. To select from the remaining options, noting that the client in the question is an infant will direct you to the correct option. Review: the procedure for cleaning teeth in an infant. Reference:McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 105). St. Louis: Elsevier. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Giddens Concepts: Client Education, Development HESI Concepts: Developmental, Teaching and Learning/Client Education Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9476988604 A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? A. "I can mix the food in the my infant's bottle if he won't eat it." B. "Fluoride supplementation is not necessary until permanent teeth come in." C. "Egg white should not be given to my infant because of the risk for an allergy." Correct D. "Meats are really important for iron, and I should start feeding meats to my infant right away." Rationale: Egg white, even in small quantities, is not given to the infant until the end of the first year of life because it is a common food allergen. Fluoride supplementation may be needed beginning at of 6 months, depending on the infant’s intake of fluoridated tap water. Foods are never mixed with formula in the bottle. It may be difficult for the infant to consume the formula, and it will also be difficult to determine the infant’s intake of the formula. Solid foods may be introduced into the diet when the infant is 5 to 6 months old. Rice cereal may be introduced first because of its low allergenic potential; or, depending on the pediatrician’s preference, fruits and vegetables may be introduced first. Test-Taking Strategy: Note the words “indicates an understanding of theinformation.” Read each option carefully and think about the principles associated with feeding and nutrition. Recalling that allergy is a concern will direct you to the correct option. Review: the principles related to nutrition an infant. Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 102). St. Louis: Elsevier. Hockenberry, M., & Wilson, D. (2013). Wong’s Essentials of pediatric nursing (9th ed., p. 329). St. Louis: Mosby. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Nutrition Giddens Concepts: Development, Nutrition HESI Concepts: Developmental, Nutrition Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 9476995316 A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz (3.2 kg) about car safety. What should the nurse tell the mother? A. To secure the infant in the middle of the back seat in a rearfacing infant safety seat Correct B. To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant C. That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags D. That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car Rationale: Infants should not be restrained in the front seats of cars. If a passenger-side air bag is deployed, the air bag may severely jolt an infant safety seat, harming the infant. Infants weighing less than 20 lb (9.1 kg) and those younger than 1 year should always be in the middle of the back seat in a rear-facing car safety seat. An infant must be placed in an infant safety seat and is never to be held by another person when riding in a car. Test-Taking Strategy: Eliminate the options that are comparable or alike and recommend placing the infant in the front seat. To select from the remaining options, keep safety in mind and remember that the infant should never be held and should be placed in an infant safety seat. Review: car safety principles for an infant. References: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 107-108). St. Louis: Elsevier.American Academy of Pediatrics for information on car safety www.healthychildren.org/English/safety-prevention/on-thego/Pages/Car-Safety-Seats-Information-for-Families.aspx. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Giddens Concepts: Development, Safety HESI Concepts: Developmental, Safety Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9476993884 A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? A. "I need to keep large toys out of the crib." B. "The drop side needs to be impossible for my infant to release." C. "Wood surfaces on the crib need to be free of splinters and cracks." D. "The distance between the slats needs to be no more than 4 inches (10 cm) wide to prevent entrapment of my infant's head or body." [Show Less]
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HESI Extra Credit Module 1 Exam Developmental Stages and Transitions [NEW!!] 2022 (65 Pages)
Module 1 Exam 1. 1.ID: 22104063291 A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development... [Show More] of an infant. Using Erikson's theory of psychosocial development, what should the nurse tell the group about the infants? A. Rely on the fact that their needs will be met Correct B. Tolerate a great deal of frustration and discomfort to develop a healthy personality C. Ignore needs for short periods to develop a healthy personality D. Experience frustration to allow an infant to cry for a while before meeting his or her needs Rationale: According to Erikson’s theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore the other options are incorrect. Test-Taking Strategy: Eliminate the option that contains the closed-ended word "must." Eliminate the options that are comparable or alike and indicate that experiencing frustration is necessary. Review: Erikson’s theory of psychosocial development as it relates to the infant. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Giddens Concepts: Development, Reproduction HESI Concepts: Developmental, Sexuality/Reproduction Awarded 99.0 points out of 99.0 possible points. 2. 2.ID: 22104063288 A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz (2.9 kg). The nurse notes that the infant now weighs 13 lb (5.9 kg). Which action should the nurse take? A. Tell the mother that the infant's weight is increasing as expected Correct B. Tell the mother to decrease the daily number of feedings because the weight gain is excessive C. Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizesD. Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate Rationale: Infants usually double their birth weight by 6 months and triple it by 1 year of age. If the infant is 6 lb 8 oz (2.9 kg), at birth, a weight of 13 lb (5.9 kg) at 6 months of age is to be expected. Semisolid foods are usually introduced between 4 and 6 months of age. Test-Taking Strategy: Focus on the subject in the question, the current weight of the infant. Recalling that infants double their weight by 6 months of age will direct you to the correct option. Review: The growth rate of an infant. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Giddens Concepts: Development, Nutrition HESI Concepts: Developmental, Nutrition Awarded 99.0 points out of 99.0 possible points. 3. 3.ID: 22104063285 A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. Based on this finding, what should the nurse do? A. Suspect the presence of hydrocephalus B. Suggest to the pediatrician that a skull x-ray be performed C. Tell the mother that the infant is growing faster than expected D. Document these measurements in the infant's health-care record Correct Rationale: The head circumference growth rate during the first year is approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the infant’s head and chest circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling the mother that the infant is growing faster than expected, and suggesting that a skull x-ray be performed are incorrect. Test-Taking Strategy: Eliminate the options that are comparable or alike and indicate that the infant has a physiological problem. Review: The expected growth rate of an infant. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Giddens Concepts: Clinical Judgment, Development HESI Concepts: Clinical Decision-Making/Clinical Judgment, Developmental Awarded 99.0 points out of 99.0 possible points. 4. 4.ID: 22104063282A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? A. "Yes, your infant is protected from all infections." B. "If you breastfeed, your infant is protected from infection." C. "The transfer of your antibodies protects your infant until the infant is 12 months old." D. "The immune system of an infant is immature, and the infant is at risk for infection." Correct Rationale: Transplacental transfer of maternal antibodies supplements the infant’s weak response to infection until approximately 3 to 4 months of age. Although the infant begins to produce immunoglobulin (Ig) soon after birth, by 1 year of age the infant has only approximately 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level. Breast milk transmits additional IgA protection. The activity of T-lymphocytes also increases after birth. Even though the immune system matures during infancy, maximal protection against infection is not achieved until early childhood. This immaturity places the infant at risk for infection. Test-Taking Strategy: Eliminate the option containing the closed-ended word "all." Recalling that breastfeeding alone does not protect the infant from infection will assist you in eliminating the option that suggests breastfeeding protects the infant. From the remaining options, use the strategy of selecting the umbrella option to answer correctly. Review: The physiological concepts related to the maturity of body systems in an infant. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Giddens Concepts: Development, Immunity HESI Concepts: Developmental, Immunity Awarded 99.0 points out of 99.0 possible points. 5. 5.ID: 22104063279 A nurse is assessing the language development of a 9-month-old infant. Which developmental milestones does the nurse expect to note in an infant of this age? Select all that apply. A. The infant babbles. B. The infant says "Mama." Correct C. The infant smiles and coos. D. The infant babbles single consonants. E. Words begin to have meaning for the infant. Correct F. The infant strings vowels and consonants together. Correct Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as "Mama," "Daddy," "bye-bye," and "baby," begin to have meaning. A1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4- month-old. Single-consonant babbling occurs between 6 and 8 months of age. Test-Taking Strategy: Focus on the subject, the age of the infant. Recalling the language development that occurs during infancy will direct you to the correct option. Remember that an 8- to 9-month-old infant can string vowels and consonants together. Review: The developmental milestones related to language development in an infant. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Developmental Stages Giddens Concepts: Communication, Development HESI Concepts: Communication, Developmental Awarded 33.0 points out of 99.0 possible points. 6. 6.ID: 22104063276 The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. What should the nurse instruct the mother to do? A. Schedule an appointment with a dentist for a dental evaluation B. Rub the infant's gums with baby aspirin that has been dissolved in water C. Obtain an over-the-counter (OTC) topical medication for gum-pain relief D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast Correct Rationale: Although sometimes asymptomatic, teething is often signaled by behaviors such as nighttime awakening, daytime restlessness, increase in nonnutritive sucking, excess drooling, and temporary loss of appetite. Some degree of discomfort is normal. It is unnecessary to obtain a dental evaluation, but a health-care professional should further investigate any incidence of increased temperature, irritability, ear-tugging, or diarrhea. The nurse may suggest that the mother provide cool liquids and hard foods such as dry toast, Popsicles, or a frozen bagel for chewing to relieve discomfort. Hard, cold teethers and ice wrapped in cloth may also provide comfort for inflamed gums. OTC medications for gum relief should only be used as directed by the healthcare provider. Home remedies such as rubbing the gums with aspirin should be discouraged, but acetaminophen (Tylenol), administered as directed for the child’s age, can relieve discomfort. Test-Taking Strategy: Focus on the subject, teething and relieving the infant’s discomfort. First recall that it is unnecessary to consult with a dentist. Next, eliminate the options that are comparable or alike and involve administering medication to the infant. Review: The measures that will relieve the discomfort of teething. Level of Cognitive Ability: ApplyingClient Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Giddens Concepts: Comfort, Development HESI Concepts: Comfort—Pain, Developmental Awarded 99.0 points out of 99.0 possible points. 7. 7.ID: 22104063273 A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. What should the nurse tell the mother to do? A. Use water and a cotton swab and rub the teeth Correct B. Use diluted fluoride and rub the teeth with a soft washcloth C. Use a small amount of toothpaste and a soft-bristle toothbrush D. Dip the infant's pacifier in maple syrup so that the infant will suck Rationale: Because the primary teeth are used for chewing until the permanent teeth erupt and because decay of the primary teeth often results in decay of the permanent teeth, dental care must be started in infancy. The mother can use cotton swabs or a soft washcloth to clean the teeth. Appropriate amounts of fluoride are necessary for the development of healthy teeth, but infants usually receive fluoride when formula and cereal are mixed with fluoridated water or through fluoride supplementation. Toothpaste is not recommended because infants tend to swallow it, possibly ingesting excessive amounts of fluoride. Dipping the infant’s pacifier in maple syrup is unacceptable because of the risk of tooth decay. Test-Taking Strategy: Focus on the subject, cleaning the teeth. Recalling the risk associated with tooth decay will help eliminate the option that identifies the use of maple syrup. To select from the remaining options, noting that the client in the question is an infant will direct you to the correct option. Review: The procedure for cleaning teeth in an infant. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Giddens Concepts: Client Education, Development HESI Concepts: Developmental, Teaching and Learning/Client Education Awarded 99.0 points out of 99.0 possible points. 8. 8.ID: 22104063270 A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? A. "I can mix the food in my infant's bottle if he won't eat the food." B. "Fluoride supplementation is not necessary until permanent teeth come in." C. "Egg white should not be given to my infant because of the risk for an allergy." CorrectD. "Meats are really important for iron, and I should start feeding meats to my infant right away." Rationale: Egg white, even in small quantities, is not given to the infant until the end of the first year of life because it is a common food allergen. Fluoride supplementation may be needed beginning at of 6 months, depending on the infant’s intake of fluoridated tap water. Foods are never mixed with formula in the bottle. It may be difficult for the infant to consume the formula, and it will also be difficult to determine the infant’s intake of the formula. Solid foods may be introduced into the diet when the infant is 5 to 6 months old. Rice cereal may be introduced first because of its low allergenic potential; or, depending on the pediatrician’s preference, fruits and vegetables may be introduced first. Test-Taking Strategy: Note the strategic words “indicates an understanding of the information.” Read each option carefully and think about the principles associated with feeding and nutrition. Recalling that allergy is a concern will direct you to the correct option. Review: The principles related to nutrition in an infant. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Nutrition Giddens Concepts: Development, Nutrition HESI Concepts: Developmental, Nutrition Awarded 99.0 points out of 99.0 possible points. 9. 9.ID: 22104063237 A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz (3.2 kg) about car safety. What should the nurse tell the mother? A. To secure the infant in the middle of the back seat in a rear-facing infant safety seat Correct B. To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant C. That it is acceptable to place the infant in the front seat in a rearfacing infant safety seat as long as the car has passenger-side air bags D. That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car Rationale: Infants should not be restrained in the front seats of cars. If a passengerside air bag is deployed, the air bag may severely jolt an infant safety seat, harming the infant. Infants weighing less than 20 lb (9.1 kg) and those younger than 1 year should always be in the middle of the back seat in a rear-facing car safety seat. An infant must be placed in an infant safety seat and is never to be held by another person when riding in a car. Test-Taking Strategy: Eliminate the options that are comparable or alike and recommend placing the infant in the front seat. To select from the remaining options,keep safety in mind and remember that the infant should never be held and should be placed in an infant safety seat. Review: car safety principles for an infant. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Giddens Concepts: Development, Safety HESI Concepts: Developmental, Safety Awarded 99.0 points out of 99.0 possible points. 10. 10.ID: 22104063234 A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? A. "I need to keep large toys out of the crib." B. "The drop side needs to be impossible for my infant to release." C. "Wood surfaces on the crib need to be free of splinters and cracks." D. "The distance between the slats needs to be no more than 4 inches (10 cm) wide to prevent entrapment of my infant's head or body [Show Less]
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HESI Extra Credit Module 2 Exam Health Promotion and Disease Prevention [NEW!!] 2022 (73 Pages)
A nurse performing a physical assessment of a client gathers both subjective and objective data. Which finding would the nurse document as subjective dat... [Show More] a? A. The client appears anxious. B. Blood pressure is 170/80 mm Hg. C. The client states that he has a rash. Correct D. The client has diminished reflexes in the legs. Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Test-Taking Strategy: Eliminate the options that are comparable or alike and include data that the nurse would obtain during the physical examination. Review: the difference between subjective and objective data . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9477073956 A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data? A. The client is allergic to strawberries. B. The last menstrual period was 30 days ago. C. The client takes acetaminophen (Tylenol) for headaches. D. A 1 × 2-inch (5 cm) scar is present on the lower right portion of the abdomen. Correct Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what theExtra Credit HESI Module 2 – Health Promotion and Disease Prevention nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data. Test-Taking Strategy: Eliminate the options that are comparable or alike and include data that the nurse would obtain from the client during the health history. Review: the difference between subjective and objective data . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9477071188 A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client? A. Episodic B. Follow-up C. Emergency D. Complete Correct Rationale: A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting such as a pediatric or family practice clinic, an independent or group private practice, a college health service, a women’s healthcare agency, a visiting nurse agency, or a community health agency. An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or one body system. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed. Test-Taking Strategy: Noting the words “initial home visit” in the question will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p.8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and MaintenanceExtra Credit HESI Module 2 – Health Promotion and Disease Prevention Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Technology and Informatics HESI Concepts: Evidence-Based Practice/Evidence, Informatics/Technology Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9477071128 A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting which? A. Data related to follow-up care B. A complete (total health) database Incorrect C. Data related to the respiratory system Correct D. Data related to the treatment for the cold Rationale: An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. Test-Taking Strategy: Focusing on the data in the question and noting the words “now complaining of chest congestion and cough” will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Gas Exchange HESI Concepts: Evidence-Based Practice/Evidence, Oxygenation/Gas Exchange Awarded 0.0 points out of 1.0 possible points. 5. 5.ID: 9477071111 A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? A. Collect health history information first, then perform the physical examinationExtra Credit HESI Module 2 – Health Promotion and Disease Prevention B. Ask health history questions while performing the examination and initiating emergency measures Correct C. Collect all information requested on the history form, including social support, strengths, and coping patterns D. Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room Rationale: If the client is alert and cooperative and if the situation is not lifethreatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address the priority, which is treating the client. Collecting all data requested on the history does not specifically address the client’s immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment. Test-Taking Strategy: Focus on the data in the question and note the words “alert and cooperative.” Noting that the client has not sustained life-threatening injuries will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Health Care Quality HESI Concepts: Evidence-Based Practice/Evidence, Health Policy/Systems— Health Care Quality Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477073919 A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? A. Emergency B. Follow-up Correct C. Complete (total) D. Problem-centered Rationale: A follow-up database is compiled to evaluate the status of an identified problem at regular and appropriate intervals. An emergency database calls for rapid collection of the data, often at the same time lifesaving measures are being performed. A complete database includes a complete health historyExtra Credit HESI Module 2 – Health Promotion and Disease Prevention and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. An episodic database (problem-centered) is compiled for a limited or short-term problem. It is focused mainly on one problem or body system. Test-Taking Strategy: Focus on the subject, a checkup 3 months after a diagnosis. Noting the words “at the clinic for a check-up” in the question will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Technology and Informatics HESI Concepts: Evidence-Based Practice/Evidence, Informatics/Technology Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9477073943 A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. What is the primary purpose of including cultural information in the health assessment? A. Confirm the medical diagnosis B. Make accurate nursing diagnoses C. Identify any hereditary traits related to the epilepsy D. Determine what the client believes has caused the epilepsy Correct Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican-American culture, epilepsy is seen as a reflection of physical imbalance. Although the nurse may obtain data related to family history (hereditary) and formulate nursing diagnoses, these are not the primary reasons for including cultural information in the health assessment. A nurse gathers assessment data but does not confirm a medical diagnosis. Test-Taking Strategy: Eliminate the option that indicates to confirm a medical diagnosis, because this is not the role of the nurse. To select from the remaining options, recall that cultural beliefs exist in relation to the cause of a disease; this will direct you to the correct option. Review: the nurse’s role in data collection and cultural considerations . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 52). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and MaintenanceExtra Credit HESI Module 2 – Health Promotion and Disease Prevention Integrated Process: Nursing Process/Assessment Content Area: Cultural Awareness Priority Concepts: Culture, Evidence HESI Concepts: Cultural/Spiritual, Evidence-Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9477071171 A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. What does the nurse determine? A. The client has a fever B. The skin temperature is normal Correct C. The client needs to drink additional fluids D. The client needs to have the blanket removed Rationale: To assess skin temperature, the nurse would first note the temperature of his or her own hands, then use the backs (dorsa) of the hands to palpate the client’s skin bilaterally. The skin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status. The hands and feet may feel slightly cooler in a cool environment. Giving the client additional fluids, removing the blanket, and checking for a fever are all incorrect responses to this finding. Test-Taking Strategy: Focus on the data in the question. Note the word “warm.” Recalling that warmth suggests normal circulatory status will direct you to the correct option. Review: normal skin temperature . References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 467). St. Louis: Saunders. Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 232). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Integumentary Priority Concepts: Evidence, Thermoregulation HESI Concepts: Evidence-Based Practice/Evidence, Intracranial Regulation— Thermoregulation Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 9477071124 A nurse performing a skin assessment notes that the client's skin is very dry. How should the nurse document this finding? A. Xerosis Correct B. PruritusExtra Credit HESI Module 2 – Health Promotion and Disease Prevention C. Seborrhea D. Actinic keratoses [Show Less]
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HESI Extra Credit Module 2 Exam Health Promotion and Disease Prevention [NEW!!] 2022 (103 Pages)
A nurse performing a physical assessment of a client gathers both subjective and objective data. Which of the following findings would the nurse document ... [Show More] as subjective data? The client appears anxious. Incorrect Blood pressure is 170/80 mm Hg. The client states that he has a rash. Correct The client has diminished reflexes in the legs. Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike and include data that the nurse would obtain during the physical examination. Review the difference between subjective and objective data if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation SendContent Area: Health Assessment/Physical Exam Awarded 0.0 points out of 1.0 possible points. 2.ID: 383734535 A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data? The client is allergic to strawberries. The last menstrual period was 30 days ago. The client takes acetaminophen (Tylenol) for headaches. A 1 × 2-inch scar is present on the lower right portion of the abdomen. Correct Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike and include data that the nurse would obtain from the client during the health history. Review the difference between subjective and objective data if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical ExamAwarded 0.0 points out of 1.0 possible points. 3.ID: 383734539 A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client? Episodic Follow-up Emergency Complete Correct Rationale: A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting such as a pediatric or family practice clinic, an independent or group private practice, a college health service, a women’s healthcare agency, a visiting nurse agency, or a community health agency. An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or one body system. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed. Test-Taking Strategy: Use the process of elimination. Noting the words “initial home visit” in the question will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p.8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and MaintenanceIntegrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Awarded 0.0 points out of 1.0 possible points. 4.ID: 383734509 A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting: Data related to follow-up care A complete (total health) database Data related to the respiratory system Correct Data related to the treatment for the cold Rationale: An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question and noting the words “now complaining of chest congestion and cough” will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and MaintenanceIntegrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Awarded 0.0 points out of 1.0 possible points. 5.ID: 383734545 A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? Collect health history information first, then perform the physical examination Ask health history questions while performing the examination and initiating emergency measures Correct Collect all information requested on the history form, including social support, strengths, and coping patterns Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room Rationale: If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address the priority, which is treating the client. Collecting all data requested on the history does not specifically address the client’s immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and note the words “alert and cooperative.” Noting that the client has not sustained life-threatening injuries will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: ApplyingClient Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Awarded 0.0 points out of 1.0 possible points. 6.ID: 383733744 A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? Emergency Follow-up Correct Complete (total) Problem-centered Rationale: A follow-up database is compiled to evaluate the status of an identified problem at regular and appropriate intervals. An emergency database calls for rapid collection of the data, often at the same time lifesaving measures are being performed. A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. An episodic database (problemcentered) is compiled for a limited or short-term problem. It is focused mainly on one problem or body system. Test-Taking Strategy: Focus on the data in the question. Noting the words “at the clinic for a check-up” in the question will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying [Show Less]
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HESI Extra Credit Module 2 Exam Health Promotion and Disease Prevention [NEW!!] 2022 (73 Pages)
A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which of the following findings does the nurse expect to note if c... [Show More] holecystitis is present? A. Homan sign B. Murphy sign Correct C. Blumberg sign D. McBurney sign Rationale: The Murphy sign is an indicator of gallbladder disease. The client is asked to inhale while the examiner’s fingers are hooked under the liver border, at the bottom of the rib cage. Inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder is inflamed. The Homan sign is pain in the calf area on sharp dorsiflexion of the client’s foot. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen. Rebound tenderness is a reliable sign of peritoneal irritation. The McBurney sign is a reaction of the client indicating severe pain and extreme tenderness when the McBurney point (midway between the umbilicus and the anterior iliac crest in the right lower quadrant of the abdomen) is palpated. Such a reaction indicates appendicitis. 2.ID: 383733763 A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the client's pulse is normal. Which of the following notations would the nurse make in the client's record to document the force of the client's pulse? E. 4+F. 3+ G. 2+ Correct H. 1+ Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4point scale may be used to assess the force (amplitude) of the pulse: 4+, bounding pulse; 3+, increased pulse; 2+, normal pulse; 1+, weak pulse. In this case the nurse would grade the client’s pulse as 2+. 3.ID: 383732836 A nurse performing a physical examination is assessing the client for costovertebral angle tenderness. When the nurse percusses the area, the client complains of sharp pain. The nurse interprets this finding as most indicative of: I. Liver enlargement J. Ovarian infection K. Spleen enlargement L. Kidney inflammation Correct Rationale: When assessing for costovertebral angle tenderness, the nurse is checking for kidney tenderness. Sharp pain that occurs on percussion of the costovertebral angle indicates inflammation of the kidney or paranephric area. To assess the kidney, the nurse places one hand over the 12th rib, at the costovertebral angle, on the back. The nurse then thumps that hand with the ulnar edge of the other fist. The client normally feels a thud and should notexperience pain. Ovarian infection, liver, or spleen enlargement are not associated with the costovertebral angle. 4.ID: 383733729 A nurse performing a neurological examination is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which of the following actions does the nurse take to test this nerve? M. Asking the client to raise his or her eyebrows and looking for symmetry N. Asking the client to clench the teeth, then palpating the masseter muscles just above the mandibular angle O. Asking the client to close the eyes and then identify light and sharp touch with a cotton ball and a pin on both sides of the face P. Asking the client to close his or her eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear Correct Rationale: To test the cochlear portion of the acoustic nerve, the nurse has the client close the eyes and indicate when a ticking watch or rustling of the examiner’s fingertips is heard as the stimulus is brought closer to the ear. To test the motor component of the trigeminal nerve, the nurse asks the client to clench the teeth and palpates the masseter muscles just above the mandibular angle. To test the sensory component of the trigeminal nerve (cranial nerve V), the nurse has the client identify light and sharp touch on both sides of the face. Asking the client to raise the eyebrows and watching for symmetry is one method of testing the function of the facial nerve (cranial nerve VII). 1. 5.ID: 383732891 A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client?A. Supine B. Standing C. Lithotomy D. Left lateral Correct Rationale: A female client is placed in the left lateral position for a rectal examination. If the examiner is examining the genitalia as well as the rectum, the woman is placed in the lithotomy position. A male client is placed in the left lateral or standing position. It would be difficult to perform a rectal examination on a client in the supine position. TestTaking Strategy: Use the process of elimination and focus on the subject, a rectal examination of a female client. Recalling that the left lateral position is used to administer an enema will assist in directing you to the correct option. Review the procedure for performing a rectal examination of a female client if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patientcentered collaborative care (6th ed., p. 1651). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Health Assessment/Physical Exam Awarded 1.0 points out of 1.0 possible points. 2. 6.ID: 383733761 A nurse is preparing to listen to a client's breath sounds. The nurse should:A. Ask the client to lie down B. Listen to the right lung, then the left lung C. Ask the client to take shallow rapid breaths through the mouth D. Use the diaphragm of the stethoscope, holding it firmly against the client's chest Correct Rationale: The nurse asks the client to sit and lean forward slightly, with the arms resting comfortably across the lap. The client is asked to breathe through the mouth a little more deeply than usual but is told to stop if he or she begins to feel dizzy. The nurse uses the flat diaphragm endpiece of the stethoscope, holding it firmly on the chest wall, and listens for at least one full respiration in each location, moving from side to side to compare sounds. TestTaking Strategy: Use the process of elimination. The fact that it would be difficult to listen to breath sounds if the client were lying down will assist you in eliminating this option. Next eliminate the option containing the word “rapid.” To select from the remaining options, visualize the procedure and recall that sidetoside comparison is important in the assessment of breath sounds. Review respiratory assessment procedures if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patientcentered collaborative care (6th ed., p. 561). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Awarded 1.0 points out of 1.0 possible points. 3. 7.ID: 383734529A clinic nurse about to meet a new client plans to gather subjective data regarding the client's health history. Which of the following actions does the nurse take to help ensure the success of the interview? Select all that apply. A. Ensuring that the room is private Correct B. Seeing that distracting objects are removed from the room Correct C. Having the client sit across a desk or table to give the client some personal space D. Maintaining a distance of 2 feet or closer between the nurse and client E. Switching on a dim light that will make the room cozier and help the client relax Rationale: The physical environment of an interview room should provide optimal conditions to encourage a smooth interview and make the client feel comfortable. The nurse ensures that privacy is maintained, that there are no interruptions during the interview, that the room temperature is comfortable, that lighting is sufficient, that ambient noise is reduced, and that distracting objects are removed from the room. The nurse also ensures that the client and nurse are seated comfortably, eye to eye, without a desk or table between them, because a desk or table would act as a barrier. The nurse should maintain a distance of 4 to 5 feet from the client to avoid invading the client’s private space, which might create anxiety on the part of the client. TestTaking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike and involves personal space (2 feet or closer and the client sits across a desk or table). To select from the remaining options, recall that adequate lighting is important for the nurse to observe the client during the interview and a private room without distractions is important. Review the physical environment and its effect on a client interview if you had difficulty with this question. References: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 57). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 236239). St. Louis: Mosby.Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Health Assessment/Physical Exam Awarded 1.0 points out of 1.0 possible points. 4. 8.ID: 383733788 A nurse performing a neurological assessment is preparing to assess the optic nerve. The nurse performs this examination by: A. Assessing visual acuity Correct B. Inspecting the eyelids for ptosis C. Assessing pupil constriction D. Assessing ocular movements Rationale: The optic nerve is assessed through the testing of visual acuity and visual fields by means of confrontation. Ptosis, a drooping of the eyelid, can be assessed by means of inspection of the eyelids. Testing of the abducens, oculomotor, and trochlear nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and assessing extraocular movements through the cardinal positions of gaze. 9.ID: 383732838 A nurse is preparing to screen a client’s vision with the use of a Snellen chart. The nurse:E. Tests the right eye, then tests the left eye, and finally tests both eyes together Correct F. Assesses both eyes together, then assesses the right and left eyes separately G. Asks the client to stand 40 feet from the chart and read the largest line on the chart H. Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a welllit spot with the chart at the client’s eye level. The client is positioned on a mark exactly 20 feet from the chart. The client uses an opaque card to shield one eye at a time during the test; after each eye is tested, both eyes are assessed together. The client is asked to read through the chart to the smallest line of letters he or she can discern. The client is encouraged to read the next smallest line as well. Therefore the other options are incorrect. 10.ID: 383732872 A nurse is preparing to listen to the breath sounds of a client. The nurse should: I. Ask the client to lie prone J. Ask the client to breathe in and out through the nose K. Hold the bell of the stethoscope lightly against the chestL. Listen for at least one full respiration in each location on the chest Correct Rationale: To best listen to breathe sounds, the nurse asks the client to sit, leaning slightly forward, with the arms resting comfortably across the lap. The client is instructed to breathe through the mouth, a little deeper than usual, but to stop if he or she feels dizzy. The flat diaphragm endpiece of the stethoscope is held firmly against the client’s chest wall. The nurse listens for at least one full respiration in each location on the chest. Sidetoside comparison is most important in the assessment of breath sounds. 11.ID: 383733780 During a physical assessment, the client tells the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing: [Show Less]
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HESI Extra Credit Module 2 Exam Health Promotion and Disease Prevention [NEW!!] 2022 (79 Pages)
Questions 1. 1.ID: 18630134746 A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nu... [Show More] rse document as subjective data? A. The client appears anxious. Incorrect B. Blood pressure is 170/80 mm Hg. C. The client states that he has a rash. Correct Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that include data that the nurse would obtain during the physical examination. Review the difference between subjective and objective data if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam D. The client has diminished reflexes in the legs. Awarded 0.0 points out of 1.0 possible points. 2. 2.ID: 18630134750 A nurse is reviewing the findings of a physical examination that have been documented in a client’s record. Which piece of information does the nurse recognize as objective data?A. The client is allergic to strawberries. B. The last menstrual period was 30 days ago. C. The client takes acetaminophen (Tylenol) for headaches. D. A 1 × 2-inch scar is present on the lower right portion of the abdomen. Correct Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that include data that the nurse would obtain from the client during the health history. Review the difference between subjective and objective data if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 18630134760 A nurse is reading the report from the registered nurse for an initial home visit to a client with chronic obstructive pulmonary disease. The client was recently discharged from the hospital. Which type of database does the nurse read that contains this information from the client? A. Episodic B. Follow-up Incorrect C. Emergency D. Complete Correct Rationale: A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting, such as a pediatric or family practice clinic; an independent or group private practice; a college health service; a women’s health care agency; a visiting nurse agency; or a community health agency. An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or one body system. A follow-up database is used to evaluate an identified problem at regular and appropriateintervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed. Test-Taking Strategy: Use the process of elimination. Noting the strategic words “initial home visit” in the question will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam Awarded 0.0 points out of 1.0 possible points. 4. 4.ID: 18630134758 A 25-year-old client was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should assist with the data collection by collecting which information? A. Data related to follow-up care B. A complete (total health) database C. Data related to the respiratory system Correct Rationale: An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client's current and past state of health and forms a baseline against which all future changes can be measured. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question and noting the words “now complaining of chest congestion and cough” will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data CollectionContent Area: Health Assessment/Physical Exam D. Data related to the treatment for the cold Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 18630134722 A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? A. Collect health history information first, then perform the physical examination. B. Ask health history questions while performing the examination and initiating emergency measures. Correct Rationale: If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address the priority, which is treating the client. Collecting all data requested on the history does not specifically address the client's immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and note the strategic words “alert and cooperative.” Noting that the client has not sustained life-threatening injuries will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam C. Collect all information requested on the history form, including social support, strengths, and coping patterns. D.Perform emergency measures and not ask any health history questions until the client’s fractures have been treated in the operating room. Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 18630133996 A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? A. Emergency B. Follow-up Correct Rationale: A follow-up database is compiled to evaluate the status of an identified problem at regular and appropriate intervals. An emergency database calls for rapid collection of the data, often at the same time lifesaving measures are being performed. A complete database includes a complete health history and a full physical examination. It describes the client's current and past state of health and forms a baseline against which all future changes can be measured. An episodic database (problem-centered) is compiled for a limited or short-term problem. It is focused mainly on one problem or body system. Test-Taking Strategy: Focus on the data in the question. Noting the strategic words “at the clinic for a checkup” in the question will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam C. Complete (total) D. Problem-centered Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 18630133962 A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment? A. Confirm the medical diagnosis. B. Make accurate nursing diagnoses.C. Identify any hereditary traits related to the epilepsy. Incorrect D. Determine what the client believes has caused the epilepsy. Correct Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. Although the nurse may obtain data related to family history (hereditary) and formulate nursing diagnoses, these are not the primary reasons for including cultural information in the health assessment. A nurse gathers assessment data but does not confirm a medical diagnosis. Test-Taking Strategy: Use knowledge of the subject, Mexican American cultural beliefs, to begin the process of elimination. Eliminate the option that indicates to confirm a medical diagnosis because this is not the role of the nurse. To select from the remaining options, recall that cultural beliefs exist in relation to the cause of a disease; this will direct you to the correct option. Review the nurse’s role in data collection and cultural considerations if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Cultural Diversity Awarded 0.0 points out of 1.0 possible points. 8. 8.ID: 18630134740 A nurse assisting with data collection uses the back of the hand to feel the client’s skin on both arms and notes that the skin is warm. The nurse makes which determination? A. The client has a fever. B. The skin temperature is normal. Correct Rationale: To assess skin temperature, the nurse would first note the temperature of his or her own hands, then use the backs (dorsa) of the hands to palpate the client’s skin bilaterally. The skin should be warm, and the temperature should be equal bilaterally;warmth suggests normal circulatory status. The hands and feet may feel slightly cooler in a cool environment. Giving the client additional fluids, removing the blanket, and checking for a fever are all incorrect responses to this finding. Test-Taking Strategy: Focus on the data in the question. Note the strategic word “warm.” Recalling that warmth suggests normal circulatory status will direct you to the correct option. Review normal skin temperature if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary C. The client needs to drink additional fluids. D. The client needs to have the blanket removed. Incorrect Awarded 0.0 points out of 1.0 possible points. 9. 9.ID: 18630133918 A nurse assisting with data collection notes that the client’s skin is very dry. The nurse documents this finding using which term? A. Xerosis Correct Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Causes include too-frequent bathing, low humidity, and decreased production of sebum in aging skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin. Seborrhea is one of several common skin conditions in which an overproduction of sebum results in excessive oiliness or dry scales. Actinic keratoses are red-tan scaly plaques that grow over the years, becoming raised and roughened. A silverywhite scale may adhere to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. Actinic keratoses are premalignant and may develop into squamous cell carcinoma. Test-Taking Strategy: Knowledge of the subject, the characteristics of various skin conditions and lesions, is needed to answer this question. This knowledge and noting the words “very dry” in the question will direct you to the correct option. Review the skin conditions identified in the options if you had difficulty with this question.Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Integumentary B. Pruritus C. Seborrhea D. Actinic keratoses Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 18630134702 A nurse is preparing to assist the health care provider examine a client’s skin with the use of a Wood light. In preparing for this diagnostic test, the nurse should perform which action? A. Darken the room Correct Rationale: A handheld long-wavelength ultraviolet (black) light, or Wood light, is sometimes used during physical examination of the skin. Areas of blue-green or red fluorescence are associated with certain skin conditions. Hypopigmented skin appears more prominent when it is viewed under black light, greatly facilitating the evaluation of pigment changes in fair-skinned clients. Examination of the skin is always carried out in a darkened room. The test is noninvasive, and the nurse should reassure the client that no discomfort is associated with a Wood light examination. Test-Taking Strategy: Use data in the question to focus on the name of the test. Recalling that this test is noninvasive will assist you in eliminating the incorrect options. Review the procedure for performing a Wood light test if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Adult Health/Integumentary B. Obtain informed consent from the client C. Obtain a scalpel and a slide for diagnostic evaluation D. Obtain medication to anesthetize the skin area before proceeding with the examination Incorrect Awarded 0.0 points out of 1.0 possible points.11. 11.ID: 18630133966 A nurse assisting with data collection for a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding using which terminology? [Show Less]
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HESI Extra Credit Module 2 Exam Health Promotion and Disease Prevention [NEW!!] 2022 (72 Pages)
Questions 1. 1.ID: 9477077870 A nurse performing a physical assessment of a client gathers both subjective and objective data. Which finding would the n... [Show More] urse document as subjective data? A. The client appears anxious. B. Blood pressure is 170/80 mm Hg. C. The client states that he has a rash. Correct D. The client has diminished reflexes in the legs. Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. TestTaking Strategy: Eliminate the options that are comparable or alike and include data that the nurse would obtain during the physical examination. Review: the difference between subjective and objective data . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical DecisionMaking/Clinical Judgment, EvidenceBased Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9477073956 A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data? A. The client is allergic to strawberries.B. The last menstrual period was 30 days ago. C. The client takes acetaminophen (Tylenol) for headaches. D. A 1 × 2inch scar is present on the lower right portion of the abdomen. Correct Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data. TestTaking Strategy: Eliminate the options that are comparable or alike and include data that the nurse would obtain from the client during the health history. Review: the difference between subjective and objective data . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical DecisionMaking/Clinical Judgment, EvidenceBased Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9477071188 A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client? A. Episodic B. Followup C. Emergency D. Complete Correct Rationale: A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting such as a pediatric or family practice clinic, an independent or group private practice, a college health service, a women’s healthcare agency, a visiting nurse agency, or a community health agency. An episodic database is compiled for a limited or shortterm problem and is focused mainly on one problem or one body system. A followup database is used to evaluate an identified problem at regular andappropriate intervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed. TestTaking Strategy: Noting the words “initial home visit” in the question will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p.8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Technology and Informatics HESI Concepts: EvidenceBased Practice/Evidence, Informatics/Technology Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9477071128 A nurse is examining a 25yearold client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting which? A. Data related to followup care B. A complete (total health) database C. Data related to the respiratory system Correct D. Data related to the treatment for the cold Rationale: An episodic database is compiled for a limited or shortterm problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. A followup database is used to evaluate an identified problem at regular and appropriate intervals. TestTaking Strategy: Focusing on the data in the question and noting the words “now complaining of chest congestion and cough” will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Gas Exchange HESI Concepts: EvidenceBased Practice/Evidence, Oxygenation/Gas Exchange Awarded 1.0 points out of 1.0 possible points.5. 5.ID: 9477071111 A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? A. Collect health history information first, then perform the physical examination B. Ask health history questions while performing the examination and initiating emergency measures Correct C. Collect all information requested on the history form, including social support, strengths, and coping patterns D. Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room Rationale: If the client is alert and cooperative and if the situation is not lifethreatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address the priority, which is treating the client. Collecting all data requested on the history does not specifically address the client’s immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment. TestTaking Strategy: Focus on the data in the question and note the words “alert and cooperative.” Noting that the client has not sustained lifethreatening injuries will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Health Care Quality HESI Concepts: EvidenceBased Practice/Evidence, Health Policy/Systems—Health Care Quality Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477073919 A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? A. Emergency B. Followup Correct C. Complete (total)D. Problemcentered Rationale: A followup database is compiled to evaluate the status of an identified problem at regular and appropriate intervals. An emergency database calls for rapid collection of the data, often at the same time lifesaving measures are being performed. A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. An episodic database (problemcentered) is compiled for a limited or shortterm problem. It is focused mainly on one problem or body system. TestTaking Strategy: Focus on the subject, a checkup 3 months after a diagnosis. Noting the words “at the clinic for a checkup” in the question will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Technology and Informatics HESI Concepts: EvidenceBased Practice/Evidence, Informatics/Technology Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9477073943 A MexicanAmerican client with epilepsy is being seen at the clinic for an initial examination. What is the primary purpose of including cultural information in the health assessment? A. Confirm the medical diagnosis B. Make accurate nursing diagnoses C. Identify any hereditary traits related to the epilepsy D. Determine what the client believes has caused the epilepsy Correct Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In MexicanAmerican culture, epilepsy is seen as a reflection of physical imbalance. Although the nurse may obtain data related to family history (hereditary) and formulate nursing diagnoses, these are not the primary reasons for including cultural information in the health assessment. A nurse gathers assessment data but does not confirm a medical diagnosis. TestTaking Strategy: Eliminate the option that indicates to confirm a medical diagnosis, because this is not the role of the nurse. To select from the remaining options, recall that cultural beliefs exist in relation to the cause of a disease; this will direct you to the correct option. Review: the nurse’s role in data collection and cultural considerations . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 52). St. Louis:Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Cultural Awareness Priority Concepts: Culture, Evidence HESI Concepts: Cultural/Spiritual, EvidenceBased Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9477071171 A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. What does the nurse determine? A. The client has a fever B. The skin temperature is normal Correct C. The client needs to drink additional fluids D. The client needs to have the blanket removed Rationale: To assess skin temperature, the nurse would first note the temperature of his or her own hands, then use the backs (dorsa) of the hands to palpate the client’s skin bilaterally. The skin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status. The hands and feet may feel slightly cooler in a cool environment. Giving the client additional fluids, removing the blanket, and checking for a fever are all incorrect responses to this finding. TestTaking Strategy: Focus on the data in the question. Note the word “warm.” Recalling that warmth suggests normal circulatory status will direct you to the correct option. Review: normal skin temperature . References: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patientcentered collaborative care (6th ed., p. 467). St. Louis: Saunders. Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 232). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Integumentary Priority Concepts: Evidence, Thermoregulation HESI Concepts: EvidenceBased Practice/Evidence, Intracranial Regulation—Thermoregulation Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 9477071124 A nurse performing a skin assessment notes that the client's skin is very dry. How should the nurse document this finding?A. Xerosis Correct B. Pruritus C. Seborrhea D. Actinic keratoses Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Causes include toofrequent bathing, low humidity, and decreased production of sebum in aging skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin. Seborrhea is one of several common skin conditions in which an overproduction of sebum results in excessive oiliness or dry scales. Actinic keratoses are redtan scaly plaques that grow over the years, becoming raised and roughened. A silverywhite scale may adhere to the plaque. They occur on sunexposed surfaces and are directly related to sun exposure. Actinic keratoses are premalignant and may develop into squamous cell carcinoma. TestTaking Strategy: Knowledge of the characteristics of various skin conditions and lesions is needed to answer this question. This knowledge and noting the words “very dry” in the question will direct you to the correct option. Review: the conditions identified in the options . Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patientcentered collaborative care (6th ed., pp. 465, 480). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health/Integumentary Priority Concepts: Evidence, Tissue Integrity HESI Concepts: EvidenceBased Practice/Evidence, Tissue Integrity Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9477073962 A nurse is preparing to perform a skin examination with the use of a Wood light. Which action should the nurse perform to prepare for this diagnostic test? A. Darken the room Correct B. Obtain informed consent from the client C. Obtain a scalpel and a slide for diagnostic evaluation D. Obtain medication to anesthetize the skin area before proceeding with the examination Rationale: A handheld longwa [Show Less]
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HESI Extra Credit Module 3 Exam with Rationale Mental Health Concepts [NEW!!] 2022 (94 Pages)100%
Extra Credit HESI Module 3 – Mental Health Concepts 1. Questions 1. 1.ID: 9477081360 The mother of a 3-year-old child tells the nurse that her child h... [Show More] it her doll after the mother scolded her for picking the neighbors’ flowers. Which defense mechanism used by the child does the nurse identify in the mother’s report? A. Projection B. Sublimation C. Displacement Correct D. Identification Rationale: The defense mechanism of displacement involves the discharge of intense feelings for one person onto a substitute person or object that is less threatening to satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse, such as that which occurs in blaming or scapegoating, to someone else. Sublimation is the act of rechanneling an impulse into a more socially acceptable object. Identification involves modeling behavior after someone else's. Test-Taking Strategy: Note the subject of the question, defense mechanisms. Focusing on the data in the question and the child’s behavior will direct you to the correct option. Review: these defense mechanisms . Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 133). St. Louis: Saunders. Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Development, Mood and Affect HESI Concepts: Developmental, Mood and Affect Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9477084316 A client says to the nurse, “I’ve been following my diet and taking my medication. What else do you want to talk about today?” Which response would be most helpful during the working phase of the therapeutic alliance? A. “Sounds fine to me. Let’s meet again in 6 months.” B. “I don’t believe that you have been following your diet, because you haven’t lost any weight.” C. “Well, you’ve talked about diet in your terms, but perhaps I should test you on specific things.”Extra Credit HESI Module 3 – Mental Health Concepts D. “Some people have added exercise to diet and medication therapy and gotten positive results. Do you think that this would work for you?” Correct Rationale: Although suggestion or overt giving of advice is sometimes nontherapeutic, these strategies are therapeutic when used in the working phase, because in this situation they will increase the client’s perception of all available options in the treatment plan. Answering, “Sounds fine to me. Let’s meet again in 6 months” stops the communication process. Stating to the client that he or she has not lost any weight implies disbelief and does not explore the reasons for the client’s failure to lose weight. “Testing” challenges the client and is nontherapeutic. Test-Taking Strategy: Note the strategic word “most” and remember therapeutic communication techniques. Noting the words “working phase” in the question will direct you to the correct option. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 553). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Health Promotion HESI Concepts: Communication, Health, Wellness, and Illness—Health Promotion Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9477084348 As the nurse prepares to interview a client being admitted to the mental health unit, the client says, “I asked my family to bring me in here to talk to someone, but now I don’t know where to begin.” Which response by the nurse would be most helpful? A. “Why not just start talking and see where it takes you?” B. “If I were you, I’d begin with what you were doing this morning.” C. “Perhaps you can start by sharing some of your most recent concerns.” Correct D. “Don’t worry. Everyone who comes in here for the first time feels reluctant to talk.” Rationale: The intake interview is usually the first contact with the client. It is intended to establish rapport, to help the nurse understand the client’s current problem and level of functioning, and to help the nurse formulate a nursing care plan. The clinician usually allows the client to set the pace of the interview andExtra Credit HESI Module 3 – Mental Health Concepts uses open-ended questions to elicit a comprehensive diagnostic picture of the client’s problems and level of coping. Sharing concerns is a good place to start the conversation, because it will allow the client to express feelings. The response “Why not just start talking and see where it takes you?” is too general and does not provide the client with a focus on self. Telling the client not to worry is nontherapeutic and avoids addressing the client’s concerns. Test-Taking Strategy: Note the strategic word “most.” Use your knowledge of therapeutic communication techniques. Focusing on the client’s feelings will direct you to the correct option. Review: therapeutic communication techniques . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 117-118). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Mood and Affect HESI Concepts: Communication, Mood and Affect Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9477092800 During a mental health intake interview, a young adult client who lives with his family rent free says, “I’m tired of not being able to offer my friends a beer just because my folks don’t believe in taking a drink socially.” Which nursing response would be therapeutic? A. “Well, I guess you could move out and live on your own if you wanted to.” B. “It seems that your parents expect you to follow their rules when you live under their roof.” Correct C. “You tell me you live rent free, yet you expect the same privileges as an adult who supports the household?” D. “Well, if you directly discussed your concerns with them, I guess it’s a case of ‘When in Rome, do as the Romans do.’” Rationale: The therapeutic nursing response uses reflection, in which the nurse directs the content of the client’s message back for the client to review from a new perspective. This technique also includes an element of focusing on the crux of the issue — in this case, that it is his parents’ home and they set the rules for living in their home, just as he someday will in his. Telling the client to move out is giving advice or suggestions to the client prematurely. Although thisExtra Credit HESI Module 3 – Mental Health Concepts technique can be useful in the working phase, it is usually nontherapeutic when the nurse needs to promote client understanding and self-exploration. Stating, “You tell me you live rent free, yet you expect the same privileges as an adult who supports the household?” is judgmental and poorly timed in that it humiliates the client unnecessarily. The client has acknowledged that he pays no rent, so there is no helpful purpose in reemphasizing this fact. Stating, “Well, if you directly discussed your concerns with them, I guess it’s a case of ‘When in Rome, do as the Romans do.’” is nontherapeutic in that it offers a cliché and expresses hopelessness and powerlessness, two emotions that the client is no doubt already experiencing. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. This will direct you to the correct option, the nursing response that focuses on the client’s concerns and feelings. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental—Family Dynamics Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 9477089705 The nurse developing a plan of care for a client whose spouse recently died determines the client has a problem with dysfunctional grieving. Which priority intervention does the nurse incorporate into the plan? A. Monitoring the client’s sleep pattern B. Assessing the client’s risk for violence toward self and others health care provider Correct C. Obtaining a health care provider’s prescription for an antidepressant D. Assisting the client in resolving the grief through emotional, cognitive, and behavioral means Rationale: The priority intervention for a client with dysfunctional grieving is assessing the client’s risk for violence toward self and others. Although the nurse will assist the client in resolving the grief and will monitor the client’s sleep pattern, these are not priorities in the list of options given. Obtaining a health care provider’s prescription for an antidepressant is not a priority. In fact, chemical dependency can present a barrier to the client’s goal attainment. Test-Taking Strategy: Use the steps of the nursing process. Both monitoring theExtra Credit HESI Module 3 – Mental Health Concepts client’s sleep pattern and assessing the client’s risk for violence toward self and others involve assessment. From these options, select the one that addresses the safety of the client. Review: interventions for a client with dysfunctional grieving . Reference: Fortinash, K., & Holoday-Worret, P. (2008). Psychiatric mental health nursing (4th ed., pp. 596, 599-600). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Mood and Affect HESI Concepts: Clinical Decision-Making, Mood and Affect Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477084360 A client in the mental health unit tells the nurse, “My husband makes all the decisions about money, but I’m the one who’s making the money now, not him. He needs to back off, but he’s always directing every decision we make.” Which nursing response would be the most therapeutic? A. “Have you told your husband to back off”? B. “You’re making the most money, so the decisions should be left to you.” C. “How do you feel the money decisions could best be handled in your household?” Correct D. “You seem frustrated with your husband’s habit of controlling financial decisions.” Rationale: The therapeutic nursing response is the one that provides a broad opening or statement and is focused on the client’s feelings. In this response, the nurse will be able to assess what the client believes concerning family financial decision-making. Asking, “Have you told your husband to ‘back off’?” is improperly paraphrasing the client and assumes that the client’s stance is correct. Stating, “You’re making the most money, so decisions should be left to you,” is inappropriate restating and provides an opinion; this response may be seen by the client as reassurance that her interpretation is being judged correct. When stating, “You seem to feel frustrated….,” the nurse is sharing perceptions, which may appear to be challenging to the client when used in this context. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Remember to focus on the client’s feelings and to provide the client the opportunity to communicate. This will direct you to the correct option. Review: therapeutic communication techniques . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9thExtra Credit HESI Module 3 – Mental Health Concepts ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 380, 381). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental—Family Dynamics Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9477084328 The nurse is developing a plan of care for a client who recently received a diagnosis of acquired immunodeficiency syndrome and is experiencing difficulty adjusting to the illness. Which action is an inappropriate intervention for this client? A. Monitoring the client for signs of self-harm B. Helping the client verbalize concerns related to fear C. Assisting the client with problem-solving and decision-making D. Discouraging social networking to prevent the spread of infection Correct Rationale: In planning care for a client experiencing difficulty in adjusting to an illness, the nurse develops interventions to promote (not discourage) social networking that will provide needed information to the client. The other options are appropriate interventions. Test-Taking Strategy: Note the strategic word “inappropriate.” Recalling that social support is important will direct you to the correct option. Also, note the relationship between the word “inappropriate” in the question and “discouraging” in the correct option. Review: interventions for a client experiencing difficulty in adjusting to an illness. Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 483, 484). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Clinical Judgment, Immunity HESI Concepts: Clinical Decision-Making/Clinical Judgment, Immunity Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9477084366Extra Credit HESI Module 3 – Mental Health Concepts How does a client who has lost a spouse show that she is successfully completing the tasks of mourning? Select all that apply. A. Relating that its better “he went first” B. Reporting that sleeping alone is so hard now Correct C. Purchasing a smaller car she is comfortable driving Correct D. Placing a picture of her husband on the bedside stand Correct E. Heard explaining to family that illness “took” her husband Correct Rationale: The tasks of mourning have been identified as accepting the reality of the loss; experiencing the pain of grief; adjusting to life without the lost one; and relocating and memorializing the loved one. It is not necessary to find a positive aspect to the loss in order to deal with the loss in a psychologically healthy manner. Therefore relating that its better “he went first” is incorrect. Test-Taking Strategy: Use the process of elimination and focus on the subject, completing the tasks of mourning. Recalling the tasks of mourning will direct you to the correct options. Review the tasks related to mourning and grief and loss if you had difficulty with this question. Reference:Varcarolis, E., & Halter, M. (2010). Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. (6th ed., p. 453). Philadelphia: W.B. Saunders. Cognitive Ability:Analyzing Client Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Family Dynamics, Stress HESI Concepts: Grief and Loss, Stress and Coping Awarded 4.0 points out of 4.0 possible points. 9. 9.ID: 9477089778 The psychiatric nurse is caring for a 15-year-old girl who has been hospitalized for bipolar disorder. The client tells the nurse that she had her hair styled just like her young math teacher, whom she admires. Which defense mechanism should the nurse recognize that the client is using? A. Projection B. Regression C. Identification Correct D. Intellectualization Rationale: Identification is the process by which a person tries to become like someone he or she admires by taking on the beliefs, mannerisms, or tastes of that person. Projection is attributing one's thoughts or impulses to another person. Regression is retreating to a behavior characteristic of an earlier level of development. Intellectualization is excessive reasoning or logic used to avoidExtra Credit HESI Module 3 – Mental Health Concepts experiencing disturbed feelings. Test-Taking Strategy: Focus on the subject, the client adjusting her appearance based on a person she admires. Noting that the client is mimicking a characteristic of another person will direct you to the correct option. Review: these defense mechanisms . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 377, 378). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 136). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Mood and Affect HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9477089792 The mental health home care nurse says to the client, “Do you feel ready to try attending a group session at the clinic?” The client shakes his head. Which nursing statement would be therapeutic? A. “No? Why not?” B. “You seem to be saying no. Would you tell me more about your reluctance?” Correct C. “OK, but I hope you will let me know when you feel ready to attend a group session at the clinic.” D. “Perhaps a group session would be too overwhelming for you right now. How about just seeing me?” [Show Less]
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HESI Extra Credit Module 3 Exam with Rationale Mental Health Concepts [NEW!!]2022 (146 Pages)100%
Question 1 1 / 1 pts A client whose adolescent son committed suicide by hanging himself in the family’s garage says to the nurse, “The coroner just i... [Show More] nformed us that our son had AIDS.” Which response to the client by the nurse is appropriate? “Your son had an autopsy because he committed suicide, but the coroner didn’t have to tell you that he was ill.” “Your poor son. How troubled he must have been. It’s a shame he couldn’t talk to you and get some help.” “You didn’t know that he had AIDS? How did he see the family health care provider without your knowing?” “Your son was keeping a very troubling diagnosis to himself. I am so sorry. No matter how close and loving children are to their parents, some children just aren’t able to confide in their parents.” Correct! Correct!Bailiff, Yanaira's Quiz History: Module 3 Exam 2/7/21, 1:31 PM https://gwinnettcollege.instructure.com/courses/3171/quizzes/12854/history?version=1 Page 2 of 146 Rationale: The therapeutic response is the one that makes observations and is helpful in supporting the client as he or she grieves. “You didn’t know he had AIDS? How did he see the family health care provider without your knowing?” is a redundant question that simply places emphasis on the client’s not having the child’s confidence. It is also nontherapeutic, because the nurse is changing the subject. “Your poor son. How troubled he must have been. It’s a shame he couldn’t talk to you and get some help” is nontherapeutic because it is social and fosters a sense of guilt. In stating, “Your son had an autopsy because he committed suicide, but the coroner didn’t have to tell you that he was ill,” the nurse makes a social statement that changes the focus and moves away from the client’s grief. Test-Taking Strategy: The correct option is the only one that shows supportiveness of the client. Review: measures for providing support to a client who is grieving . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 317, 318). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental—Family Dynamics Question 2 1 / 1 ptsBailiff, Yanaira's Quiz History: Module 3 Exam 2/7/21, 1:31 PM https://gwinnettcollege.instructure.com/courses/3171/quizzes/12854/history?version=1 Page 3 of 146 The nurse is caring for a patient with a chronic illness who is having conflicts with beliefs. Which health care team member will the nurse ask to see this patient? A social worker An occupational therapist A psychiatrist Correct! Correct! The clergy Other important resources to patients are spiritual advisors and members of the clergy. Spiritual care helps people identify meaning and purpose in life, look beyond the present, and maintain personal relationships, as well as a relationship with a higher being or life force. A psychiatrist is for emotional health. A social worker focuses on social, financial, and community resources. An occupational therapist provides care with vocational issues and functioning within physical limitations. Question 3 1 / 1 pts The nurse is evaluating the coping skills of a client with a diagnosis of depression. Which statement indicates to the nurse the need to help the client learn and appropriately use these skills?Bailiff, Yanaira's Quiz History: Module 3 Exam 2/7/21, 1:31 PM https://gwinnettcollege.instructure.com/courses/3171/quizzes/12854/history?version=1 Page 4 of 146 “I need to take my medications.” Correct! Correct! “I won’t ever be depressed again.” “I have learned ways to deal with stress.” “I know that I can’t do everything.”Bailiff, Yanaira's Quiz History: Module 3 Exam 2/7/21, 1:31 PM https://gwinnettcollege.instructure.com/courses/3171/quizzes/12854/history?version=1 Page 5 of 146 Rationale: Depression may be a recurring illness for some people. The client needs to understand the symptoms and recognize when or if treatment needs to be started again. Statements such as “I need to take my medications,” “I know that I can’t do everything,” and “I have learned ways to deal with stress,” indicate that the client has learned some coping skills, such as setting limits and taking medications. Test-Taking Strategy: Note the words "need to help the client learn and appropriately use these skills.” Eliminate the options that are comparable or alike and are positive and realistic. A client statement such as “I won’t ever be depressed again” is unrealistic and therefore indicates that further assistance is needed. Review: the indicators of effective use of coping skills . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidencebased care (p. 225). St. Louis: Saunders. Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Giddens Concepts: Client Education, Mood and Affect HESI Concepts: Mood and Affect, Teaching and Learning/Client Education Question 4 1 / 1 ptsBailiff, Yanaira's Quiz History: Module 3 Exam 2/7/21, 1:31 PM https://gwinnettcollege.instructure.com/courses/3171/quizzes/12854/history?version=1 Page 6 of 146 A 12-year-old client who has been reported for drawing sexually explicit scenes in her textbooks during class says to the psychiatric nurse, “I just felt like it.” Which response by the nurse would be therapeutic and aid assessment of abuse-related symptoms? “Your parents and teachers are very concerned about your drawings.” “You just felt like destroying your textbooks?” “I am concerned about you. Are you being or have you ever been abused?” Correct! Correct! “Well, a picture paints a thousand words.”Bailiff, Yanaira's Quiz History: Module 3 Exam 2/7/21, 1:31 PM https://gwinnettcollege.instructure.com/courses/3171/quizzes/12854/history?version=1 Page 7 of 146 Rationale: The behavior that this child has engaged in is a signal of distress. The correct option is the only option that specifically addresses abuse and demonstrates the nurse’s concern about the client. In stating, “Well, a picture paints a thousand words,” the nurse is insensitive, sarcastic, and intrusive. In asking, “You just felt like destroying your textbooks?” the nurse is addressing the client’s destructive behaviors, not the possibility of sexual abuse. By stating, “Your parents and teachers are very concerned about your drawings,” the nurse is trying to assess the client’s abuse-related symptoms, using indirect means rather than a straightforward expression of concern. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques, focusing on the subject of the question. Note the relationship of the words “assessment of abuse-related symptoms” and the words in the correct option. Review: assessment techniques for possible abuse . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 717). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Communication, Sexuality HESI Concepts: Communication, Sexuality/Reproduction Question 5 1 / 1 ptsBailiff, Yanaira's Quiz History: Module 3 Exam 2/7/21, 1:31 PM https://gwinnettcollege.instructure.com/courses/3171/quizzes/12854/history?version=1 Page 8 of 146 The husband of a terminally ill client says to the nurse, “My company went bankrupt, my son is a drug addict, my daughter is an alcoholic, and now this! My doctor wants me to try some stress reduction because my blood pressure is up. Whose wouldn’t be? I’ve tried music and relaxation, but they don’t work.” Which statement by the nurse would be therapeutic? “You have a lot of problems. How long does your wife have to live, and what is her relationship with your children?” Correct! Correct! “Let’s talk more about what has been helpful to you in the past.” “Can you afford to pay for therapy sessions? I see that your benefits are pretty much maxed out, and I’d hate to ask you to take on any additional burden.” “Before we talk about stress management, let’s discuss your children.” Rationale: The client is specifically asking the nurse to help him choose stress-management techniques and has already identified two that are not effective for him. Although the nurse will explore the client’s stressors, the problem that is directly harming the client physically is his blood pressure, so the nurse focuses on this first and determines what stress-management strategies have been effective in the past. By stating, “Before we talk about stress management, let’s discuss your children,” the nurse changes the subject, a nontherapeutic communication. By stating, “You have a lot of problems. How long does your wife have to live, and what is her relationship to your children?” theBailiff, Yanaira's Quiz History: Module 3 Exam 2/7/21, 1:31 PM https://gwinnettcollege.instructure.com/courses/3171/quizzes/12854/history?version=1 Page 9 of 146 have to live, and what is her relationship to your children?” the nurse changes the subject and engages in probing, both of which are nontherapeutic actions. “Can you afford to pay for therapy sessions? I see that your benefits are pretty much maxed out, and I’d hate to ask you to take on any additional burden?” is an inappropriately timed and somewhat probing question that changes the subject. Test-Taking Strategy: Eliminate the options that are comparable or alike and change the subject of the client’s concern. Next, note the relationship of the words “I’ve tried music and relaxation, but they don’t work” in the question and the correct option. Review: therapeutic communication techniques and stress management techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 253). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidencebased care (p. 40). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Coping HESI Concepts: Clinical Decision-Making/Clinical Judgment, Stress and Coping Question 6 1 / 1 ptsBailiff, Yanaira's Quiz History: Module 3 Exam 2/7/21, 1:31 PM https://gwinnettcollege.instructure.com/courses/3171/quizzes/12854/history?version=1 Page 10 of 146 The nurse is reading the medical record of a client who has a diagnosis of moderate anxiety and notes that the health care provider has documented that the client exhibits eustress. Based on this information, which finding would the nurse expect to encounter while assessing the client? The client complains of feeling anxious. The client complains of feeling drained. The client complains of fatigue. Correct! Correct! The client engages in purposeful movement [Show Less]
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HESI Extra Credit Module 3 Exam with Rationale Mental Health Concepts [NEW!!] 2022 (85Pages)100% C
1.ID: 21776939077 The mother of a 3-year-old child tells the nurse that her child hit her doll after the mother scolded her for picking the neighbors’ ... [Show More] flowers. Which defense mechanism used by the child does the nurse identify in the mother’s report? A. Projection B. Sublimation C. Displacement Correct D. Identification Rationale: The defense mechanism of displacement involves the discharge of intense feelings for one person onto a substitute person or object that is less threatening to satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse, such as that which occurs in blaming or scapegoating, to someone else. Sublimation is the act of rechanneling an impulse into a more socially acceptable object. Identification involves modeling behavior after someone else's. Test-Taking Strategy: Note the subject of the question, defense mechanisms. Focusing on the data in the question and the child’s behavior will direct you to the correct option. Review: these defense mechanisms . Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 133). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Development, Anxiety HESI Concepts: Developmental, Mood and Affect, Stress & Coping Awarded 100.0 points out of 100.0 possible points. 2. 2.ID: 21776939074 A client says to the nurse, “I’ve been following my diet and taking my medication. What else do you want to talk about today?” Which response would be most helpful during the working phase of the therapeutic alliance? A. “Sounds fine to me. Let’s meet again in 6 months.” B. “I don’t believe that you have been following your diet, because you haven’t lost any weight.” C. “Well, you’ve talked about diet in your terms, but perhaps I should test you on specific things.” D. “Some people have added exercise to diet and medication therapy and gotten positive results. Do you think that this would work for you?” CorrectRationale: Although suggestion or overt giving of advice is sometimes nontherapeutic, these strategies are therapeutic when used in the working phase, because in this situation they will increase the client’s perception of all available options in the treatment plan. Answering, “Sounds fine to me. Let’s meet again in 6 months” stops the communication process. Stating to the client that he or she has not lost any weight implies disbelief and does not explore the reasons for the client’s failure to lose weight. “Testing” challenges the client and is nontherapeutic. Test-Taking Strategy: Note the strategic word “most” and remember therapeutic communication techniques. Noting the words “working phase” in the question will direct you to the correct option. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 553). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Health Promotion HESI Concepts: Communication, Health Promotion Awarded 100.0 points out of 100.0 possible points. 3. 3.ID: 21776939071 As the nurse prepares to interview a client being admitted to the mental health unit, the client says, “I asked my family to bring me in here to talk to someone, but now I don’t know where to begin.” Which response by the nurse would be most helpful? A. “Why not just start talking and see where it takes you?” B. “If I were you, I’d begin with what you were doing this morning.” C. “Perhaps you can start by sharing some of your most recent concerns.” Correct D. “Don’t worry. Everyone who comes in here for the first time feels reluctant to talk.” Rationale: The intake interview is usually the first contact with the client. It is intended to establish rapport, to help the nurse understand the client’s current problem and level of functioning, and to help the nurse formulate a nursing care plan. The clinician usually allows the client to set the pace of the interview and uses open-ended questions to elicit a comprehensive diagnostic picture of the client’s problems and level of coping. Sharing concerns is a good place to start the conversation, because it will allow the client to express feelings. The response “Why not just start talking and see where it takes you?” is too general and does not provide the client with a focus on self. Telling the client not to worry is nontherapeutic and avoids addressing the client’s concerns. Test-Taking Strategy: Note the strategic word “most.” Use your knowledge of therapeutic communication techniques. Focusing on the client’s feelings will direct you to the correct option. Review: therapeutic communication techniques .References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 117-118). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Mood and Affect HESI Concepts: Communication, Mood & Affect Awarded 100.0 points out of 100.0 possible points. 4. 4.ID: 21776939068 During a mental health intake interview, a young adult client who lives with his family rent free says, “I’m tired of not being able to offer my friends a beer just because my folks don’t believe in taking a drink socially.” Which nursing response would be therapeutic? A. “Well, I guess you could move out and live on your own if you wanted to.” B. “It seems that your parents expect you to follow their rules when you live under their roof.” Correct C. “You tell me you live rent free, yet you expect the same privileges as an adult who supports the household?” D. “Well, if you directly discussed your concerns with them, I guess it’s a case of ‘When in Rome, do as the Romans do.’” Rationale: The therapeutic nursing response uses reflection, in which the nurse directs the content of the client’s message back for the client to review from a new perspective. This technique also includes an element of focusing on the crux of the issue — in this case, that it is his parents’ home and they set the rules for living in their home, just as he someday will in his. Telling the client to move out is giving advice or suggestions to the client prematurely. Although this technique can be useful in the working phase, it is usually nontherapeutic when the nurse needs to promote client understanding and selfexploration. Stating, “You tell me you live rent free, yet you expect the same privileges as an adult who supports the household?” is judgmental and poorly timed in that it humiliates the client unnecessarily. The client has acknowledged that he pays no rent, so there is no helpful purpose in reemphasizing this fact. Stating, “Well, if you directly discussed your concerns with them, I guess it’s a case of ‘When in Rome, do as the Romans do.’” is nontherapeutic in that it offers a cliché and expresses hopelessness and powerlessness, two emotions that the client is no doubt already experiencing. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. This will direct you to the correct option, the nursing response that focuses on the client’s concerns and feelings. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp.27-31). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental Awarded 100.0 points out of 100.0 possible points. 5. 5.ID: 21776939065 The nurse developing a plan of care for a client whose spouse recently died, determines the client has a problem with dysfunctional grieving. Which priority intervention does the nurse incorporate into the plan? A. Monitoring the client’s sleep pattern B. Assessing the client’s risk for violence toward self and others Correct C. Obtaining a health care provider’s prescription for an antidepressant D. Assisting the client in resolving the grief through emotional, cognitive, and behavioral means Rationale: The priority intervention for a client with dysfunctional grieving is assessing the client’s risk for violence toward self and others. Although the nurse will assist the client in resolving the grief and will monitor the client’s sleep pattern, these are not priorities in the list of options given. Obtaining a health care provider’s prescription for an antidepressant is not a priority. Test-Taking Strategy: Use the steps of the nursing process. Both monitoring the client’s sleep pattern and assessing the client’s risk for violence toward self and others involve assessment. From these options, select the one that addresses the safety of the client. Review: interventions for a client with dysfunctional grieving . Reference: Fortinash, K., & Holoday-Worret, P. (2008). Psychiatric mental health nursing (4th ed., pp. 596, 599-600). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Mood and Affect, Safety HESI Concepts: Grief & Loss, Safety Awarded 100.0 points out of 100.0 possible points. 6. 6.ID: 21776939062 A client in the mental health unit tells the nurse, “My husband makes all the decisions about money, but I’m the one who’s making the money now, not him. He needs to back off, but he’s always directing every decision we make.” Which nursing response would be the most therapeutic?A. “Have you told your husband to back off”? B. “You’re making the most money, so the decisions should be left to you.” C. “How do you feel the money decisions could best be handled in your household?” Correct D. “You seem frustrated with your husband’s habit of controlling financial decisions.” Rationale: The therapeutic nursing response is the one that provides a broad opening or statement and is focused on the client’s feelings. In this response, the nurse will be able to assess what the client believes concerning family financial decision-making. Asking, “Have you told your husband to ‘back off’?” is improperly paraphrasing the client and assumes that the client’s stance is correct. Stating, “You’re making the most money, so decisions should be left to you,” is inappropriate restating and provides an opinion; this response may be seen by the client as reassurance that her interpretation is being judged correct. When stating, “You seem to feel frustrated….,” the nurse is sharing perceptions, which may appear to be challenging to the client when used in this context. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Remember to focus on the client’s feelings and to provide the client the opportunity to communicate. This will direct you to the correct option. Review: therapeutic communication techniques . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 380, 381). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental Awarded 100.0 points out of 100.0 possible points. 7. 7.ID: 21776939059 The new nurse employee is developing a plan of care, with the registered nurse, for a client who recently received a diagnosis of acquired immunodeficiency syndrome (AIDS) and is experiencing difficulty adjusting to the illness. The registered nurse should suggest revision of which intervention for this client? A. Monitoring the client for signs of self-harm B. Helping the client verbalize concerns related to fear C. Assisting the client with problem-solving and decision-making D. Discouraging social networking to prevent the spread of infection CorrectRationale: In planning care for a client experiencing difficulty in adjusting to an illness, the nurse develops interventions to promote (not discourage) social networking that will provide needed information to the client. The other options are appropriate interventions. Test-Taking Strategy: Note the strategic word “ revision.” Recalling that social support is important will direct you to the correct option. Also, use data in the question and note the relationship between the word “inappropriate” in the question and “discouraging” in the correct option. Review: interventions for a client experiencing difficulty in adjusting to an illness. Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 483, 484). St. Louis: Mosby. Level of Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Collaboration, Immunity HESI Concepts: Collaboration/Managing, Immunity Awarded 100.0 points out of 100.0 possible points. 8. 8.ID: 21776939056 A nurse is caring for a patient whose spouse has died. How does the nurse determine that a client who has lost a spouse has successfully completed the tasks of mourning? Select all that apply. A. Relating that “its better he went first” B. Reporting that sleeping alone is so hard now Correct C. Purchasing a smaller car she is comfortable driving Correct D. Placing a picture of her husband on the bedside stand Correct E. Heard explaining to family that illness “took” her husband Correct Rationale: The tasks of mourning have been identified as accepting the reality of the loss; experiencing the pain of grief; adjusting to life without the lost one; and relocating and memorializing the loved one. It is not necessary to find a positive aspect to the loss in order to deal with the loss in a psychologically healthy manner. Therefore relating that “its better he went first” is incorrect. Test-Taking Strategy: Use the process of elimination and focus on the subject, completing the tasks of mourning. Recalling the tasks of mourning will direct you to the correct options. Review: the tasks related to mourning and Grief & Loss if you had difficulty with this question. Reference: Varcarolis, E., & Halter, M. (2010). Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. (6th ed., p. 453). Philadelphia: W.B. Saunders. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/AssessmentContent Area: Mental Health Giddens Concepts: Family Dynamics, Stress HESI Concepts: Grief & Loss, Stress & Coping Awarded 100.0 points out of 100.0 possible points. 9. 9.ID: 21776938796 The nurse is caring for a 15-year-old girl who has been hospitalized. The client tells the nurse that she had her hair styled just like her young math teacher, whom she admires. Which defense mechanism should the nurse recognize that the client is using? A. Projection B. Regression C. Identification Correct D. Intellectualization Rationale: Identification is the process by which a person tries to become like someone he or she admires by taking on the beliefs, mannerisms, or tastes of that person. Projection is attributing one's thoughts or impulses to another person. Regression is retreating to a behavior characteristic of an earlier level of development. Intellectualization is excessive reasoning or logic used to avoid experiencing disturbed feelings. Test-Taking Strategy: Focus on the subject, the client adjusting her appearance based on a person she admires. Noting that the client is mimicking a characteristic of another person will direct you to the correct option. Review: these defense mechanisms . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 377, 378). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 136). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Coping, Mood and Affect HESI Concepts: Mood and Affect, Stress & Coping Awarded 100.0 points out of 100.0 possible points. 10. 10.ID: 21776938793 The mental health home care nurse says to the client, “Do you feel ready to try attending a group session at the clinic?” The client shakes his head. Which nursing statement would be therapeutic? A. “No? Why not?” B. “You seem to be saying no. Would you tell me more about your reluctance?” Correct C. “OK, but I hope you will let me know when you feel ready to attend a group session at the clinic.”D. “Perhaps a group session would be too overwhelming for you right now. How about just seeing me?” [Show Less]
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HESI Extra Credit Module 3 Exam with Rationale Mental Health Concepts [NEW!!] 2022 (94 Pages)100%
Extra Credit HESI Module 3 – Mental Health Concepts 1. Questions 1. 1.ID: 9477081360 The mother of a 3-year-old child tells the nurse that her child h... [Show More] it her doll after the mother scolded her for picking the neighbors’ flowers. Which defense mechanism used by the child does the nurse identify in the mother’s report? A. Projection B. Sublimation C. Displacement Correct D. Identification Rationale: The defense mechanism of displacement involves the discharge of intense feelings for one person onto a substitute person or object that is less threatening to satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse, such as that which occurs in blaming or scapegoating, to someone else. Sublimation is the act of rechanneling an impulse into a more socially acceptable object. Identification involves modeling behavior after someone else's. Test-Taking Strategy: Note the subject of the question, defense mechanisms. Focusing on the data in the question and the child’s behavior will direct you to the correct option. Review: these defense mechanisms . Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 133). St. Louis: Saunders. Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Development, Mood and Affect HESI Concepts: Developmental, Mood and Affect Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9477084316 A client says to the nurse, “I’ve been following my diet and taking my medication. What else do you want to talk about today?” Which response would be most helpful during the working phase of the therapeutic alliance? A. “Sounds fine to me. Let’s meet again in 6 months.” B. “I don’t believe that you have been following your diet, because you haven’t lost any weight.” C. “Well, you’ve talked about diet in your terms, but perhaps I should test you on specific things.”Extra Credit HESI Module 3 – Mental Health Concepts D. “Some people have added exercise to diet and medication therapy and gotten positive results. Do you think that this would work for you?” Correct Rationale: Although suggestion or overt giving of advice is sometimes nontherapeutic, these strategies are therapeutic when used in the working phase, because in this situation they will increase the client’s perception of all available options in the treatment plan. Answering, “Sounds fine to me. Let’s meet again in 6 months” stops the communication process. Stating to the client that he or she has not lost any weight implies disbelief and does not explore the reasons for the client’s failure to lose weight. “Testing” challenges the client and is nontherapeutic. Test-Taking Strategy: Note the strategic word “most” and remember therapeutic communication techniques. Noting the words “working phase” in the question will direct you to the correct option. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 553). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Health Promotion HESI Concepts: Communication, Health, Wellness, and Illness—Health Promotion Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9477084348 As the nurse prepares to interview a client being admitted to the mental health unit, the client says, “I asked my family to bring me in here to talk to someone, but now I don’t know where to begin.” Which response by the nurse would be most helpful? A. “Why not just start talking and see where it takes you?” B. “If I were you, I’d begin with what you were doing this morning.” C. “Perhaps you can start by sharing some of your most recent concerns.” Correct D. “Don’t worry. Everyone who comes in here for the first time feels reluctant to talk.” Rationale: The intake interview is usually the first contact with the client. It is intended to establish rapport, to help the nurse understand the client’s current problem and level of functioning, and to help the nurse formulate a nursing care plan. The clinician usually allows the client to set the pace of the interview andExtra Credit HESI Module 3 – Mental Health Concepts uses open-ended questions to elicit a comprehensive diagnostic picture of the client’s problems and level of coping. Sharing concerns is a good place to start the conversation, because it will allow the client to express feelings. The response “Why not just start talking and see where it takes you?” is too general and does not provide the client with a focus on self. Telling the client not to worry is nontherapeutic and avoids addressing the client’s concerns. Test-Taking Strategy: Note the strategic word “most.” Use your knowledge of therapeutic communication techniques. Focusing on the client’s feelings will direct you to the correct option. Review: therapeutic communication techniques . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 117-118). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Mood and Affect HESI Concepts: Communication, Mood and Affect Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9477092800 During a mental health intake interview, a young adult client who lives with his family rent free says, “I’m tired of not being able to offer my friends a beer just because my folks don’t believe in taking a drink socially.” Which nursing response would be therapeutic? A. “Well, I guess you could move out and live on your own if you wanted to.” B. “It seems that your parents expect you to follow their rules when you live under their roof.” Correct C. “You tell me you live rent free, yet you expect the same privileges as an adult who supports the household?” D. “Well, if you directly discussed your concerns with them, I guess it’s a case of ‘When in Rome, do as the Romans do.’” Rationale: The therapeutic nursing response uses reflection, in which the nurse directs the content of the client’s message back for the client to review from a new perspective. This technique also includes an element of focusing on the crux of the issue — in this case, that it is his parents’ home and they set the rules for living in their home, just as he someday will in his. Telling the client to move out is giving advice or suggestions to the client prematurely. Although thisExtra Credit HESI Module 3 – Mental Health Concepts technique can be useful in the working phase, it is usually nontherapeutic when the nurse needs to promote client understanding and self-exploration. Stating, “You tell me you live rent free, yet you expect the same privileges as an adult who supports the household?” is judgmental and poorly timed in that it humiliates the client unnecessarily. The client has acknowledged that he pays no rent, so there is no helpful purpose in reemphasizing this fact. Stating, “Well, if you directly discussed your concerns with them, I guess it’s a case of ‘When in Rome, do as the Romans do.’” is nontherapeutic in that it offers a cliché and expresses hopelessness and powerlessness, two emotions that the client is no doubt already experiencing. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. This will direct you to the correct option, the nursing response that focuses on the client’s concerns and feelings. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental—Family Dynamics Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 9477089705 The nurse developing a plan of care for a client whose spouse recently died determines the client has a problem with dysfunctional grieving. Which priority intervention does the nurse incorporate into the plan? A. Monitoring the client’s sleep pattern B. Assessing the client’s risk for violence toward self and others health care provider Correct C. Obtaining a health care provider’s prescription for an antidepressant D. Assisting the client in resolving the grief through emotional, cognitive, and behavioral means Rationale: The priority intervention for a client with dysfunctional grieving is assessing the client’s risk for violence toward self and others. Although the nurse will assist the client in resolving the grief and will monitor the client’s sleep pattern, these are not priorities in the list of options given. Obtaining a health care provider’s prescription for an antidepressant is not a priority. In fact, chemical dependency can present a barrier to the client’s goal attainment. Test-Taking Strategy: Use the steps of the nursing process. Both monitoring theExtra Credit HESI Module 3 – Mental Health Concepts client’s sleep pattern and assessing the client’s risk for violence toward self and others involve assessment. From these options, select the one that addresses the safety of the client. Review: interventions for a client with dysfunctional grieving . Reference: Fortinash, K., & Holoday-Worret, P. (2008). Psychiatric mental health nursing (4th ed., pp. 596, 599-600). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Mood and Affect HESI Concepts: Clinical Decision-Making, Mood and Affect Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477084360 A client in the mental health unit tells the nurse, “My husband makes all the decisions about money, but I’m the one who’s making the money now, not him. He needs to back off, but he’s always directing every decision we make.” Which nursing response would be the most therapeutic? A. “Have you told your husband to back off”? B. “You’re making the most money, so the decisions should be left to you.” C. “How do you feel the money decisions could best be handled in your household?” Correct D. “You seem frustrated with your husband’s habit of controlling financial decisions.” Rationale: The therapeutic nursing response is the one that provides a broad opening or statement and is focused on the client’s feelings. In this response, the nurse will be able to assess what the client believes concerning family financial decision-making. Asking, “Have you told your husband to ‘back off’?” is improperly paraphrasing the client and assumes that the client’s stance is correct. Stating, “You’re making the most money, so decisions should be left to you,” is inappropriate restating and provides an opinion; this response may be seen by the client as reassurance that her interpretation is being judged correct. When stating, “You seem to feel frustrated….,” the nurse is sharing perceptions, which may appear to be challenging to the client when used in this context. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Remember to focus on the client’s feelings and to provide the client the opportunity to communicate. This will direct you to the correct option. Review: therapeutic communication techniques . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9thExtra Credit HESI Module 3 – Mental Health Concepts ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 380, 381). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental—Family Dynamics Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9477084328 The nurse is developing a plan of care for a client who recently received a diagnosis of acquired immunodeficiency syndrome and is experiencing difficulty adjusting to the illness. Which action is an inappropriate intervention for this client? A. Monitoring the client for signs of self-harm B. Helping the client verbalize concerns related to fear C. Assisting the client with problem-solving and decision-making D. Discouraging social networking to prevent the spread of infection Correct Rationale: In planning care for a client experiencing difficulty in adjusting to an illness, the nurse develops interventions to promote (not discourage) social networking that will provide needed information to the client. The other options are appropriate interventions. Test-Taking Strategy: Note the strategic word “inappropriate.” Recalling that social support is important will direct you to the correct option. Also, note the relationship between the word “inappropriate” in the question and “discouraging” in the correct option. Review: interventions for a client experiencing difficulty in adjusting to an illness. Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 483, 484). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Clinical Judgment, Immunity HESI Concepts: Clinical Decision-Making/Clinical Judgment, Immunity Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9477084366Extra Credit HESI Module 3 – Mental Health Concepts How does a client who has lost a spouse show that she is successfully completing the tasks of mourning? Select all that apply. A. Relating that its better “he went first” B. Reporting that sleeping alone is so hard now Correct C. Purchasing a smaller car she is comfortable driving Correct D. Placing a picture of her husband on the bedside stand Correct E. Heard explaining to family that illness “took” her husband Correct Rationale: The tasks of mourning have been identified as accepting the reality of the loss; experiencing the pain of grief; adjusting to life without the lost one; and relocating and memorializing the loved one. It is not necessary to find a positive aspect to the loss in order to deal with the loss in a psychologically healthy manner. Therefore relating that its better “he went first” is incorrect. Test-Taking Strategy: Use the process of elimination and focus on the subject, completing the tasks of mourning. Recalling the tasks of mourning will direct you to the correct options. Review the tasks related to mourning and grief and loss if you had difficulty with this question. Reference:Varcarolis, E., & Halter, M. (2010). Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. (6th ed., p. 453). Philadelphia: W.B. Saunders. Cognitive Ability:Analyzing Client Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Family Dynamics, Stress HESI Concepts: Grief and Loss, Stress and Coping Awarded 4.0 points out of 4.0 possible points. 9. 9.ID: 9477089778 The psychiatric nurse is caring for a 15-year-old girl who has been hospitalized for bipolar disorder. The client tells the nurse that she had her hair styled just like her young math teacher, whom she admires. Which defense mechanism should the nurse recognize that the client is using? A. Projection B. Regression C. Identification Correct D. Intellectualization Rationale: Identification is the process by which a person tries to become like someone he or she admires by taking on the beliefs, mannerisms, or tastes of that person. Projection is attributing one's thoughts or impulses to another person. Regression is retreating to a behavior characteristic of an earlier level of development. Intellectualization is excessive reasoning or logic used to avoidExtra Credit HESI Module 3 – Mental Health Concepts experiencing disturbed feelings. Test-Taking Strategy: Focus on the subject, the client adjusting her appearance based on a person she admires. Noting that the client is mimicking a characteristic of another person will direct you to the correct option. Review: these defense mechanisms . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 377, 378). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 136). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Mood and Affect HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9477089792 The mental health home care nurse says to the client, “Do you feel ready to try attending a group session at the clinic?” The client shakes his head. Which nursing statement would be therapeutic? A. “No? Why not?” B. “You seem to be saying no. Would you tell me more about your reluctance?” Correct C. “OK, but I hope you will let me know when you feel ready to attend a group session at the clinic.” D. “Perhaps a group session would be too overwhelming for you right now. How about just seeing me?” [Show Less]
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HESI Extra Credit Module 4 Exam with Rationale [NEW!!] 2022 (74 Pages) 100% CORRECT
Module 4 Exam 1. 1.ID: 22114677593 A client with schizophrenia says, “I’m away for the day ... but don’t think we should play or do we have feet o... [Show More] f clay?” Which alteration in the client’s speech does the nurse document? A. Neologism B. Word salad C. Clang association Correct D. Associative looseness Rationale: Clang association is the meaningless rhyming of words in which the rhyming is more important than the context of the words. A neologism is a made-up word that has meaning only to the client. Word salad is the term for a mixture of meaningless phrases, either to the client or to the listener. Associative looseness is a term used to describe schizophrenic speech in which connections and threads are interrupted or missing. Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client with schizophrenia is needed to answer this question. Focus on the subject in the question, the meaningless rhyming of words. Review: these speech patterns . Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 281). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition Awarded 100.0 points out of 100.0 possible points. 2. 2.ID: 22114677590 A client with schizophrenia and his parents are meeting with the nurse. One of the young man’s parents says to the nurse, “We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he’s had another relapse, and we can’t understand why he stopped his medication.” Which response by the nurse is appropriate? A. Telling the parents, “Medication noncompliance is the most frequent reason that people with this diagnosis relapse.” B. Telling the parents, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.”C. Asking the client, “How can we help you to take your medicine or to tell us when you’re having problems so that your medication can be adjusted?” Correct D. Saying to the parents, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication.” Rationale: The therapeutic response is the one in which the nurse models speaking directly to the client. This facilitates further assessment of the situation and helps elicit the causes of and motivations for the client’s behavior for both the nurse and the family. In the correct option, the nurse also seeks clarification of the degree of openness and mutuality felt by the client and his family toward each other. The nurse provides information to the family when stating that noncompliance is the most frequent reason for relapse in people with this diagnosis. However, the statement is nontherapeutic at this time because it does not facilitate the expression of feelings. The nurse uses a superego style of communication when stating, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” The content of this statement may be true, but it is nontherapeutic in that it carries a threatening message and may prevent the family from trusting the nurse. By stating, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication,” the nurse gives approval and prematurely analyzes the client’s motivation without sufficient assessment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. Also note that the correct option is the only option in which the nurse directly addresses the client. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 297). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Adherence, Psychosis HESI Concepts: Adherence, Cognition Awarded 100.0 points out of 100.0 possible points. 3. 3.ID: 22114677587 An acutely ill client with schizophrenia says to the nurse, “He keeps saying that he likes you, and I keep telling him you’re married, but he won’t listen, and I think he’s going to get fresh with you.” Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriate statement? A. “Try not to listen to the voices right now so that I can talk with you.” CorrectB. “I think that you can help him stop his behavior if you concentrate.” C. “Tell him I said to mind his p’s and q’s or I’ll call the police on him.” D. “I think that you’re trying to share your own feelings toward me, but you’re shy.” Rationale: The appropriate statement by the nurse is the one that does not acknowledge the client’s hallucinations. By responding, “I think that you can help him stop his behavior if you concentrate” or “Tell him I said to mind his p’s and q’s or I’ll call the police on him,” the nurse acknowledges the hallucinations. The nurse attempts to interpret the client’s thinking with a statement such as “I think that you’re trying to share your own feelings toward me, but you’re shy.” Test-Taking Strategy: Note the strategic words “most appropriate.” Use your knowledge of therapeutic communication techniques and remember that the nurse should not acknowledge the client’s hallucinations. Also note that the correct option is the only one that encourages realistic verbalization from the client. Review: therapeutic communication techniques with a client who is hallucinating . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 287, 288). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition, Communication Awarded 100.0 points out of 100.0 possible points. 4. 4.ID: 22114677584 A client says to the nurse, “It’s over for me — the whole thing is over.” Which response by the nurse would be therapeutic? A. “What do you mean, ‘The whole thing is over’?” B. “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence.” C. “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential.” D. “Let’s talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members.” Correct Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs the client that the nurse needs to share any information that requires crisis intervention with other staff members. Asking, “What do you mean, ‘The whole thing is over’?” employs paraphrasing, but the message is blunt and closed-ended. In stating, “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictestconfidence,” the nurse uses hysterical exaggeration (at an inappropriate time) and gives incorrect information regarding confidentiality. In stating, “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential,” the nurse uses the therapeutic technique of seeking clarification but does not clarify with the client that the information might need to be shared. Test-Taking Strategy: Eliminate the comparable or alike options that indicate that shared information will be maintained as confidential. To select from the remaining options, focus on the statement that addresses the client’s feelings. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition, Communication Awarded 100.0 points out of 100.0 possible points. 5. 5.ID: 22114677581 The nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse? A. “No, I wasn’t, but I am now, thanks to you.” Correct B. “I hadn’t thought of that, but I can see that you are.” C. “Of course not, but there are days when I think that I should be.” D. “What is suicide going to do for me except get me excommunicated from the church?” Rationale: The client’s response that he is now thinking about suicide is of the greatest concern to the nurse. In making the statement “I hadn’t thought of that, but I can see that you are” the client projects his own thoughts of suicide onto the nurse. In stating, “Of course not, but there are days when I think that I should be,” the client is being sarcastic but is not specifically talking about suicide. In stating, “What is suicide going to do for me except get me excommunicated from the church?” the client indicates that suicide is not an option because of his religious beliefs. Test-Taking Strategy: Note the strategic word “most.” Note the words “but I am now” in the correct option. This is the only option that identifies definite suicidal thoughts. Review: lethality assessment in the suicidal client . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 412). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Mood and Affect, Safety HESI Concepts: Mood & Affect, Safety Awarded 100.0 points out of 100.0 possible points. 6. 6.ID: 22114677578 A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, “Well, I’m feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney.” Which response by the nurse is most appropriate? A. “Good grief! You don’t look organized to me.” B. “Okay, what are you up to today? Your behavior is not appropriate.” C. “You talk about getting organized. Are you thinking of killing yourself?” Correct D. “If you keep behaving like this, you know that I’ll have to tell the health care provider, and we’ll have to seclude you.” Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of suddenly “feeling so much better” and putting affairs in order are key verbal and behavioral clues that the client is planning to commit suicide. In exclaiming, “Good grief! You don’t look organized to me,” the nurse nontherapeutically uses hysterical exaggeration, which minimizes the client’s feelings. In asking, “Okay, what are you up to today? Your behavior is not appropriate,” the nurse uses teasing to determine the client’s behaviors, which minimizes them. Additionally, the nurse is employing a nontherapeutic technique of judging. In stating, “If you keep behaving like this, you know that I’ll have to tell the health care provider and we’ll have to seclude you,” the nurse uses a threat. Test-Taking Strategy: Focus on the information in the question and note the relationship between the words “expressed suicidal ideation” in the question and “thinking of killing yourself” in the correct option. Review: the clues that indicate the potential for suicide . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 316). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Mood and Affect, Safety HESI Concepts: Mood & Affect, Safety Awarded 100.0 points out of 100.0 possible points. 7. 7.ID: 22114677575An adolescent client says, “I’m just a burden to my folks. They wish I’d never been born. My dad told me he had to marry Mom because she got pregnant.” Which response by the nurse would be therapeutic? A. “You’re feeling that your folks didn’t want you, but they chose to marry and have you.” Correct B. “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right.” C. “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted.” D. “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him.” Rationale: In the correct option, the nurse uses reflection to explore the client’s lethality risk and then uses reframing to determine whether the client is able to view what happened in a different way. In suggesting, “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right,” the nurse uses paraphrasing but is then nontherapeutic in trying to persuade the client to talk to the parents. In suggesting, “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted,” the nurse uses a parental approach, which may be threatening to the client, who seems to have been unable to talk with the parents before now. In stating, “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him,” the nurse offers an opinion about the client’s father and then provides false reassurance. Test-Taking Strategy: Eliminate the comparable or alike options that address discussing the client’s feelings with the parents. In selecting from the remaining options, remember to focus on the client’s feelings. This will direct you to the correct option. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 683). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental Awarded 100.0 points out of 100.0 possible points. 8. 8.ID: 22114677572 A client says to the nurse, “I’ve ruined my life. I left college with only a few credits to go. I keep telling myself that I’m going to make it as a writer, but I’ll be a loser and a nothing for the rest of my life.” Which response by the nurse is therapeutic? A. “What are you saying? Sounds like you need to pull yourself together and go back to school.” B. “Having faith in yourself is one thing, but looking at your alternatives realistically is another.”C. “You seem to be saying that your choices are final and that you’ve lost any other opportunities.” Correct D. “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get.” Rationale: The client in this question is engaging in catastrophizing rather than reframing and viewing other alternatives. The task for the nurse is to assess the lethality of the client’s situation and to help the client feel empowered to take another course of action and find the perseverance and confidence to do so. The therapeutic response here is the one that is nonjudgmental. In responding, “What are you saying? Sounds like you need to pull yourself together and go back to school,” or “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get,” the nurse communicates with the client as a parent, using a judging style. In stating, “Having faith in yourself is one thing, but looking at your options realistically is another,” the nurse communicates prematurely and gives advice. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the comparable or alike options in that the nurse uses a judging style to deal with the client. To select from the remaining options, eliminate the option that is nontherapeutic in that the nurse gives advice. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 94). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Mood and Affect HESI Concepts: Communication, Mood & Affect Awarded 100.0 points out of 100.0 possible points. 9. 9.ID: 22114677566 A client who has twice attempted suicide says, “If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do.” Which response should the nurse give to the client? A. “Of course you can’t be left alone to get on with what you want to do.” B. “Okay, go ahead and do whatever you want to do. Human beings have free will.” C. “You’ve tried to end your life twice, yet you feel that everyone should let you do what you want to do?” Correct D. “Sounds like you’re angry with people for caring enough about you to try to keep you from hurting yourself.” Rationale: The therapeutic response is the one that offers reflection, which permits the client to observe the content of what she is saying. In stating, “Of course, you can’t be left alone to get on with what you want to do,” the nurse makes a response that is socialand belittles the client’s feelings. In stating, “Okay, go ahead and do whatever you want to do. Human beings have free will,” the nurse makes a response that seems sarcastic and angry; it is also judgmental and biased. In stating, “Sounds like you’re angry with people for caring enough about you to try to keep you from hurting yourself,” the nurse makes a premature judgment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only response that is therapeutic in that it uses reflection. Review: therapeutic communication techniques . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 413, 415, 416). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Safety HESI Concepts: Communication, Safety Awarded 100.0 points out of 100.0 possible points. 10. 10.ID: 22114677563 A client experiencing homelessness, with an antisocial disorder, is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, “I need to be hospitalized. It’s getting cold out, and I need a warm bed. If you don’t get me into a hospital, I’ll jump off a bridge.” Which nursing intervention would be therapeutic? A. Sending the client to the psychiatric hospital intake center immediately for evaluation B. Asking the police to pick the client up and arrest him for vagrancy, as they should have done immediately C. Discharging the client with a follow-up appointment for the next day and guaranteeing him a hospital bed if he shows up D. Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide [Show Less]
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HESI Extra Credit Module 4 Exam with Rationale [NEW!!] 2022 (49 Pages) 100% CORRECT
MODULE 4 Exam Questions 1. 1.ID: 9476884715 A schizophrenic client says, “I’m away for the day ... but don’t think we should play or do we have fe... [Show More] et of clay?” Which alteration in the client’s speech does the nurse document? A. Neologism B. Word salad C. Clang association Correct D. Associative looseness Rationale: Clang association is the meaningless rhyming of words in which the rhyming is more important than the context of the words. A neologism is a made-up word that has meaning only to the client. Word salad is the term for a mixture of meaningless phrases, either to the client or to the listener. Associative looseness is a term used to describe schizophrenic speech in which connections and threads are interrupted or missing. Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client with schizophrenia is needed to answer this question. Focus on the subject in the question, the meaningless rhyming of words. Review: these speech patterns . . 2. 2.ID: 9476884735 A client with schizophrenia and his parents are meeting with the nurse. One of the young man’s parents says to the nurse, “We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he’s had another relapse, and we can’t understand why he stopped his medication.” Which response by the nurse is appropriate? A. Telling the parents, “Medication noncompliance is the most frequent reason that people with this diagnosis relapse.” B. Telling the parents, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” C. Asking the client, “How can we help you to take your medicine or to tell us when you’re having problems so that your medication can be adjusted?” Correct D. Saying to the parents, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication.” Rationale: The therapeutic response is the one in which the nurse models speaking directly to the client. This facilitates further assessment of the situation and helps elicit the causes of and motivations for the client’s behavior for both the nurse and the family. In the correct option, the nurse also seeks clarification of the degree of openness and mutuality felt by the client and his family toward each other. The nurse provides information to the family when stating that noncompliance is the most frequent reason for relapse in people with this diagnosis. However, the statement is nontherapeutic at this time because it does not facilitate the expression of feelings. The nurse uses a superego style of communication when stating, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” The content of this statement may be true, but it is nontherapeutic in that it carries a threatening message and may prevent the family fromtrusting the nurse. By stating, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication,” the nurse gives approval and prematurely analyzes the client’s motivation without sufficient assessment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. Also note that the correct option is the only option in which the nurse directly addresses the client. Review: therapeutic communication techniques . . 3. 3.ID: 9476898981 An acutely ill schizophrenic client says to the nurse, “He keeps saying that he likes you, and I keep telling him you’re married, but he won’t listen, and I think he’s going to get fresh with you.” Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriate statement? A. “Try not to listen to the voices right now so that I can talk with you.” Correct B. “I think that you can help him stop his behavior if you concentrate.” C. “Tell him I said to mind his p’s and q’s or I’ll call the police on him.” D. “I think that you’re trying to share your own feelings toward me, but you’re shy.” Incorrect Rationale: The appropriate statement by the nurse is the one that does not acknowledge the client’s hallucinations. By responding, “I think that you can help him stop his behavior if you concentrate” or “Tell him I said to mind his p’s and q’s or I’ll call the police on him,” the nurse acknowledges the hallucinations. The nurse attempts to interpret the client’s thinking with a statement such as “I think that you’re trying to share your own feelings toward me, but you’re shy.” Test-Taking Strategy: Note the strategic words “most appropriate.” Use your knowledge of therapeutic communication techniques and remember that the nurse should not acknowledge the client’s hallucinations. Also note that the correct option is the only one that encourages realistic verbalization from the client. Review: therapeutic communication techniques with a client who is hallucinating . 4. 4.ID: 9476882056 A client says to the nurse, “It’s over for me — the whole thing is over.” Which response by the nurse would be therapeutic? A. “What do you mean, ‘The whole thing is over’?” Incorrect B. “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence.” C. “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential.” D. “Let’s talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members.” Correct Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs the client that the nurse needs to share any information that requires crisis intervention with other staff members. Asking, “What do you mean, ‘The whole thing is over’?” employs paraphrasing, but themessage is blunt and closed-ended. In stating, “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence,” the nurse uses hysterical exaggeration (at an inappropriate time) and gives incorrect information regarding confidentiality. In stating, “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential,” the nurse uses the therapeutic technique of seeking clarification but does not clarify with the client that the information might need to be shared. Test-Taking Strategy: Eliminate the options that are comparable or alike and indicate that shared information will be maintained as confidential. To select from the remaining options, focus on the statement that addresses the client’s feelings. Review: therapeutic communication techniques . . 5. 5.ID: 9476895020 The nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse? A. “No, I wasn’t, but I am now, thanks to you.” Correct B. “I hadn’t thought of that, but I can see that you are.” C. “Of course not, but there are days when I think that I should be.” D. “What is suicide going to do for me except get me excommunicated from the church?” Rationale: The client’s response that he is now thinking about suicide is of the greatest concern to the nurse. In making the statement “I hadn’t thought of that, but I can see that you are” the client projects his own thoughts of suicide onto the nurse. In stating, “Of course not, but there are days when I think that I should be,” the client is being sarcastic but is not specifically talking about suicide. In stating, “What is suicide going to do for me except get me excommunicated from the church?” the client indicates that suicide is not an option because of his religious beliefs. Test-Taking Strategy: Note the strategic word “most.” Note the words “but I am now” in the correct option. This is the only option that identifies definite suicidal thoughts. Review: lethality assessment in the suicidal client . . 6. 6.ID: 9476886322 A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, “Well, I’m feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney.” Which response by the nurse is most appropriate? A. “Good grief! You don’t look organized to me.” B. “Okay, what are you up to today? Your behavior is not appropriate.” C. “You talk about getting organized. Are you thinking of killing yourself?” Correct D. “If you keep behaving like this, you know that I’ll have to tell the health care provider, and we’ll have to seclude you.” Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of suddenly “feeling so much better” and putting affairs in order are key verbal and behavioral clues that the client is planning to commit suicide. In exclaiming, “Good grief! You don’t look organized to me,” thenurse nontherapeutically uses hysterical exaggeration, which minimizes the client’s feelings. In asking, “Okay, what are you up to today? Your behavior is not appropriate,” the nurse uses teasing to determine the client’s behaviors, which minimizes them. Additionally, the nurse is employing a nontherapeutic technique of judging. In stating, “If you keep behaving like this, you know that I’ll have to tell the health care provider and we’ll have to seclude you,” the nurse uses a threat. Test-Taking Strategy: Focus on the information in the question and note the relationship between the words “expressed suicidal ideation” in the question and “thinking of killing yourself” in the correct option. Review: the clues that indicate the potential for suicide . . 7. 7.ID: 9476896317 An adolescent client says, “I’m just a burden to my folks. They wish I’d never been born. My dad told me he had to marry Mom because she got pregnant.” Which response by the nurse would be therapeutic? A. “You’re feeling that your folks didn’t want you, but they chose to marry and have you.” Correct B. “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right.” C. “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted.” D. “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him.” Rationale: In the correct option, the nurse uses reflection to explore the client’s lethality risk and then uses reframing to determine whether the client is able to view what happened in a different way. In suggesting, “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right,” the nurse uses paraphrasing but is then nontherapeutic in trying to persuade the client to talk to the parents. In suggesting, “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted,” the nurse uses a parental approach, which may be threatening to the client, who seems to have been unable to talk with the parents before now. In stating, “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him,” the nurse offers an opinion about the client’s father and then provides false reassurance. Test-Taking Strategy: Eliminate the options that are comparable or alike and address discussing the client’s feelings with the parents. In selecting from the remaining options, remember to focus on the client’s feelings. This will direct you to the correct option. Review: therapeutic communication techniques . . 8. 8.ID: 9476897762 A client says to the nurse, “I’ve ruined my life. I left college with only a few credits to go. I keep telling myself that I’m going to make it as a writer, but I’ll be a loser and a nothing for the rest of my life.” Which response by the nurse is therapeutic?A. “What are you saying? Sounds like you need to pull yourself together and go back to school.” B. “Having faith in yourself is one thing, but looking at your alternatives realistically is another.” C. “You seem to be saying that your choices are final and that you’ve lost any other opportunities.” Correct D. “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get.” Rationale: The client in this question is engaging in catastrophizing rather than reframing and viewing other alternatives. The task for the nurse is to assess the lethality of the client’s situation and to help the client feel empowered to take another course of action and find the perseverance and confidence to do so. The therapeutic response here is the one that is nonjudgmental. In responding, “What are you saying? Sounds like you need to pull yourself together and go back to school,” or “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get,” the nurse communicates with the client as a parent, using a judging style. In stating, “Having faith in yourself is one thing, but looking at your options realistically is another,” the nurse communicates prematurely and gives advice. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the options that are comparable or alike in that the nurse uses a judging style to deal with the client. To select from the remaining options, eliminate the option that is nontherapeutic in that the nurse gives advice. Review: therapeutic communication techniques . . 9. 9.ID: 9476898996 A client who has twice attempted suicide says, “If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do.” Which response should the nurse give to the client? A. “Of course you can’t be left alone to get on with what you want to do.” B. “Okay, go ahead and do whatever you want to do. Human beings have free will.” C. “You’ve tried to end your life twice, yet you feel that everyone should let you do what you want to do?” Correct D. “Sounds like you’re angry with people for caring enough about you to try to keep you from hurting yourself.” Incorrect Rationale: The therapeutic response is the one that offers reflection, which permits the client to observe the content of what she is saying. In stating, “Of course, you can’t be left alone to get on with what you want to do,” the nurse makes a response that is social and belittles the client’s feelings. In stating, “Okay, go ahead and do whatever you want to do. Human beings have free will,” the nurse makes a response that seems sarcastic and angry; it is also judgmental and biased. In stating, “Sounds like you’re angry with people for caring enough about you to try to keep you from hurting yourself,” the nurse makes a premature judgment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only response that is therapeutic in that it uses reflection. Review: therapeutic communication techniques .. 10. 10.ID: 9476887480 A homeless client with an antisocial disorder is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, “I need to be hospitalized. It’s getting cold out, and I need a warm bed. If you don’t get me into a hospital, I’ll jump off a bridge.” Which nursing intervention would be therapeutic? A. Sending the client to the psychiatric hospital intake center immediately for evaluation B. Asking the police to pick the client up and arrest him for vagrancy, as they should have done immediately C. Discharging the client with a follow-up appointment for the next day and guaranteeing him a hospital bed if he shows up D. Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide [Show Less]
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HESI Extra Credit Module 4 Exam with Rationale [NEW!!] 2022 (74 Pages) 100% CORRECT
Module 4 Exam 1. 1.ID: 22114677593 A client with schizophrenia says, “I’m away for the day ... but don’t think we should play or do we have feet o... [Show More] f clay?” Which alteration in the client’s speech does the nurse document? A. Neologism B. Word salad C. Clang association Correct D. Associative looseness Rationale: Clang association is the meaningless rhyming of words in which the rhyming is more important than the context of the words. A neologism is a made-up word that has meaning only to the client. Word salad is the term for a mixture of meaningless phrases, either to the client or to the listener. Associative looseness is a term used to describe schizophrenic speech in which connections and threads are interrupted or missing. Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client with schizophrenia is needed to answer this question. Focus on the subject in the question, the meaningless rhyming of words. Review: these speech patterns . Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 281). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition Awarded 100.0 points out of 100.0 possible points. 2. 2.ID: 22114677590 A client with schizophrenia and his parents are meeting with the nurse. One of the young man’s parents says to the nurse, “We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he’s had another relapse, and we can’t understand why he stopped his medication.” Which response by the nurse is appropriate? A. Telling the parents, “Medication noncompliance is the most frequent reason that people with this diagnosis relapse.” B. Telling the parents, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.”C. Asking the client, “How can we help you to take your medicine or to tell us when you’re having problems so that your medication can be adjusted?” Correct D. Saying to the parents, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication.” Rationale: The therapeutic response is the one in which the nurse models speaking directly to the client. This facilitates further assessment of the situation and helps elicit the causes of and motivations for the client’s behavior for both the nurse and the family. In the correct option, the nurse also seeks clarification of the degree of openness and mutuality felt by the client and his family toward each other. The nurse provides information to the family when stating that noncompliance is the most frequent reason for relapse in people with this diagnosis. However, the statement is nontherapeutic at this time because it does not facilitate the expression of feelings. The nurse uses a superego style of communication when stating, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” The content of this statement may be true, but it is nontherapeutic in that it carries a threatening message and may prevent the family from trusting the nurse. By stating, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication,” the nurse gives approval and prematurely analyzes the client’s motivation without sufficient assessment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. Also note that the correct option is the only option in which the nurse directly addresses the client. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 297). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Adherence, Psychosis HESI Concepts: Adherence, Cognition Awarded 100.0 points out of 100.0 possible points. 3. 3.ID: 22114677587 An acutely ill client with schizophrenia says to the nurse, “He keeps saying that he likes you, and I keep telling him you’re married, but he won’t listen, and I think he’s going to get fresh with you.” Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriate statement? A. “Try not to listen to the voices right now so that I can talk with you.” CorrectB. “I think that you can help him stop his behavior if you concentrate.” C. “Tell him I said to mind his p’s and q’s or I’ll call the police on him.” D. “I think that you’re trying to share your own feelings toward me, but you’re shy.” Rationale: The appropriate statement by the nurse is the one that does not acknowledge the client’s hallucinations. By responding, “I think that you can help him stop his behavior if you concentrate” or “Tell him I said to mind his p’s and q’s or I’ll call the police on him,” the nurse acknowledges the hallucinations. The nurse attempts to interpret the client’s thinking with a statement such as “I think that you’re trying to share your own feelings toward me, but you’re shy.” Test-Taking Strategy: Note the strategic words “most appropriate.” Use your knowledge of therapeutic communication techniques and remember that the nurse should not acknowledge the client’s hallucinations. Also note that the correct option is the only one that encourages realistic verbalization from the client. Review: therapeutic communication techniques with a client who is hallucinating . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 287, 288). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition, Communication Awarded 100.0 points out of 100.0 possible points. 4. 4.ID: 22114677584 A client says to the nurse, “It’s over for me — the whole thing is over.” Which response by the nurse would be therapeutic? A. “What do you mean, ‘The whole thing is over’?” B. “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence.” C. “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential.” D. “Let’s talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members.” Correct Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs the client that the nurse needs to share any information that requires crisis intervention with other staff members. Asking, “What do you mean, ‘The whole thing is over’?” employs paraphrasing, but the message is blunt and closed-ended. In stating, “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictestconfidence,” the nurse uses hysterical exaggeration (at an inappropriate time) and gives incorrect information regarding confidentiality. In stating, “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential,” the nurse uses the therapeutic technique of seeking clarification but does not clarify with the client that the information might need to be shared. Test-Taking Strategy: Eliminate the comparable or alike options that indicate that shared information will be maintained as confidential. To select from the remaining options, focus on the statement that addresses the client’s feelings. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition, Communication Awarded 100.0 points out of 100.0 possible points. 5. 5.ID: 22114677581 The nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse? A. “No, I wasn’t, but I am now, thanks to you.” Correct B. “I hadn’t thought of that, but I can see that you are.” C. “Of course not, but there are days when I think that I should be.” D. “What is suicide going to do for me except get me excommunicated from the church?” Rationale: The client’s response that he is now thinking about suicide is of the greatest concern to the nurse. In making the statement “I hadn’t thought of that, but I can see that you are” the client projects his own thoughts of suicide onto the nurse. In stating, “Of course not, but there are days when I think that I should be,” the client is being sarcastic but is not specifically talking about suicide. In stating, “What is suicide going to do for me except get me excommunicated from the church?” the client indicates that suicide is not an option because of his religious beliefs. Test-Taking Strategy: Note the strategic word “most.” Note the words “but I am now” in the correct option. This is the only option that identifies definite suicidal thoughts. Review: lethality assessment in the suicidal client . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 412). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Mood and Affect, Safety HESI Concepts: Mood & Affect, Safety Awarded 100.0 points out of 100.0 possible points. 6. 6.ID: 22114677578 A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, “Well, I’m feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney.” Which response by the nurse is most appropriate? A. “Good grief! You don’t look organized to me.” B. “Okay, what are you up to today? Your behavior is not appropriate.” C. “You talk about getting organized. Are you thinking of killing yourself?” Correct D. “If you keep behaving like this, you know that I’ll have to tell the health care provider, and we’ll have to seclude you.” Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of suddenly “feeling so much better” and putting affairs in order are key verbal and behavioral clues that the client is planning to commit suicide. In exclaiming, “Good grief! You don’t look organized to me,” the nurse nontherapeutically uses hysterical exaggeration, which minimizes the client’s feelings. In asking, “Okay, what are you up to today? Your behavior is not appropriate,” the nurse uses teasing to determine the client’s behaviors, which minimizes them. Additionally, the nurse is employing a nontherapeutic technique of judging. In stating, “If you keep behaving like this, you know that I’ll have to tell the health care provider and we’ll have to seclude you,” the nurse uses a threat. Test-Taking Strategy: Focus on the information in the question and note the relationship between the words “expressed suicidal ideation” in the question and “thinking of killing yourself” in the correct option. Review: the clues that indicate the potential for suicide . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 316). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Mood and Affect, Safety HESI Concepts: Mood & Affect, Safety Awarded 100.0 points out of 100.0 possible points. 7. 7.ID: 22114677575An adolescent client says, “I’m just a burden to my folks. They wish I’d never been born. My dad told me he had to marry Mom because she got pregnant.” Which response by the nurse would be therapeutic? A. “You’re feeling that your folks didn’t want you, but they chose to marry and have you.” Correct B. “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right.” C. “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted.” D. “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him.” Rationale: In the correct option, the nurse uses reflection to explore the client’s lethality risk and then uses reframing to determine whether the client is able to view what happened in a different way. In suggesting, “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right,” the nurse uses paraphrasing but is then nontherapeutic in trying to persuade the client to talk to the parents. In suggesting, “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted,” the nurse uses a parental approach, which may be threatening to the client, who seems to have been unable to talk with the parents before now. In stating, “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him,” the nurse offers an opinion about the client’s father and then provides false reassurance. Test-Taking Strategy: Eliminate the comparable or alike options that address discussing the client’s feelings with the parents. In selecting from the remaining options, remember to focus on the client’s feelings. This will direct you to the correct option. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 683). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Family Dynamics HESI Concepts: Communication, Developmental Awarded 100.0 points out of 100.0 possible points. 8. 8.ID: 22114677572 A client says to the nurse, “I’ve ruined my life. I left college with only a few credits to go. I keep telling myself that I’m going to make it as a writer, but I’ll be a loser and a nothing for the rest of my life.” Which response by the nurse is therapeutic? A. “What are you saying? Sounds like you need to pull yourself together and go back to school.” B. “Having faith in yourself is one thing, but looking at your alternatives realistically is another.”C. “You seem to be saying that your choices are final and that you’ve lost any other opportunities.” Correct D. “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get.” Rationale: The client in this question is engaging in catastrophizing rather than reframing and viewing other alternatives. The task for the nurse is to assess the lethality of the client’s situation and to help the client feel empowered to take another course of action and find the perseverance and confidence to do so. The therapeutic response here is the one that is nonjudgmental. In responding, “What are you saying? Sounds like you need to pull yourself together and go back to school,” or “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get,” the nurse communicates with the client as a parent, using a judging style. In stating, “Having faith in yourself is one thing, but looking at your options realistically is another,” the nurse communicates prematurely and gives advice. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the comparable or alike options in that the nurse uses a judging style to deal with the client. To select from the remaining options, eliminate the option that is nontherapeutic in that the nurse gives advice. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31, 94). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Mood and Affect HESI Concepts: Communication, Mood & Affect Awarded 100.0 points out of 100.0 possible points. 9. 9.ID: 22114677566 A client who has twice attempted suicide says, “If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do.” Which response should the nurse give to the client? A. “Of course you can’t be left alone to get on with what you want to do.” B. “Okay, go ahead and do whatever you want to do. Human beings have free will.” C. “You’ve tried to end your life twice, yet you feel that everyone should let you do what you want to do?” Correct D. “Sounds like you’re angry with people for caring enough about you to try to keep you from hurting yourself.” [Show Less]
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HESI Extra Credit Module 4 Exam with Rationale [NEW!!] 2022 (72 Pages) 100% CORRECT
Module 4 1.ID: 9476884715 A schizophrenic client says, “I’m away for the day ... but don’t think we should play or do we have feet of clay?” Whi... [Show More] ch alteration in the client’s speech does the nurse document? · Word salad · Associative looseness · Clang association Correct · Neologism Rationale: Clang association is the meaningless rhyming of words in which the rhyming is more important than the context of the words. A neologism is a made-up word that has meaning only to the client. Word salad is the term for a mixture of meaningless phrases, either to the client or to the listener. Associative looseness is a term used to describe schizophrenic speech in which connections and threads are interrupted or missing. Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client with schizophrenia is needed to answer this question. Focus on the subject in the question, the meaningless rhyming of words. Review: these speech patterns . Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 281). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Psychosis HESI Concepts: Clinical Decision-Making/Clinical Judgment, Cognition—Psychosis Awarded 1.0 points out of 1.0 possible points. 2.ID: 9476884735 A client with schizophrenia and his parents are meeting with the nurse. One of the young man’s parents says to the nurse, “We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he’s had another relapse, and we can’t understand why he stopped his medication.” Which response by the nurse is appropriate? · Telling the parents, “Medication noncompliance is the most frequent reason that people with this diagnosis relapse.” · Saying to the parents, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication.” · Asking the client, “How can we help you to take your medicine or to tell us when you’re having problems so that your medication can be adjusted?” Correct· Telling the parents, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” Rationale: The therapeutic response is the one in which the nurse models speaking directly to the client. This facilitates further assessment of the situation and helps elicit the causes of and motivations for the client’s behavior for both the nurse and the family. In the correct option, the nurse also seeks clarification of the degree of openness and mutuality felt by the client and his family toward each other. The nurse provides information to the family when stating that noncompliance is the most frequent reason for relapse in people with this diagnosis. However, the statement is nontherapeutic at this time because it does not facilitate the expression of feelings. The nurse uses a superego style of communication when stating, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” The content of this statement may be true, but it is nontherapeutic in that it carries a threatening message and may prevent the family from trusting the nurse. By stating, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication,” the nurse gives approval and prematurely analyzes the client’s motivation without sufficient assessment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. Also note that the correct option is the only option in which the nurse directly addresses the client. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 297). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Adherence, Psychosis HESI Concepts: Behaviors—Adherence, Cognition—Psychosis Awarded 1.0 points out of 1.0 possible points. 3.ID: 9476898981 An acutely ill schizophrenic client says to the nurse, “He keeps saying that he likes you, and I keep telling him you’re married, but he won’t listen, and I think he’s going to get fresh with you.” Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriate statement? · “Try not to listen to the voices right now so that I can talk with you.” Correct · “Tell him I said to mind his p’s and q’s or I’ll call the police on him.” · “I think that you can help him stop his behavior if you concentrate.” · “I think that you’re trying to share your own feelings toward me, but you’re shy.” Rationale: The appropriate statement by the nurse is the one that does not acknowledge the client’s hallucinations. By responding, “I think that you can help him stop hisbehavior if you concentrate” or “Tell him I said to mind his p’s and q’s or I’ll call the police on him,” the nurse acknowledges the hallucinations. The nurse attempts to interpret the client’s thinking with a statement such as “I think that you’re trying to share your own feelings toward me, but you’re shy.” Test-Taking Strategy: Note the strategic words “most appropriate.” Use your knowledge of therapeutic communication techniques and remember that the nurse should not acknowledge the client’s hallucinations. Also note that the correct option is the only one that encourages realistic verbalization from the client. Review: therapeutic communication techniques with a client who is hallucinating . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (pp. 287, 288). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition—Psychosis, Communication Awarded 1.0 points out of 1.0 possible points. 4.ID: 9476882056 A client says to the nurse, “It’s over for me — the whole thing is over.” Which response by the nurse would be therapeutic? · “What do you mean, ‘The whole thing is over’?” · “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential.” Incorrect · “Let’s talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members.” Correct · “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence.” Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs the client that the nurse needs to share any information that requires crisis intervention with other staff members. Asking, “What do you mean, ‘The whole thing is over’?” employs paraphrasing, but the message is blunt and closed-ended. In stating, “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence,” the nurse uses hysterical exaggeration (at an inappropriate time) and gives incorrect information regarding confidentiality. In stating, “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential,” the nurse uses the therapeutic technique of seeking clarification but does not clarify with the client that the information might need to be shared. Test-Taking Strategy: Eliminate the options that are comparable or alike and indicate that shared information will be maintained as confidential. To select from the remainingoptions, focus on the statement that addresses the client’s feelings. Review: therapeutic communication techniques . Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Psychosis, Safety HESI Concepts: Cognition—Psychosis, Safety Awarded 0.0 points out of 1.0 possible points. 5.ID: 9476895020 The nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse? · “I hadn’t thought of that, but I can see that you are.” · “No, I wasn’t, but I am now, thanks to you.” Correct · “Of course not, but there are days when I think that I should be.” Incorrect · “What is suicide going to do for me except get me excommunicated from the church?” Rationale: The client’s response that he is now thinking about suicide is of the greatest concern to the nurse. In making the statement “I hadn’t thought of that, but I can see that you are” the client projects his own thoughts of suicide onto the nurse. In stating, “Of course not, but there are days when I think that I should be,” the client is being sarcastic but is not specifically talking about suicide. In stating, “What is suicide going to do for me except get me excommunicated from the church?” the client indicates that suicide is not an option because of his religious beliefs. Test-Taking Strategy: Note the strategic word “most.” Note the words “but I am now” in the correct option. This is the only option that identifies definite suicidal thoughts. Review: lethality assessment in the suicidal client . References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (p. 412). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Mental Health Giddens Concepts: Psychosis, Safety HESI Concepts: Cognition—Psychosis, Safety Awarded 0.0 points out of 1.0 possible points. 6.ID: 9476886322 A client who has expressed suicidal ideation in the past says to the nurse, while shufflingseveral documents in an effort to organize them, “Well, I’m feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney.” Which response by the nurse is most appropriate? · “Good grief! You don’t look organized to me.” · “You talk about getting organized. Are you thinking of killing yourself?” Correct · “If you keep behaving like this, you know that I’ll have to tell the health care provider, and we’ll have to seclude you.” · “Okay, what are you up to today? Your behavior is not appropriate.” [Show Less]
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HESI Extra Credit Module 5 Exam Management of Care [NEW!!] 2022 (107 Pages) 100% CORRECT
A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and ot... [Show More] her possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? Justice Fidelity Autonomy Nonmaleficence Correct Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Healthcare professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action. Test-Taking Strategy: Use the process of elimination and think about the definition of each item in the options. Note the relationship of the words “least possible harm” in the question and the definition of nonmaleficence. Review the principles of healthcare ethics if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 314). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment SendIntegrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 0.0 points out of 1.0 possible points. 2.ID: 383691785 Which action by the nurse represents the ethical principle of beneficence? The nurse upholds a client’s decision to refuse chemotherapy for lung cancer. The nurse follows a plan of care designed to relieve pain in a client with cancer. The nurse administers an immunization to a child even though it may cause discomfort. Correct The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Fidelity is keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that you are agreeing to respect that person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients. Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action to help others will direct you to the correct option. Review the principles of healthcare ethics if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 314). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Awarded 0.0 points out of 1.0 possible points. 3.ID: 383693578 The nursing instructor asks a student to name an example of false imprisonment. Which of the following situations reflects a violation of this client right? Performing a procedure without consent Telling the client that he or she may not leave the hospital Correct Threatening to give a client a medication against his or her will Observing the provision of care to the client without the client’s permission Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy. Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of the subject and the words in the correct option. If you had difficulty with this question, review the concept of false imprisonment. References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends & management (4th ed., pp. 175, 176). St. Louis: Mosby. Zerwekh, J., & Claborn, J. (2009). Nursing today: Transition and trends (6th ed., p. 424). Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and LearningContent Area: Ethical/Legal Awarded 0.0 points out of 1.0 possible points. 4.ID: 383692438 A nurse and a nursing assistant enter a client’s room to provide care and find the client lying on the floor. The nurse should first: Ask the nursing assistant to complete an incident report Check the client’s level of consciousness and vital signs Correct Ask the nursing assistant to assist in getting the client back to bed Contact the unit secretary on the intercom and ask that the client’s physician be called Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client’s level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to move the client, the nurse should ask the nursing assistant to assist in getting the client into bed. The nurse should then contact the physician and file an incident report. Test-Taking Strategy: Note the strategic word “first.” Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Remember to always assess the client first if a client sustains a fall. Review client injuries and procedures for filing incident reports if you had difficulty with this question. References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient–centered collaborative care (6th ed., p. 180). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 403). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/ImplementationContent Area: Delegating/Prioritizing Awarded 0.0 points out of 1.0 possible points. 5.ID: 383691791 Which of the following actions exemplifies the use of evidence-based practice in the delivery of client care? Donning sterile gloves to change an abdominal wound dressing Correct Encouraging a client to take an herbal substance to treat his insomnia Advising a client to agree to the treatment recommended by her physician Taking a rectal temperature from a client for whom bleeding precautions have been instituted Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing reflects evidence-based practice, because it prevents the entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based practice. Taking an herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to advise a client to agree to a treatment. Because of the risk of injury to the rectal mucosa, rectal temperature-taking is avoided in the client for whom bleeding precautions have been instituted. Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall the definition of evidence-based practice and note the words “sterile gloves” in the correct option. Review the situations that reflect evidence-based practice if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 54-60). St. Louis: Mosby. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/ImplementationContent Area: Leadership/Management Awarded 0.0 points out of 1.0 possible points. 6.ID: 383693538 The registered nurse has accepted a new position as case manager in a hospital. Which of the following responsibilities are part of the nurse’s new role? Select all that apply. Evaluating and updating the plan of care as needed Correct Prescribing treatments specific to the client’s needs Assessing the client’s needs for home supplies and equipment Correct Coordinating consultations and referrals to facilitate discharge Correct Establishing a safe and cost-effective plan of care with the client Correct Rationale: A case manager is a nurse who assumes responsibility for coordinating the client's care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and cost-effective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s diagnosis, self-care ability, and prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments. Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the word “prescribing” in the incorrect option. It is not within the role of the nurse to prescribe. Review the responsibilities of the case manager if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 21). St. Louis: Mosby.Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Awarded 0.0 points out of 1.0 possible points. 7.ID: 383692428 The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which of the following actions should the auditing nurse plan to perform in this type of audit? Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay Correct Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “looking back,” audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits.Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the word “retrospective” in the question and the description in the correct option. Review the procedures for quality improvement and retrospective and concurrent audits if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 64, 65). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Awarded 0.0 points out of 1.0 possible points. 8.ID: 383692448 A nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace? Ask the client whether the necklace is gold Ask the client for permission to lock the necklace in the hospital safe Correct Ask the client to remove the necklace and place it in the top drawer of the bedside table Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure Rationale: When a client has valuables, the nurse should give them to a family member or secure them for safekeeping. Most healthcare institutions require that a client sign a release form that frees the institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not safeguard the client’s necklace. Valuables may be locked in a designated location such as the hospital’s safe. Removing the necklace and putting it in a drawer does not safeguard it. Asking the client whether the necklace is gold is inappropriate and unrelated to the subject.Test-Taking Strategy: Use the process of elimination and focus on the subject, safeguarding the client’s necklace. Focusing on the subject and noting the word “lock” in the correct option will help you answer correctly. Review the procedures for safeguarding a client’s valuables if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 1387). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 0.0 points out of 1.0 possible points. 9.ID: 383692487 A nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. The nurse should: Tape the wedding band in place Explain to the client why the wedding band must be removed Correct Ask the client whether she would like to remove the wedding band or wear it to surgery Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery [Show Less]
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HESI Extra Credit Module 5 Exam Management of Care [NEW!!] 2022 (50 Pages) 100% CORRECT
MODULE 5 Questions 1. 1.ID: 9477027534 A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the ri... [Show More] sks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? A. Justice B. Fidelity C. Autonomy D. Nonmaleficence Correct Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Healthcare professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action. Test-Taking Strategy: Focus on the subject - the ethical principle being utilized. Recall the definition of each item in the options. Note the relationship of the words “least possible harm” in the question and the definition of nonmaleficence. Review: principles of healthcare ethics. . 2. 2.ID: 9477024200 Which action by the nurse represents the ethical principle of beneficence? A. The nurse upholds a client’s decision to refuse chemotherapy for lung cancer. Incorrect B. The nurse follows a plan of care designed to relieve pain in a client with cancer. C. The nurse administers an immunization to a child even though it may cause discomfort. Correct D. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Fidelity is keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that you are agreeing to respect that person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients. Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action to help others will direct you to the correct option. Review: the principles of healthcare ethics . . 3. 3.ID: 9477029451The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right? A. Performing a procedure without consent B. Telling the client that he or she may not leave the hospital Correct C. Threatening to give a client a medication against his or her will D. Observing the provision of care to the client without the client’s permission Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy. Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of the subject and the words in the correct option. Review: the concept of false imprisonment. . 4. 4.ID: 9477017756 The nurse and an unlicensed assistive personnel (UAP)enter a client’s room to provide care and find the client lying on the floor. Which action should the nurse take first? A. Ask the nursing assistant to complete an incident report B. Check the client’s level of consciousness and vital signs Correct C. Ask the nursing assistant to assist in getting the client back to bed D. Contact the unit secretary on the intercom and ask that the client’s health care provider be called Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client’s level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to move the client, the nurse should ask the UAP to assist in getting the client into bed. The nurse should then contact the health care provider and file an incident report. Test-Taking Strategy: Note the strategic word “first.” Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Remember to always assess the client first if a client sustains a fall. Review: client injuries and procedures for filing incident reports . . 5. 5.ID: 9477020809 Which action exemplifies the use of evidence-based practice in the delivery of client care? A. Donning sterile gloves to change an abdominal wound dressing Correct B. Encouraging a client to take an herbal substance to treat his insomnia C. Advising a client to agree to the treatment recommended by her health care provider D. Taking a rectal temperature from a client for whom bleeding precautions have been institutedRationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing reflects evidence-based practice, because it prevents the entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based practice. Taking an herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to advise a client to agree to a treatment. Because of the risk of injury to the rectal mucosa, rectal temperature-taking is avoided in the client for whom bleeding precautions have been instituted. Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall the definition of evidence-based practice and note the words “sterile gloves” in the correct option. Review: the situations that reflect evidence-based practice . . 6. 6.ID: 9477020817 The registered nurse has accepted a new position as case manager in a hospital. Which responsibilities are part of the nurse’s new role? Select all that apply. A. Evaluating and updating the plan of care as needed Correct B. Prescribing treatments specific to the client’s needs C. Assessing the client’s needs for home supplies and equipment Correct D. Coordinating consultations and referrals to facilitate discharge Correct E. Establishing a safe and cost-effective plan of care with the client Correct Rationale: A case manager is a nurse who assumes responsibility for coordinating the client's care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and cost-effective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s diagnosis, self-care ability, and prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments. Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the word “prescribing” in the incorrect option. It is not within the role of the nurse to prescribe. Review: the responsibilities of the case manager if you have difficulty with this question. . 7. 7.ID: 9477028765 The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit? A. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shiftB. Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed D. Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay Correct Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “looking back,” audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits. Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the word “retrospective” in the question and the description in the correct option. Review: the procedures for quality improvement and retrospective and concurrent audits if you have difficulty with this question. . 8. 8.ID: 9477022320 The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace? A. Ask the client whether the necklace is gold B. Ask the client for permission to lock the necklace in the hospital safe Correct C. Ask the client to remove the necklace and place it in the top drawer of the bedside table D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure Rationale: When a client has valuables, the nurse should give them to a family member or secure them for safekeeping. Most health care institutions require that a client sign a release form that frees the institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not safeguard the client’s necklace. Valuables may be locked in a designated location such as the hospital’s safe. Removing the necklace and putting it in a drawer does not safeguard it. Asking the client whether the necklace is gold is inappropriate and unrelated to the subject. Test-Taking Strategy: Focus on the subject, safeguarding the client’s necklace. Focusing on the subject and noting the word “lock” in the correct option will help you answer correctly. Review: the procedures for safeguarding a client’s valuables . . 9. 9.ID: 9477017796The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which action should the nurse take? A. Tape the wedding band in place B. Explain to the client why the wedding band must be removed Correct C. Ask the client whether she would like to remove the wedding band or wear it to surgery Incorrect D. Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery Rationale: In most situations a wedding band may be taped in place and worn during a surgical procedure. However, if the possibility exists that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is asked to sign a form that frees the agency from responsibility if a client’s valuable is lost. After mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in swelling of the arm and hand on the affected side. Therefore the appropriate nursing action is to ask the client to remove the wedding band and explain why. Test-Taking Strategy: Focus on the data in the question. Eliminate the options that are comparable or alike in that they indicate that the client may wear the wedding band during the surgical procedure. Next, recall the complications associated with mastectomy, which will direct you to the correct option. Review: preoperative procedures for a client’s valuables . . 10. 10.ID: 9477014230 The nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take? A. Asking the client to remove the medal until the x-ray has been completed B. Assisting the client in pinning the medal and chain to the waistband of the client’s pajama bottoms Correct C. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department D. Telling the client that the medal and chain will be kept at the nurses’ station for safekeeping while the client is undergoing the x-ray Incorrect Rationale: A client undergoing a chest x-ray must remove all metal objects to help prevent artifacts on the x-ray. If the client expresses concern about removing the medal, the nurse should help the client pin the medal and chain to the hospital gown or in another area where it will not appear on the x-ray image. The nurse should also alert staff in the radiology department that this has been done. If the client is expressing concern about removing the medal, asking the client to remove it or leave it with the nurse or in the bedside stand is inappropriate. Each of these actions also increases the likelihood that the medal and chain will be lost. Test-Taking Strategy: Note that the client is expressing concern about removing the religious medal. Eliminate the options that are comparable or alike in that they indicate that the client should removethe medal. Also note that the correct option is the only option that addresses the client’s concern. Review: care of clients’ valuables . 11. 11.ID: 9477030405 A health care provider writes a medication prescription in a client’s record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client’s condition. What is the appropriate action for the nurse to take? A. Contacting the nursing supervisor Correct B. Continuing to transcribe the prescription Incorrect C. Asking the nurse assigned to care for the client to administer the medication D. Verifying the prescribed dose with the client before administering the medication Rationale: A nurse must follow a physician’s prescription unless he or she believes that the prescription is in error or that it would harm the client. If a prescription is found to be incorrect or harmful, further clarification from the health care provider is necessary. If the health care provider confirms the prescription and the nurse still believes that it is inappropriate, the nurse should contact the nursing supervisor. The nurse should not continue transcribing the prescription or ask another nurse to implement the prescription. The nurse might ask the client about the medication and the dose taken at home but would not administer the medication. Test-Taking Strategy: Eliminate the options that are comparable or alike in that they indicate that the medication would be administered. Review: the nurse’s responsibilities in regard to a physician’s prescriptions . . 12. 12.ID: 9477016885 The nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client’s lung has reexpanded and notifies the health care provider. The health care provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. Which action should the nurse take first? A. Call the nursing supervisor B. Explain the procedure to the client, then remove the chest tube C. Inform the health care provider that removal of a chest tube is not a nursing procedure Correct D. Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube Rationale: Actual removal of a chest tube is the duty of a health care provider. Therefore the nurse would first inform the health care provider that this is not a nursing procedure. If the health care provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agency’s policies and procedures may permit an advanced practice nurse (a nurse with a master’s degree in a specialized area of nursing) to remove a chest tube. However, there is no information inthe question to indicate that the nurse is an advanced practice nurse. Test-Taking Strategy: Eliminate the options that are comparable or alike in that they indicate that the nurse would remove the chest tube. To select from the remaining options, note the strategic word “first.” The nurse should discuss the prescription with the physician. Review: nursing responsibilities with regard to removal of a chest tube . . 13. 13.ID: 9477025841 The nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse? A. Calling the health care provider who gave the telephone prescription to clarify the prescription Correct B. Calling the nursing supervisor for assistance in determining the route of administration C. Administering the medication intravenously, because this route is generally used for clients with CHF D. Administering the medication orally and clarifying the prescription once the health care provider has finished caring for the client in the emergency department Rationale: Telephone prescriptions involve a health care provider’s dictating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating the prescription clearly and precisely to the physician. The nurse then writes the prescription on the physician’s prescription sheet. Under no circumstances should the nurse try to interpret an unclear prescription or administer a medication by a route that has not been expressly prescribed. The nurse must call the health care provider who gave the telephone prescription and clarify the prescription. Test-Taking Strategy: Eliminate the options that are comparable or alike in that they indicate that the nurse should administer the medication without clarifying the physician’s prescription. Review: the procedures for accepting telephone prescriptions . . 14. 14.ID: 9477026697 A nurse is assisting a health care provider in assessing a hospitalized client. During the assessment, the health care provider is paged to report to the recovery room. The health care provider leaves the client’s bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation? A. Calling the nursing supervisor to obtain permission to accept the verbal prescription B. Changing the solution and rate of the IV fluid per the physician’s verbal prescription C. Asking the health care provider to write the prescription in the client’s record before leaving the nursing unit CorrectD. Telling the health care provider that the prescription will not be implemented until it is documented in the client’s record Rationale: The health care provider should write all prescriptions. Verbal prescriptions are not recommended, because they increase the risk for error. If a verbal prescription is necessary, such as during an emergency, it should be written and signed by the health care provider as soon as possible, usually within 24 hours. The nurse must follow agency policies and procedures regarding verbal prescriptions. The appropriate nursing action would be to ask the health care provider to write the prescription in the client’s record before leaving the nursing unit. Changing the solution in keeping with the verbal prescription and contacting the supervisor to obtain permission to accept the verbal prescription each imply that the nurse accepts the verbal prescription. Telling the health care provider that the prescription will not be implemented until it is documented in the client’s record delays necessary treatment. Test-Taking Strategy: and note the strategic word “appropriate.” Eliminate the options that are comparable or alike in that they imply acceptance of the verbal prescription by the nurse. To select from the remaining options, recall the guidelines and principles for implementing health care provider prescriptions. This will direct you to the correct option. Review: nursing responsibilities related to verbal prescriptions . . 15. 15.ID: 9477014249 A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client’s advocate by taking which action? A. Reassuring the client that the risks are minimal B. Calling the surgeon and asking that the risks be explained to the client Correct C. Noting in the client’s record that the client was not told about the risks of the surgery D. Writing a note on the front of the client’s record so that the surgeon will see it when the client arrives in the operating room [Show Less]
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HESI Extra Credit Module 5 Exam Management of Care [NEW!!] 2022 (88 Pages) 100% CORRECT
Module 5 Exam Questions 1. 1.ID: 327498249 A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing t... [Show More] he risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? A. Justice B. Fidelity C. Autonomy D. Nonmaleficence Correct Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Healthcare professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action. TestTaking Strategy: Use the process of elimination and think about the definition of each item in the options. Note the relationship of the words “least possible harm” in the question and the definition of nonmaleficence. Review the principles of healthcare ethics if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 314). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 327496879Which action by the nurse represents the ethical principle of beneficence? A. The nurse upholds a client’s decision to refuse chemotherapy for lung cancer. B. The nurse follows a plan of care designed to relieve pain in a client with cancer. C. The nurse administers an immunization to a child even though it may cause discomfort. Correct D. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Fidelity is keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that you are agreeing to respect that person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients. TestTaking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action to help others will direct you to the correct option. Review the principles of healthcare ethics if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 314). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 327498211 The nursing instructor asks a student to name an example of false imprisonment. Which of the following situations reflects a violation of this client right? A. Performing a procedure without consent B. Telling the client that he or she may not leave the hospital Correct C. Threatening to give a client a medication against his or her will D. Observing the provision of care to the client without the client’s permissionRationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy. TestTaking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of the subject and the words in the correct option. If you had difficulty with this question, review the concept of false imprisonment. References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends & management (4th ed., pp. 175, 176). St. Louis: Mosby. Zerwekh, J., & Claborn, J. (2009). Nursing today: Transition and trends (6th ed., p. 424). Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 327497519 A nurse and a nursing assistant enter a client’s room to provide care and find the client lying on the floor. The nurse should first: A. Ask the nursing assistant to complete an incident report B. Check the client’s level of consciousness and vital signs Correct C. Ask the nursing assistant to assist in getting the client back to bed D. Contact the unit secretary on the intercom and ask that the client’s physician be called Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client’s level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to move the client, the nurse should ask the nursing assistant to assist in getting the client into bed. The nurse should then contact the physician and file an incident report. TestTaking Strategy: Note the strategic word “first.” Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Remember to always assess the client first if a client sustains a fall. Review client injuries and procedures for filing incidentreports if you had difficulty with this question. References: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patient–centered collaborative care (6th ed., p. 180). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 403). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 327496885 Which of the following actions exemplifies the use of evidencebased practice in the delivery of client care? A. Donning sterile gloves to change an abdominal wound dressing Correct B. Encouraging a client to take an herbal substance to treat his insomnia C. Advising a client to agree to the treatment recommended by her physician D. Taking a rectal temperature from a client for whom bleeding precautions have been instituted Rationale: Evidencebased practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing reflects evidencebased practice, because it prevents the entrance of harmful bacteria into the wound. The remaining options do not reflect evidencebased practice. Taking an herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to advise a client to agree to a treatment. Because of the risk of injury to the rectal mucosa, rectal temperaturetaking is avoided in the client for whom bleeding precautions have been instituted. TestTaking Strategy: Read each option carefully, focusing on the subject, evidencebased practice. Recall the definition of evidencebased practice and note the words “sterile gloves” in the correct option. Review the situations that reflect evidencebased practice if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 5460). St. Louis: Mosby.Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 327497573 The registered nurse has accepted a new position as case manager in a hospital. Which of the following responsibilities are part of the nurse’s new role? Select all that apply. A. Evaluating and updating the plan of care as needed Correct B. Prescribing treatments specific to the client’s needs C. Assessing the client’s needs for home supplies and equipment Correct D. Coordinating consultations and referrals to facilitate discharge Correct E. Establishing a safe and costeffective plan of care with the client Correct Rationale: A case manager is a nurse who assumes responsibility for coordinating the client's care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and costeffective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s diagnosis, selfcare ability, and prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments. TestTaking Strategy: Focus on the subject, the responsibilities of the case manager. Note the word “prescribing” in the incorrect option. It is not within the role of the nurse to prescribe. Review the responsibilities of the case manager if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 21). St. Louis: Mosby. Cognitive Ability: Understanding Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/Implementation Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 327497511 The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which of the following actions should the auditing nurse plan to perform in this type of audit? A. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift B. Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed D. Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay Correct Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “looking back,” audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits. TestTaking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the word “retrospective” in the question and the description in the correct option. Review the procedures for quality improvement and retrospective and concurrent audits if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 64, 65). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/Planning Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 327497529 A nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace? A. Ask the client whether the necklace is gold B. Ask the client for permission to lock the necklace in the hospital safe Correct C. Ask the client to remove the necklace and place it in the top drawer of the bedside table D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure Rationale: When a client has valuables, the nurse should give them to a family member or secure them for safekeeping. Most healthcare institutions require that a client sign a release form that frees the institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not safeguard the client’s necklace. Valuables may be locked in a designated location such as the hospital’s safe. Removing the necklace and putting it in a drawer does not safeguard it. Asking the client whether the necklace is gold is inappropriate and unrelated to the subject. TestTaking Strategy: Use the process of elimination and focus on the subject, safeguarding the client’s necklace. Focusing on the subject and noting the word “lock” in the correct option will help you answer correctly. Review the procedures for safeguarding a client’s valuables if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 1387). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 327497555A nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. The nurse should: A. Tape the wedding band in place B. Explain to the client why the wedding band must be removed Correct C. Ask the client whether she would like to remove the wedding band or wear it to surgery D. Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery Rationale: In most situations a wedding band may be taped in place and worn during a surgical procedure. However, if the possibility exists that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is asked to sign a form that frees the agency from responsibility if a client’s valuable is lost. After mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in swelling of the arm and hand on the affected side. Therefore the appropriate nursing action is to ask the client to remove the wedding band and explain why. TestTaking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the options that are comparable or alike in that they indicate that the client may wear the wedding band during the surgical procedure. Next, recall the complications associated with mastectomy, which will direct you to the correct option. Review preoperative procedures for a client’s valuables if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 1387). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 327497559 A nurse preparing a client to go to the radiology department for a chest xray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take?A. Asking the client to remove the medal until the xray has been completed B. Assisting the client in pinning the medal and chain to the waistband of the client’s pajama bottoms Correct C. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department D. Telling the client that the medal and chain will be kept at the nurses’ station for safekeeping while the client is undergoing the xray [Show Less]
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HESI Extra Credit Module 5 Exam Management of Care [NEW!!] 2022 (69 Pages) 100% CORRECT
Module 5 Exam 1. 1.ID: 22114995478 A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks ... [Show More] and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? A. Justice B. Fidelity C. Autonomy D. Nonmaleficence Correct Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Healthcare professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action. Test-Taking Strategy: Focus on the subject - the ethical principle being utilized. Recall the definition of each item in the options. Note the relationship of the strategic words “least possible harm“ in the question and the definition of nonmaleficence. Review: Nonmaleficience Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Celluar Regulation, Ethics HESI Concepts: Advocacy/Ethical/Legal Issues, Cellular Regulation Awarded 96.0 points out of 96.0 possible points. 2. 2.ID: 22114995475 Which action by the nurse represents the ethical principle of beneficence? A. The nurse upholds a client’s decision to refuse chemotherapy for lung cancer. B. The nurse follows a plan of care designed to relieve pain in a client with cancer. C. The nurse administers an immunization to a child even though it may cause discomfort. Correct D. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Fidelity is keeping promises made to clients,families, and other healthcare professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that you are agreeing to respect that person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients. Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action to help others will direct you to the correct option. Review: Beneficence Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Ethics, Immunity HESI Concepts: Advocacy/Ethical/Legal Issues, Immunity Awarded 96.0 points out of 96.0 possible points. 3. 3.ID: 22114995472 The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right? A. Performing a procedure without consent B. Telling the client that he or she may not leave the hospital Correct C. Threatening to give a client a medication against his or her will D. Observing the provision of care to the client without the client’s permission Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy. Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of the subject and the words in the correct option. Review: false imprisonment Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Giddens Concepts: Health Care Law, Leadership HESI Concepts: Advocacy/Ethical/Legal Issues, Health Policy/Systems—Health Care Law Awarded 96.0 points out of 96.0 possible points. 4. 4.ID: 22114995469 The nurse and an assistive personnel (AP) enter a client’s room to provide care and find the client lying on the floor. Which action should the nurse take first? A. Ask the nursing assistant to complete an incident reportB. Check the client’s level of consciousness and vital signs Correct C. Ask the nursing assistant to assist in getting the client back to bed D. Contact the unit secretary on the intercom and ask that the client’s primary health care provider be called Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client’s level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to move the client, the nurse should ask the AP to assist in getting the client into bed. The nurse should then contact the primary health care provider and file an incident report. Test-Taking Strategy: Note the strategic word “first.“ Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Remember to always assess the client first if a client sustains a fall. Review: Client who falls Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Mobility, Safety HESI Concepts: Mobility, Safety Awarded 96.0 points out of 96.0 possible points. 5. 5.ID: 22114995466 Which action exemplifies the use of evidence-based practice in the delivery of client care? A. Donning sterile gloves to change an abdominal wound dressing Correct B. Encouraging a client to take an herbal substance to treat his insomnia C. Advising a client to agree to the treatment recommended by her primary health care provider D. Taking a rectal temperature from a client for whom bleeding precautions have been instituted Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing reflects evidence-based practice, because it prevents the entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based practice. Taking an herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to advise a client to agree to a treatment. Because of the risk of injury to the rectal mucosa, rectal temperature-taking is avoided in the client for whom bleeding precautions have been instituted. Test-Taking Strategy: Read each option carefully, focusing on the subject, evidencebased practice. Recall the definition of evidence-based practice and note the strategic words “sterile gloves“ in the correct option. Review: evidence-based practiceLevel of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Evidence, Safety HESI Concepts: Evidence-Based Practice/Evidence, Safety Awarded 96.0 points out of 96.0 possible points. 6. 6.ID: 22114995463 The registered nurse has accepted a new position as case manager in a hospital. Which responsibilities are part of the nurse’s new role? Select all that apply. A. Evaluating and updating the plan of care as needed Correct B. Prescribing treatments specific to the client’s needs C. Assessing the client’s needs for home supplies and equipment Correct D. Coordinating consultations and referrals to facilitate discharge Correct E. Establishing a safe and cost-effective plan of care with the client Correct Rationale: A case manager is a nurse who assumes responsibility for coordinating the client's care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and cost-effective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s diagnosis, self-care ability, and prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments. Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the strategic word “prescribing“ in the incorrect option. It is not within the role of the nurse to prescribe. Review: case management Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Care Coordination, Leadership HESI Concepts: Collaboration/Managing Care—Care Coordination, Collaboration/Managing Care–Leadership Awarded 96.0 points out of 96.0 possible points. 7. 7.ID: 22114995460 The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit?A. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift B. Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed D. Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay Correct Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “looking back,“ audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,“ audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits. Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the strategic word “retrospective“ in the question and the description in the correct option. Review: quality improvement and retrospective and concurrent audits Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Giddens Concepts: Health Care Quality, Leadership HESI Concepts: Collaboration/Managing Care—Leadership, Quality Improvement/Health Care Quality Awarded 96.0 points out of 96.0 possible points. 8. 8.ID: 22114995457 The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace? A. Ask the client whether the necklace is gold B. Ask the client for permission to lock the necklace in the hospital safe Correct C. Ask the client to remove the necklace and place it in the top drawer of the bedside table D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedureRationale: When a client has valuables, the nurse should give them to a family member or secure them for safekeeping. Most health care institutions require that a client sign a release form that frees the institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not safeguard the client’s necklace. Valuables may be locked in a designated location such as the hospital’s safe. Removing the necklace and putting it in a drawer does not safeguard it. Asking the client whether the necklace is gold is inappropriate and unrelated to the subject. Test-Taking Strategy: Focus on the subject, safeguarding the client’s necklace. Focusing on the subject and noting the word “lock“ in the correct option will help you answer correctly. Review: client’s valuables Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Ethics, Health Care Policy HESI Concepts: Advocacy/Ethical/Legal Issues, Health Policy/Systems—Health Care Policy Awarded 96.0 points out of 96.0 possible points. 9. 9.ID: 22114995415 The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which action should the nurse take? A. Tape the wedding band in place B. Explain to the client why the wedding band must be removed Correct C. Ask the client whether she would like to remove the wedding band or wear it to surgery D. Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery [Show Less]
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HESI Extra Credit Module 5 Exam Management of Care [NEW!!] 2022 (78 Pages) 100% CORRECT
Questions 1. 1.ID: 9477027534 A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and b... [Show More] enefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? A. Justice B. Fidelity C. Autonomy D. Nonmaleficence Correct Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Healthcare professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action. Test-Taking Strategy: Focus on the subject - the ethical principle being utilized. Recall the definition of each item in the options. Note the relationship of the words “least possible harm” in the question and the definition of nonmaleficence. Review: principles of healthcare ethics. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 314). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Celluar Regulation, Ethics HESI Concepts: Advocacy/Ethical/Legal Issues, Cellular Regulation Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9477024200 Which action by the nurse represents the ethical principle of beneficence? A. The nurse upholds a client’s decision to refuse chemotherapy for lung cancer. B. The nurse follows a plan of care designed to relieve pain in a client with cancer. C. The nurse administers an immunization to a child even though it may cause discomfort. CorrectExtra Credit HESI Module 5 D. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Fidelity is keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that you are agreeing to respect that person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients. Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action to help others will direct you to the correct option. Review: the principles of healthcare ethics . Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 314). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Ethics, Immunity HESI Concepts: Advocacy/Ethical/Legal Issues, Immunity Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9477029451 The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right? A. Performing a procedure without consent B. Telling the client that he or she may not leave the hospital Correct C. Threatening to give a client a medication against his or her will D. Observing the provision of care to the client without the client’s permission Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy. Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of the subject and the words in the correct option. Review: the concept of false imprisonment. References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues:Extra Credit HESI Module 5 Trends & management (4th ed., pp. 175, 176). St. Louis: Mosby. Zerwekh, J., & Claborn, J. (2009). Nursing today: Transition and trends (6th ed., p. 424). Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Giddens Concepts: Health Care Law, Leadership HESI Concepts: Advocacy/Ethical/Legal Issues, Health Policy/Systems— Health Care Law Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9477017756 The nurse and an unlicensed assistive personnel (UAP)enter a client’s room to provide care and find the client lying on the floor. Which action should the nurse take first? A. Ask the nursing assistant to complete an incident report B. Check the client’s level of consciousness and vital signs Correct C. Ask the nursing assistant to assist in getting the client back to bed D. Contact the unit secretary on the intercom and ask that the client’s health care provider be called Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client’s level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to move the client, the nurse should ask the UAP to assist in getting the client into bed. The nurse should then contact the health care provider and file an incident report. Test-Taking Strategy: Note the strategic word “first.” Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Remember to always assess the client first if a client sustains a fall. Review: client injuries and procedures for filing incident reports . References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient–centered collaborative care (6th ed., p. 180). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 403). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/PrioritizingExtra Credit HESI Module 5 Giddens Concepts: Mobility, Safety HESI Concepts: Mobility, Safety Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 9477020809 Which action exemplifies the use of evidence-based practice in the delivery of client care? A. Donning sterile gloves to change an abdominal wound dressing Correct B. Encouraging a client to take an herbal substance to treat his insomnia C. Advising a client to agree to the treatment recommended by her health care provider D. Taking a rectal temperature from a client for whom bleeding precautions have been instituted Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing reflects evidence-based practice, because it prevents the entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based practice. Taking an herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to advise a client to agree to a treatment. Because of the risk of injury to the rectal mucosa, rectal temperature-taking is avoided in the client for whom bleeding precautions have been instituted. Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall the definition of evidence-based practice and note the words “sterile gloves” in the correct option. Review: the situations that reflect evidence-based practice . Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 54-60). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Evidence, Safety HESI Concepts: Evidence-Based Practice/Evidence, Safety Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477020817 The registered nurse has accepted a new position as case manager in a hospital. Which responsibilities are part of the nurse’s new role? Select all that apply.Extra Credit HESI Module 5 A. Evaluating and updating the plan of care as needed Correct B. Prescribing treatments specific to the client’s needs C. Assessing the client’s needs for home supplies and equipment Correct D. Coordinating consultations and referrals to facilitate discharge Correct E. Establishing a safe and cost-effective plan of care with the client Correct Rationale: A case manager is a nurse who assumes responsibility for coordinating the client's care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and cost-effective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s diagnosis, self-care ability, and prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments. Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the word “prescribing” in the incorrect option. It is not within the role of the nurse to prescribe. Review: the responsibilities of the case manager if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 21). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Care Coordination, Leadership HESI Concepts: Collaboration/Managing Care—Care Coordination, Collaboration/Managing Care–Leadership Awarded 4.0 points out of 4.0 possible points. 7. 7.ID: 9477028765 The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit?Extra Credit HESI Module 5 A. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift B. Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed D. Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay Correct Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “looking back,” audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits. Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the word “retrospective” in the question and the description in the correct option. Review: the procedures for quality improvement and retrospective and concurrent audits if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 64, 65). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Giddens Concepts: Health Care Quality, Leadership HESI Concepts: Collaboration/Managing Care—Leadership, Quality Improvement/Health Care Quality Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9477022320 The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace?Extra Credit HESI Module 5 A. Ask the client whether the necklace is gold B. Ask the client for permission to lock the necklace in the hospital safe Correct C. Ask the client to remove the necklace and place it in the top drawer of the bedside table D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure Rationale: When a client has valuables, the nurse should give them to a family member or secure them for safekeeping. Most health care institutions require that a client sign a release form that frees the institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not safeguard the client’s necklace. Valuables may be locked in a designated location such as the hospital’s safe. Removing the necklace and putting it in a drawer does not safeguard it. Asking the client whether the necklace is gold is inappropriate and unrelated to the subject. Test-Taking Strategy: Focus on the subject, safeguarding the client’s necklace. Focusing on the subject and noting the word “lock” in the correct option will help you answer correctly. Review: the procedures for safeguarding a client’s valuables . Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 1387). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Ethics, Health Care Policy HESI Concepts: Advocacy/Ethical/Legal Issues, Health Policy/Systems— Health Care Policy Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 9477017796 The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which action should the nurse take? A. Tape the wedding band in place B. Explain to the client why the wedding band must be removed Correct C. Ask the client whether she would like to remove the wedding band or wear it to surgery D. Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgeryExtra Credit HESI Module 5 Rationale: In most situations a wedding band may be taped in place and worn during a surgical procedure. However, if the possibility exists that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is asked to sign a form that frees the agency from responsibility if a client’s valuable is lost. After mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in swelling of the arm and hand on the affected side. Therefore the appropriate nursing action is to ask the client to remove the wedding band and explain why. Test-Taking Strategy: Focus on the data in the question. Eliminate the options that are comparable or alike in that they indicate that the client may wear the wedding band during the surgical procedure. Next, recall the complications associated with mastectomy, which will direct you to the correct option. Review: preoperative procedures for a client’s valuables . Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 1387). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care Giddens Concepts: Cellular Regulation, Fluid and Electrolyte Balance HESI Concepts: Cellular Regulation, Fluids and Electrolytes Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9477014230 The nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take? A. Asking the client to remove the medal until the x-ray has been completed B. Assisting the client in pinning the medal and chain to the waistband of the client’s pajama bottoms Correct C. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department D. Telling the client that the medal and chain will be kept at the nurses’ station for safekeeping while the client is undergoing the xray [Show Less]
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HESI Extra Credit Module 6 Exam Safety and Infection Control [NEW!!] 2022 (88 Pages) 100% CORRECT
Module 6 Exam Questions 1. 1.ID: 327496299 Which of the following events would require a nurse to complete and file an incident report? A. A client has... [Show More] a seizure. B. The nurse determines that a client would benefit from the use of a walker to ambulate. C. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor’s blood pressure and takes the visitor to the emergency department for treatment. Correct Rationale: An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. Examples of incidents include client falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An incident report does not need to be filed if a client has a seizure unless the client sustains injury as a result of the seizure. If the nurse determines that a client would benefit from the use of a walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes that the battery of an intravenous infusion pump is not working, he or she should obtain a functioning pump and send the nonfunctioning pump to the appropriate department for repair. TestTaking Strategy: Use the process of elimination and read each option carefully. Recalling that an incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client will direct you to the correct option. Review the reasons for filing an incident report if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 336, 337, 403). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 327496839A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol (Tenormin) was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client’s vital signs, completes an incident report, and calls the physician to report the error. The physician tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? A. Notifying the nursing supervisor B. Tearing up and discarding the incident report C. Telling the physician that the error warrants the completion of an incident report Correct D. Telling the nursing supervisor that the physician did not want an incident report completed and filed Rationale: Incident reports are an important part of a healthcare agency’s quality improvement program. An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. An example of an incident is administering a medication at a time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is completed and filed in accordance with agency guidelines. The nursing supervisor would be notified of the incident; however, on the basis of the data in the question, the nurse should tell the physician that the error warrants completion and followthrough with an incident report. Therefore, the other options are incorrect. TestTaking Strategy: Focus on the subject of the question, the physician’s telling the nurse that an incident report is not needed. Eliminate the options that are comparable or alike in that they involve notifying the nursing supervisor. To select from the remaining options, recall the purpose of an incident report to select the correct option. Review the procedures involved in completing and filing incident reports if you had difficulty with this question. Reference: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 557, 558). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 327496835Contact precautions are initiated for a client with methicillinresistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant: A. To transfer the client to a semiprivate room B. That gloves only are needed to care for the client C. To wear gloves and a gown when changing the client's bed linen. Correct D. To wear a gown when caring for the client and remove the gown immediately after leaving the client’s room Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client contact is anticipated. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood or body fluids, secretions, or excretions. The client should be placed in a private room or, if a private room is not available, in a semiprivate room with another client who has active infection with the same microorganism but no other infection. The nursing assistant would remove the protective gear before leaving the client’s room. TestTaking Strategy: Use the process of elimination. Eliminate the option that includes the closedended word “only.” Next eliminate the option that involves removal of the gown after leaving the client’s room. To select from the remaining options, read each carefully and visualize the procedure instituted for contact precautions, which will direct you to the correct option. If you had difficulty with this question, review contact precautions. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 655, 663). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 327496225 A nurse hears someone calling, “Help! My bed is on fire!” On entering the room, the nurse finds a client trying to beat out the flames with a pillow. Place in order of priority the actions that the nurse should take: Correct A. Removing the client from the room B. Pulling the nearest fire alarmC. Closing the door to the room D. Running to get the nearest fire extinguisher Rationale: A nurse who encounters a fire emergency should think of the mnemonic RACE. The first step is to remove the client from the room, after which the nurse should activate the fire alarm, contain the fire, and extinguish the fire. This is a universal standard that may be applied to any type of fire emergency. Removing the client from the room is the first step. Pulling the nearest fire alarm is the second step (alarm). Closing the door to the room to contain the fire is the third action. Obtaining the nearest fire extinguisher to put out the fire is the fourth action. TestTaking Strategy: Focus on the subject, the steps to take in a fire emergency. With this in mind, sequence the actions, using the RACE mnemonic. Review fire safety if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 839, 840). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 2. 5.ID: 327495383 The mother of a 3yearold calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately: A. Call a poison control center Correct B. Administer an excessive amount of fluids to induce vomiting C. Call an ambulance to bring the child to the emergency department D. Leave a message at the physician answering service about the incident Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested was a strong corrosive or petroleum product. Also, vomiting should not be induced unless a healthcare provider has given specific instructions to induce vomiting. Neither calling an ambulance nor calling the physician’s answering service is the immediate action, because either would delay treatment. Additionally, the physician would immediately make a referral to the poison control center. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mothershould then call an ambulance. TestTaking Strategy: Note the strategic word “immediately” in the query of the question. First, recalling that vomiting should not be induced without appropriate advice to do so will help you eliminate the option that involves inducing vomiting. Next eliminate the options that will delay treatment (i.e., calling an ambulance and leaving a message with the answering service). Review immediate poison control measures if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternalchild nursing (3rd ed., pp. 120, 121). St. Louis: Elsevier. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. B. 6.ID: 327495361 A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for causalities. Which action should the nurse manager who receives the telephone call regarding this warning take first? A. Activating the agency disaster plan Correct B. Supplying the triage rooms with additional equipment C. Increasing the number of nursing staff for the day on which the hurricane is expected D. Calling the hospital maintenance department to secure the building against the storm Rationale: In an external disaster, many people may be brought to the emergency department for treatment. Although increasing the nursing staff and supplying the triage rooms with additional equipment may be steps in preparing for casualties, the initial action by the nurse manager must be activation of the disaster plan. Calling the hospital maintenance department to secure the building from the storm is not a responsibility that falls within the scope of nursing management. TestTaking Strategy: Note the strategic word “first” in the query of the question. Use the process of elimination in determining the priority action. Note that the correct option is the umbrella option. Also remember that other necessary activities will be initiated once the agency disaster plan has been activated. Review procedures related to management in times of disaster if you had difficulty withthis question. Reference: Black, J., & Hawks, J. (2009). Medicalsurgical nursing: Clinical management for positive outcomes (8th ed., pp. 76, 2213, 2214). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters Awarded 1.0 points out of 1.0 possible points. C. 7.ID: 327496843 A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client has understood the directions? Select all that apply. A. “I need to follow the oxygen prescription exactly.” Correct B. “I can use my electric razor while I’m using oxygen.” C. “I have to keep the oxygen concentrator out of direct sunlight.” Correct D. “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” E. “I have to tell everyone that they can’t smoke or have an open flame within 10 feet of the oxygen concentrator.” Correct Rationale: The client should follow the oxygen prescription exactly. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use, because fire and injury to the client could result. The oxygen concentrator is kept out of direct sunlight and slightly away from walls and corners to permit adequate air flow. The client should not allow smoking or any type of flame within 10 feet of the oxygen source. Other measures include having telephone numbers for the physician, nurse, and oxygen vendor available and teaching the client signs and symptoms requiring emergency care. TestTaking Strategy: Recall that one hazard associated with oxygen is ignition, which could result from heat in the form of flames or sparks. Evaluating the question from this perspective, eliminate the options that are unsafe. Review oxygen safety measures if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 631). St. Louis: Mosby.Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. D. 8.ID: 327495381 A nurse is providing instructions to a nursing assistant who will be caring for a client in hand restraints. The nurse instructs the nursing assistant to release the restraints to permit muscle exercise: A. Every 2 hours Correct B. Every 3 hours C. Every 4 hours D. Every 30 minutes Rationale: The nurse should instruct the nursing assistant to assess the restraints and the client’s circulatory status and skin integrity every 30 minutes. Restraints must be released at least every 2 hours to permit muscle exercise and promote circulation. Agency guidelines regarding the use of restraints should always be followed. TestTaking Strategy: Knowledge regarding the use of restraints is necessary to answer this question. Noting the strategic words “release the restraints” will help direct you to the correct option. Review nursing responsibilities regarding the use of restraints if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 837). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. E. 9.ID: 327496271A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. In this situation, the most appropriate initial action is: A. Implementing a child safety program B. Planning a focused child safety program C. Performing an analysis of health problems related to child safety D. Determining the appropriateness of the planned health activity Correct Rationale: In this situation, the best initial action would be to determine the appropriateness of the planned health activities. This would be followed by analysis, planning, and implementation. TestTaking Strategy: Use the steps of the nursing process to answer the question. Note that the correct option involves the process of assessment, the first step of the nursing process. Review the procedure for planning health activities to provide safety if you had difficulty with this question. Reference: Maurer, F., & Smith, C. (2009). Community/public health nursing practices: Health for families and populations (4th ed., p. 445). Philadelphia: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. F. 10.ID: 327496807 The nurse administers a dose of ramipril (Altace) 2.5 mg to a client at 9 am. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the physician and nursing supervisor of the error. What statement does the nurse add to the client’s record? A. An incident report was completed and filed. B. Ramipril (Altace) 2.5 mg was administered at 9 am. Correct C. Twice the amount of the prescribed ramipril was administered at 9 am. D. Client’s blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril [Show Less]
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HESI Extra Credit Module 6 Exam Safety and Infection Control [NEW!!] 2022 (72 Pages) 100% CORRECT
Which event would require a nurse to complete and file an incident report? ID: 18630127828 A. A client has a seizure. B. The nurse determines that a clie... [Show More] nt would benefit from the use of a walker to ambulate. C. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor’s blood pressure and takes the visitor to the emergency department for treatment. C Co or rr re ec ct t Rationale: Rationale: An An incident is any event that is not consistent with the routine operation of a health incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client. Examples of incidents include client falls, needlestick care unit or routine care of a client. Examples of incidents include client falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of prescribed therapies, and circumstances leading to injury or a risk for injury omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An . An incident report does not need to be filed if a client has a seizure unless the client sustains injury incident report does not need to be filed if a client has a seizure unless the client sustains injury as a result of the seizure. If the nurse determines that a client would benefit from the use of a as a result of the seizure. If the nurse determines that a client would benefit from the use of a walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes that the battery of an intravenous infusion pump is not working, he or she should obtain a notes that the battery of an intravenous infusion pump is not working, he or she should obtain a functioning pump and send the nonfunctioning pump to the appropriate department for repair functioning pump and send the nonfunctioning pump to the appropriate department for repair. . T Test-T est-Taking Strategy: aking Strategy: Use Use knowledge of the subject, reasons for filing an incident report, to knowledge of the subject, reasons for filing an incident report, to assist you with the process of elimination. Read each option carefully assist you with the process of elimination. Read each option carefully. Recalling that an incident . Recalling that an incident is any event that is not consistent with the routine operation of a health care unit or routine care is any event that is not consistent with the routine operation of a health care unit or routine care of a client will direct you to the correct option. Review the reasons for filing an incident report if of a client will direct you to the correct option. Review the reasons for filing an incident report if you had dif you had difficulty with this question. ficulty with this question. Cognitive Ability: Cognitive Ability: Applying Applying Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Ethical/Legal Ethical/Legal A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. 1.A nurse, charting the administration of medications to an assigned client at 9 p.m., notes that ID: 18630128204 atenolol (Tenormin) was prescribed to be administered at 9 a.m. instead of 9 p.m. The nurse checks the client’s vital signs, completes an incident report, and calls the health care provider to report the error. The health care provider tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? A. Notifying the nursing supervisor B. Tearing up and discarding the incident report C. Telling the health care provider that the error warrants the completion of an incident report C Co or rr re ec ct t Rationale: Rationale: Incident Incident reports are an important part of a health care agency’ reports are an important part of a health care agency’s quality improvement s quality improvement program. An incident is any event that is not consistent with the routine operation of a health program. An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client. An example of an incident is administering a medication at a care unit or routine care of a client. An example of an incident is administering a medication at a time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is completed and filed in accordance with agency guidelines. The nursing supervisor would be completed and filed in accordance with agency guidelines. The nursing supervisor would be notified of the incident; however notified of the incident; however, on the basis of the data in the question, the nurse should tell , on the basis of the data in the question, the nurse should tell the health care provider that the error warrants completion and follow-through with an incident the health care provider that the error warrants completion and follow-through with an incident report. Therefore, the other options are incorrect. report. Therefore, the other options are incorrect. T Test-T est-Taking Strategy: aking Strategy: Focus Focus on the subject of the question, the health care provider on the subject of the question, the health care provider’’s telling the s telling the nurse that an incident report is not needed. Eliminate the comparable or alike options that nurse that an incident report is not needed. Eliminate the comparable or alike options that involve notifying the nursing supervisor involve notifying the nursing supervisor. T . To select from the remaining options, recall the purpose o select from the remaining options, recall the purpose of an incident report to select the correct option. Review the procedures involved in completing of an incident report to select the correct option. Review the procedures involved in completing and filing incident reports if you had dif and filing incident reports if you had difficulty with this question. ficulty with this question. Cognitive Ability: Cognitive Ability: Applying Applying Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Ethical/Legal Ethical/Legal D. Telling the nursing supervisor that the health care provider did not want an incident report completed and filed A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. 2. Contact precautions are initiated for a client with methicillin-resistant Staphylococcus ID: 18630127846 aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant to take which action? A. To transfer the client to a semiprivate room B. That gloves only are needed to care for the client 3.C. To wear gloves and a gown when changing the client’s bed linen C Co or rr re ec ct t Rationale: Rationale: Contact Contact precautions require the use of gloves, gown, and goggles if direct client precautions require the use of gloves, gown, and goggles if direct client contact is anticipated. The client should be placed in a private room or contact is anticipated. The client should be placed in a private room or, if a private room is not , if a private room is not available, in a semiprivate room with another client who has active infection with the same available, in a semiprivate room with another client who has active infection with the same microorganism but no other infection. The nursing assistant would remove the protective gear microorganism but no other infection. The nursing assistant would remove the protective gear before leaving the client’ before leaving the client’s room. s room. T Test-T est-Taking Strategy: aking Strategy: Use Use the process of elimination. Eliminate the option that includes the the process of elimination. Eliminate the option that includes the closed-ended word “only closed-ended word “only.” Next eliminate the option that involves removal of the gown after .” Next eliminate the option that involves removal of the gown after leaving the client’ leaving the client’s room. T s room. To select from the remaining options, read each carefully and visualize o select from the remaining options, read each carefully and visualize the procedure instituted for contact precautions, which will direct you to the correct option. If you the procedure instituted for contact precautions, which will direct you to the correct option. If you had dif had difficulty with this question, review contact precautions. ficulty with this question, review contact precautions. Cognitive Ability: Cognitive Ability: Applying Applying Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment Integrated Process: Integrated Process: T Teaching and Learning eaching and Learning Content Area: Content Area: Leadership/Management Leadership/Management D. To wear a gown when caring for the client and remove the gown immediately after leaving the client s room A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank ID: 18630127871 some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately take which action? A. Call a poison control center. C Co or rr re ec ct t Rationale: Rationale: When a When a poisoning occurs, a poison center should be called immediately poisoning occurs, a poison center should be called immediately. V . Vomiting omiting should not be induced if the victim is unconscious or if the substance ingested was a strong should not be induced if the victim is unconscious or if the substance ingested was a strong corrosive or petroleum product. Also, vomiting should not be induced unless a health care corrosive or petroleum product. Also, vomiting should not be induced unless a health care provider has given specific instructions to induce vomiting. Neither calling an ambulance nor provider has given specific instructions to induce vomiting. Neither calling an ambulance nor calling the health care provider calling the health care provider’’s answering service is the immediate action, because either s answering service is the immediate action, because either would delay treatment. Additionally would delay treatment. Additionally, the health care provider would immediately make a referral , the health care provider would immediately make a referral to the poison control center to the poison control center. The poison control center may advise the mother to bring the child . The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should then call an ambulance. to the emergency department; if this is the case, the mother should then call an ambulance. T Test-T est-Taking Strategy: aking Strategy: Note Note the strategic word “immediately” in the query of the question. First, the strategic word “immediately” in the query of the question. First, recalling that vomiting should not be induced without appropriate advice to do so will help you recalling that vomiting should not be induced without appropriate advice to do so will help you 4.eliminate the option that involves inducing vomiting. Next eliminate the comparable or alike eliminate the option that involves inducing vomiting. Next eliminate the comparable or alike options that will delay treatment (i.e., calling an ambulance and leaving a message with the options that will delay treatment (i.e., calling an ambulance and leaving a message with the answering service). Review immediate poison control measures if you had dif answering service). Review immediate poison control measures if you had difficulty with this ficulty with this question. question. Cognitive Ability: Cognitive Ability: Applying Applying Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Safety Safety B. Administer an excessive amount of fluids to induce vomiting. C. Call an ambulance to bring the child to the emergency department. D. Leave a message at the health care provider answering service about the incident. A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department ID: 18630128240 of an area hospital is advised to prepare for casualties. Which action should the nurse who receives the telephone call regarding this warning take first? A. Activating the agency disaster plan C Co or rr re ec ct t Rationale: Rationale: In In an external disaster an external disaster, many people may be brought to the emergency department , many people may be brought to the emergency department for treatment. Although increasing the nursing staf for treatment. Although increasing the nursing staff and supplying the triage rooms with f and supplying the triage rooms with additional equipment may be steps in preparing for casualties, the initial action by the nurse additional equipment may be steps in preparing for casualties, the initial action by the nurse manager must be activation of the disaster plan. Calling the hospital maintenance department to manager must be activation of the disaster plan. Calling the hospital maintenance department to secure the building from the storm is not a responsibility that falls within the scope of nursing secure the building from the storm is not a responsibility that falls within the scope of nursing management. management. T Test-T est-Taking Strategy: aking Strategy: Note Note the strategic word “first” in the query of the question. Use the the strategic word “first” in the query of the question. Use the process of elimination in determining the priority action. Note that the correct option is the process of elimination in determining the priority action. Note that the correct option is the umbrella option. Also remember that other necessary activities will be initiated once the agency umbrella option. Also remember that other necessary activities will be initiated once the agency disaster plan has been activated. Review procedures related to management in times of disaster plan has been activated. Review procedures related to management in times of disaster if you had dif disaster if you had difficulty with this question. ficulty with this question. Cognitive Ability: Cognitive Ability: Applying Applying Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Disasters Disasters 5.B. Supplying the triage rooms with additional equipment C. Increasing the number of nursing staff for the day on which the hurricane is expected D. Calling the hospital maintenance department to secure the building against the storm A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. A home health nurse has instructed a client about safety measures during the use of an ID: 18630128283 oxygen concentrator in the home. Which statements by the client indicate to the nurse that the client has understood the directions? Select all that apply. A. “I need to follow the oxygen prescription exactly.” C Co or rr re ec ct t B. “I can use my electric razor while I’m using oxygen.” C. “I have to keep the oxygen concentrator out of direct sunlight.” C Co or rr re ec ct t D. “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” E. “I have to tell everyone that they can’t smoke or have an open flame within 10 feet of the oxygen concentrator.” C Co or rr re ec ct t Rationale: Rationale: The The client should follow the oxygen prescription exactly client should follow the oxygen prescription exactly. The use of electric razors or other . The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use, because fire and injury to equipment that could emit sparks should be avoided while oxygen is in use, because fire and injury to the client could result. The oxygen concentrator is kept out of direct sunlight and slightly away from the client could result. The oxygen concentrator is kept out of direct sunlight and slightly away from walls and corners to permit adequate air flow walls and corners to permit adequate air flow. The client should not allow smoking or any type of flame . The client should not allow smoking or any type of flame within 10 feet of the oxygen source. Other measures include having telephone numbers for the health within 10 feet of the oxygen source. Other measures include having telephone numbers for the health care provider care provider, nurse, and oxygen vendor available and teaching the client signs and symptoms , nurse, and oxygen vendor available and teaching the client signs and symptoms requiring emergency care. requiring emergency care. T Test-T est-Taking Strategy: aking Strategy: Recall Recall knowledge of the subject, oxygen safety measures, to assist you with knowledge of the subject, oxygen safety measures, to assist you with eliminating options. Recall that one hazard associated with oxygen is ignition, which could result from eliminating options. Recall that one hazard associated with oxygen is ignition, which could result from heat in the form of flames or sparks. Evaluating the question from this perspective, eliminate the heat in the form of flames or sparks. Evaluating the question from this perspective, eliminate the options that are unsafe. Review oxygen safety measures if you had dif options that are unsafe. Review oxygen safety measures if you had difficulty with this question. ficulty with this question. Cognitive Ability: Cognitive Ability: Evaluating Evaluating Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment Integrated Process: Integrated Process: Nursing Process/Evaluation Nursing Process/Evaluation Content Area: Content Area: Safety Safety A Awarded 3.0 points out of 3.0 possible points. warded 3.0 points out of 3.0 possible points. 6. A nurse is providing instructions to a nursing student who will be caring for a client in hand ID: 18630128226 restraints. The nurse instructs the nursing student to release the restraints to permit muscle exercise how 7.frequently? A. Every 2 hours C Co or rr re ec ct t Rationale: Rationale: The The nurse should assess the restraints and the client’ nurse should assess the restraints and the client’s circulatory status and skin s circulatory status and skin integrity every 30 minutes. Restraints must be released at least every 2 hours to permit muscle integrity every 30 minutes. Restraints must be released at least every 2 hours to permit muscle exercise and promote circulation. Agency guidelines regarding the use of restraints should exercise and promote circulation. Agency guidelines regarding the use of restraints should always be followed. always be followed. T Test-T est-Taking Strategy: aking Strategy: Knowledge Knowledge regarding the subject, the use of restraints, is necessary to regarding the subject, the use of restraints, is necessary to answer this question. Noting the strategic words “release the restraints” will help direct you to answer this question. Noting the strategic words “release the restraints” will help direct you to the correct option. Review nursing responsibilities regarding the use of restraints if you had the correct option. Review nursing responsibilities regarding the use of restraints if you had dif difficulty with this question. ficulty with this question. Cognitive Ability: Cognitive Ability: Applying Applying Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment Integrated Process: Integrated Process: T Teaching and Learning eaching and Learning Content Area: Content Area: Safety Safety B. Every 3 hours C. Every 4 hours D. Every 30 minutes A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. A community health nurse working in a school setting is concerned because parents are not ID: 18630128238 participating in health activities designed to promote child safety. In this situation, which is the most appropriate initial action? A. Implementing a child safety program B. Planning a focused child safety program C. Performing an analysis of health problems related to child safety D. Determining the appropriateness of the planned health activity C Co or rr re ec ct t Rationale: Rationale: In this situation, the best initial action would be to determine the appropriateness of In this situation, the best initial action would be to determine the appropriateness of the planned health activities. This would be followed by analysis, planning, and implementation. the planned health activities. This would be followed by analysis, planning, and implementation. T Test-T est-Taking Strategy: aking Strategy: Use Use the steps of the nursing process to answer the question. Note that the the steps of the nursing process to answer the question. Note that the correct option involves the process of data collection, the first step of the nursing process. correct option involves the process of data collection, the first step of the nursing process. Review the procedure for planning health activities to provide safety if you had dif Review the procedure for planning health activities to provide safety if you had difficulty with this ficulty with this question. question. 8.Cognitive Ability: Cognitive Ability: Applying Applying Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Safety Safety A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. The nurse administers a dose of ramipril 2.5 mg to a client at 9 a.m. While documenting ID: 18630123889 administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the health care provider and nursing supervisor of the error. What statement does the nurse add to the client’s record? A. An incident report was completed and filed. B. Ramipril (Altace) 2.5 mg was administered at 9 a.m. C Co or rr re ec ct t Rationale: Rationale: After After an incident, the nurse would document a concise and objective description of an incident, the nurse would document a concise and objective description of what occurred and any follow-up actions taken in the client’ what occurred and any follow-up actions taken in the client’s record. The nurse would not s record. The nurse would not document in the client’ document in the client’s record that an incident report was completed. Nor would the nurse s record that an incident report was completed. Nor would the nurse document that twice the prescribed dose was given or that an incorrect dose was given. document that twice the prescribed dose was given or that an incorrect dose was given. T Test-T est-Taking Strategy: aking Strategy: Focus Focus on the data in the question. Recall that notes made in a client’ on the data in the question. Recall that notes made in a client’s s record must be objective. Eliminate the comparable or alike options that indicate that an record must be objective. Eliminate the comparable or alike options that indicate that an incorrect dose of medication was administered. Next note that the correct option clearly and incorrect dose of medication was administered. Next note that the correct option clearly and accurately describes the incident in an objective manner accurately describes the incident in an objective manner. Review documentation of a medication . Review documentation of a medication error or other incident if you had dif error or other incident if you had difficulty with this question. ficulty with this question. Cognitive Ability: Cognitive Ability: Applying Applying Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment Integrated Process: Integrated Process: Communication and Documentation Communication and Documentation Content Area: Content Area: Ethical/Legal Ethical/Legal C. Twice the amount of the prescribed ramipril was administered at 9 a.m. D. Client’s blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril. A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. 9.A home health nurse has been called to the home of an older postoperative cardiovascular ID: 18630127884 client by the client’s son. The son tells the nurse, “We’re using a hospital bed here at home, but my mother has fallen out of bed three times.” Which observation by the nurse reflects an increased risk of this client’s falling out of bed? A. The client’s bed is in a low position. B. The client is oriented to person, place, and time. C. The caregiver uses the overbed table for feedings. D. The caregiver leaves both siderails down while the client is in bed [Show Less]
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HESI Extra Credit Module 6 Exam Safety and Infection Control [NEW!!] 2022 (52 Pages) 100% CORRECT
MODULE 6 Exam Questions 1. 1.ID: 9476950840 Which event would require a nurse to complete and file an incident report? A. A client has a seizure. B. Th... [Show More] e nurse determines that a client would benefit from the use of a walker to ambulate. C. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor’s blood pressure and takes the visitor to the emergency department for treatment. Correct Rationale: An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. Examples of incidents include client falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An incident report does not need to be filed if a client has a seizure unless the client sustains injury as a result of the seizure. If the nurse determines that a client would benefit from the use of a walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes that the battery of an intravenous infusion pump is not working, he or she should obtain a functioning pump and send the nonfunctioning pump to the appropriate department for repair. Test-Taking Strategy: Use the process of elimination and read each option carefully. Recalling that an incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client will direct you to the correct option. Review the reasons for filing an incident report if you had difficulty with this question. 2. 2.ID: 9476944425 A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol (Tenormin) was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client’s vital signs, completes an incident report, and calls the physician to report the error. The physician tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? A. Notifying the nursing supervisor B. Tearing up and discarding the incident report C. Telling the physician that the error warrants the completion of an incident report Correct D. Telling the nursing supervisor that the physician did not want an incident report completed and filed Rationale: Incident reports are an important part of a healthcare agency’s quality improvement program. An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. An example of an incident is administering a medication at a time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is completed and filed in accordance with agency guidelines. The nursing supervisor would be notified of the incident;however, on the basis of the data in the question, the nurse should tell the physician that the error warrants completion and follow-through with an incident report. Therefore, the other options are incorrect. Test-Taking Strategy: Focus on the subject of the question, the physician’s telling the nurse that an incident report is not needed. Eliminate the options that are comparable or alike in that they involve notifying the nursing supervisor. To select from the remaining options, recall the purpose of an incident report to select the correct option. Review the procedures involved in completing and filing incident reports if you had difficulty with this question. . 3. 3.ID: 9476948372 Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant: A. To transfer the client to a semiprivate room B. That gloves only are needed to care for the client C. To wear gloves and a gown when changing the client's bed linen. Correct D. To wear a gown when caring for the client and remove the gown immediately after leaving the client’s room Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client contact is anticipated. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood or body fluids, secretions, or excretions. The client should be placed in a private room or, if a private room is not available, in a semiprivate room with another client who has active infection with the same microorganism but no other infection. The nursing assistant would remove the protective gear before leaving the client’s room. Test-Taking Strategy: Use the process of elimination. Eliminate the option that includes the closedended word “only.” Next eliminate the option that involves removal of the gown after leaving the client’s room. To select from the remaining options, read each carefully and visualize the procedure instituted for contact precautions, which will direct you to the correct option. If you had difficulty with this question, review contact precautions. . 4. 4.ID: 10466367548 A nurse hears someone calling, “Help! My bed is on fire!” On entering the room, the nurse finds a client trying to beat out the flames with a pillow. Place in order of priority the actions that the nurse should take: Correct A. Removing the client from the room B. Pulling the nearest fire alarm C. Closing the door to the room D. Running to get the nearest fire extinguisher Rationale: A nurse who encounters a fire emergency should think of the mnemonic RACE. The first step is to remove the client from the room, after which the nurse should activate the firealarm, contain the fire, and extinguish the fire. This is a universal standard that may be applied to any type of fire emergency. Removing the client from the room is the first step. Pulling the nearest fire alarm is the second step (alarm). Closing the door to the room to contain the fire is the third action. Obtaining the nearest fire extinguisher to put out the fire is the fourth action. Test-Taking Strategy: Focus on the subject, the steps to take in a fire emergency. With this in mind, sequence the actions, using the RACE mnemonic. Review fire safety if you had difficulty with this question. 2. 5.ID: 9476945972 The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately: A. Call a poison control center Correct B. Administer an excessive amount of fluids to induce vomiting C. Call an ambulance to bring the child to the emergency department Incorrect D. Leave a message at the physician answering service about the incident Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested was a strong corrosive or petroleum product. Also, vomiting should not be induced unless a healthcare provider has given specific instructions to induce vomiting. Neither calling an ambulance nor calling the physician’s answering service is the immediate action, because either would delay treatment. Additionally, the physician would immediately make a referral to the poison control center. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should then call an ambulance. Test-Taking Strategy: Note the strategic word “immediately” in the query of the question. First, recalling that vomiting should not be induced without appropriate advice to do so will help you eliminate the option that involves inducing vomiting. Next eliminate the options that will delay treatment (i.e., calling an ambulance and leaving a message with the answering service). Review immediate poison control measures if you had difficulty with this question. . B. 6.ID: 9476944498 A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for causalities. Which action should the nurse manager who receives the telephone call regarding this warning take first? A. Activating the agency disaster plan Correct B. Supplying the triage rooms with additional equipment C. Increasing the number of nursing staff for the day on which the hurricane is expected D. Calling the hospital maintenance department to secure the building against the storm Rationale: In an external disaster, many people may be brought to the emergency department for treatment. Although increasing the nursing staff and supplying the triage rooms with additional equipment may be steps in preparing for casualties, the initial action by the nurse manager must beactivation of the disaster plan. Calling the hospital maintenance department to secure the building from the storm is not a responsibility that falls within the scope of nursing management. Test-Taking Strategy: Note the strategic word “first” in the query of the question. Use the process of elimination in determining the priority action. Note that the correct option is the umbrella option. Also remember that other necessary activities will be initiated once the agency disaster plan has been activated. Review procedures related to management in times of disaster if you had difficulty with this question. . C. 7.ID: 9476945976 A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client has understood the directions? Select all that apply. A. “I need to follow the oxygen prescription exactly.” Correct B. “I can use my electric razor while I’m using oxygen.” C. “I have to keep the oxygen concentrator out of direct sunlight.” Correct D. “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” Incorrect E. “I have to tell everyone that they can’t smoke or have an open flame within 10 feet (3 meters) of the oxygen concentrator.” Correct Rationale: The client should follow the oxygen prescription exactly. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use, because fire and injury to the client could result. The oxygen concentrator is kept out of direct sunlight and slightly away from walls and corners to permit adequate air flow. The client should not allow smoking or any type of flame within 10 feet (3 meters) of the oxygen source. Other measures include having telephone numbers for the physician, nurse, and oxygen vendor available and teaching the client signs and symptoms requiring emergency care. Test-Taking Strategy: Recall that one hazard associated with oxygen is ignition, which could result from heat in the form of flames or sparks. Evaluating the question from this perspective, eliminate the options that are unsafe. Review oxygen safety measures if you had difficulty with this question. . D. 8.ID: 9476955607 A nurse is providing instructions to a nursing assistant who will be caring for a client in hand restraints. The nurse instructs the nursing assistant to release the restraints to permit muscle exercise: A. Every 2 hours Correct B. Every 3 hours C. Every 4 hours D. Every 30 minutes Incorrect Rationale: The nurse should instruct the nursing assistant to assess the restraints and the client’s circulatory status and skin integrity every 30 minutes. Restraints must be released at least every 2 hours to permit muscle exercise and promote circulation. Agency guidelines regarding the use ofrestraints should always be followed. Test-Taking Strategy: Knowledge regarding the use of restraints is necessary to answer this question. Noting the strategic words “release the restraints” will help direct you to the correct option. Review nursing responsibilities regarding the use of restraints if you had difficulty with this question. . E. 9.ID: 9476938159 A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. In this situation, the most appropriate initial action is: A. Implementing a child safety program B. Planning a focused child safety program C. Performing an analysis of health problems related to child safety D. Determining the appropriateness of the planned health activity Correct Rationale: In this situation, the best initial action would be to determine the appropriateness of the planned health activities. This would be followed by analysis, planning, and implementation. Test-Taking Strategy: Use the steps of the nursing process to answer the question. Note that the correct option involves the process of assessment, the first step of the nursing process. Review the procedure for planning health activities to provide safety if you had difficulty with this question. . F. 10.ID: 9476950872 The nurse administers a dose of ramipril (Altace) 2.5 mg to a client at 9 am. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the physician and nursing supervisor of the error. What statement does the nurse add to the client’s record? A. An incident report was completed and filed. B. Ramipril (Altace) 2.5 mg was administered at 9 am. Correct C. Twice the amount of the prescribed ramipril was administered at 9 am. D. Client’s blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril. Rationale: After an incident, the nurse would document a concise and objective description of what occurred and any follow-up actions taken in the client’s record. The nurse would not document in the client’s record that an incident report was completed. Nor would the nurse document that twice the prescribed dose was given or that an incorrect dose was given. Test-Taking Strategy: Focus on the data in the question. Recall that notes made in a client’s record must be objective. Eliminate the options that are comparable or alike in that they indicate that an incorrect dose of medication was administered. Next note that the correct option clearly and accurately describes the incident in an objective manner. Review documentation of a medication error or other incident if you had difficulty with this question. . G. 11.ID: 9476952928A home health nurse has been called to the home of an older postoperative cardiovascular client by the client’s son. The son tells the nurse, “We’re using a hospital bed here at home, but my mother has fallen out of bed three times.” Which observation by the nurse reflects an increased risk of this client’s falling out of bed? A. The client’s bed is in a low position. B. The client is oriented to person, place, and time. C. The caregiver uses the overbed table for feedings. D. The caregiver leaves both siderails down while the client is in bed. Correct Rationale: Leaving the siderails of older client’s bed down may increase the client’s risk of falling. The aging process also increases this client’s potential for falls; therefore, evaluating the safety of the environment is a necessity. Keeping the client’s bed in a low position, orientating the client to the environment, and using the overbed table for feedings are all ways to help ensure the client’s safety. Test-Taking Strategy: Use the process of elimination, focusing on the subject, a observation of an unsafe practice. Noting that the question indicates that the bed is in the low position and that the client is oriented will assist you in eliminating these options. To select from the remaining options, choose the one that identifies an unsafe practice. Review the causes of falls in an older client if you had difficulty with this question. . H. 12.ID: 9476945988 A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. A. Skin Correct B. Lungs Correct C. Immune D. Urinary E. Lymphatic F. Gastrointestinal [Show Less]
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HESI Extra Credit Module 6 Exam Safety and Infection Control [NEW!!] 2022 (79 Pages) 100% CORRECT
Extra Credit HESI Module 6 1. Questions 1. 1.ID: 9476950840 Which event would require a nurse to complete and file an incident report? A. A client has ... [Show More] a seizure. B. The nurse determines that a client would benefit from the use of a walker to ambulate. C. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor’s blood pressure and takes the visitor to the emergency department for treatment. Correct Rationale: An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. Examples of incidents include client falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An incident report does not need to be filed if a client has a seizure unless the client sustains injury as a result of the seizure. If the nurse determines that a client would benefit from the use of a walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes that the battery of an intravenous infusion pump is not working, he or she should obtain a functioning pump and send the nonfunctioning pump to the appropriate department for repair. Test-Taking Strategy: Use the process of elimination and read each option carefully. Recalling that an incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client will direct you to the correct option. Review the reasons for filing an incident report if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 336, 337, 403). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Clinical Judgment, Health Policy HESI Concepts: Clinical Decision-Making/Clinical Judgment, Health Policy/Systems Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9476944425 A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol (Tenormin) was prescribed to be administered at 9 amExtra Credit HESI Module 6 instead of 9 pm. The nurse checks the client’s vital signs, completes an incident report, and calls the physician to report the error. The physician tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? A. Notifying the nursing supervisor B. Tearing up and discarding the incident report C. Telling the physician that the error warrants the completion of an incident report Correct D. Telling the nursing supervisor that the physician did not want an incident report completed and filed Incorrect Rationale: Incident reports are an important part of a healthcare agency’s quality improvement program. An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. An example of an incident is administering a medication at a time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is completed and filed in accordance with agency guidelines. The nursing supervisor would be notified of the incident; however, on the basis of the data in the question, the nurse should tell the physician that the error warrants completion and follow-through with an incident report. Therefore, the other options are incorrect. Test-Taking Strategy: Focus on the subject of the question, the physician’s telling the nurse that an incident report is not needed. Eliminate the options that are comparable or alike in that they involve notifying the nursing supervisor. To select from the remaining options, recall the purpose of an incident report to select the correct option. Review the procedures involved in completing and filing incident reports if you had difficulty with this question. Reference: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 557, 558). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Clinical Judgment, Health Policy HESI Concepts: Clinical Decision-Making/Clinical Judgment, Health Policy/Systems Awarded 0.0 points out of 1.0 possible points. 3. 3.ID: 9476948372 Contact precautions are initiated for a client with methicillinresistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant: A. To transfer the client to a semiprivate roomExtra Credit HESI Module 6 B. That gloves only are needed to care for the client C. To wear gloves and a gown when changing the client's bed linen. Correct D. To wear a gown when caring for the client and remove the gown immediately after leaving the client’s room Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client contact is anticipated. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood or body fluids, secretions, or excretions. The client should be placed in a private room or, if a private room is not available, in a semiprivate room with another client who has active infection with the same microorganism but no other infection. The nursing assistant would remove the protective gear before leaving the client’s room. Test-Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed-ended word “only.” Next eliminate the option that involves removal of the gown after leaving the client’s room. To select from the remaining options, read each carefully and visualize the procedure instituted for contact precautions, which will direct you to the correct option. If you had difficulty with this question, review contact precautions. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 655, 663). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Giddens Concepts: Infection, Leadership HESI Concepts: Collaboration/Managing Care—Leadership, Infection Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 10466367548 A nurse hears someone calling, “Help! My bed is on fire!” On entering the room, the nurse finds a client trying to beat out the flames with a pillow. Place in order of priority the actions that the nurse should take: Correct A. Removing the client from the room B. Pulling the nearest fire alarm C. Closing the door to the room D. Running to get the nearest fire extinguisher Rationale: A nurse who encounters a fire emergency should think of the mnemonic RACE. The first step is to remove the client from the room, after which the nurse should activate the fire alarm, contain the fire, and extinguish the fire. This is a universal standard that may be applied to any type of fire emergency. Removing the client from the room is the first step.Extra Credit HESI Module 6 Pulling the nearest fire alarm is the second step (alarm). Closing the door to the room to contain the fire is the third action. Obtaining the nearest fire extinguisher to put out the fire is the fourth action. Test-Taking Strategy: Focus on the subject, the steps to take in a fire emergency. With this in mind, sequence the actions, using the RACE mnemonic. Review fire safety if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 839, 840). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 2. 5.ID: 9476945972 The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately: A. Call a poison control center Correct B. Administer an excessive amount of fluids to induce vomiting C. Call an ambulance to bring the child to the emergency department D. Leave a message at the physician answering service about the incident Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested was a strong corrosive or petroleum product. Also, vomiting should not be induced unless a healthcare provider has given specific instructions to induce vomiting. Neither calling an ambulance nor calling the physician’s answering service is the immediate action, because either would delay treatment. Additionally, the physician would immediately make a referral to the poison control center. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should then call an ambulance. Test-Taking Strategy: Note the strategic word “immediately” in the query of the question. First, recalling that vomiting should not be induced withoutExtra Credit HESI Module 6 appropriate advice to do so will help you eliminate the option that involves inducing vomiting. Next eliminate the options that will delay treatment (i.e., calling an ambulance and leaving a message with the answering service). Review immediate poison control measures if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternalchild nursing (3rded., pp. 120, 121). St. Louis: Elsevier. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 1.0 points out of 1.0 possible points. 2. 6.ID: 9476944498 A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for causalities. Which action should the nurse manager who receives the telephone call regarding this warning take first? A. Activating the agency disaster plan Correct B. Supplying the triage rooms with additional equipment C. Increasing the number of nursing staff for the day on which the hurricane is expected D. Calling the hospital maintenance department to secure the building against the storm Rationale: In an external disaster, many people may be brought to the emergency department for treatment. Although increasing the nursing staff and supplying the triage rooms with additional equipment may be steps in preparing for casualties, the initial action by the nurse manager must be activation of the disaster plan. Calling the hospital maintenance department to secure the building from the storm is not a responsibility that falls within the scope of nursing management. Test-Taking Strategy: Note the strategic word “first” in the query of the question. Use the process of elimination in determining the priority action. Note that the correct option is the umbrella option. Also remember that other necessary activities will be initiated once the agency disaster plan has been activated. Review procedures related to management in times of disaster if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., pp. 76, 2213, 2214). St. Louis: Saunders.Extra Credit HESI Module 6 Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 1.0 points out of 1.0 possible points. 3. 7.ID: 9476945976 A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client has understood the directions? Select all that apply. A. “I need to follow the oxygen prescription exactly.” Correct B. “I can use my electric razor while I’m using oxygen.” C. “I have to keep the oxygen concentrator out of direct sunlight.” Correct D. “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” E. “I have to tell everyone that they can’t smoke or have an open flame within 10 feet (3 meters) of the oxygen concentrator.” Co [Show Less]
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HESI Extra Credit Module 7 Exam [NEW!!] 2022 (73 Pages) 100% CORRECT - DOWNLOAD TO SCORE A+
Extra Credit HESI Module 7 1. Questions 1. 1.ID: 9477003586 The nurse is instructing a client with hypertension about foods that are low in sodium. Whi... [Show More] ch menu selections by the client indicate to the nurse that the client understands what has been taught? Select all that apply. A. Spaghetti with fresh tomatoes Correct B. Boiled lobster with baked potato C. Grilled chicken with turnip greens Correct D. Instant hot cereal with bacon E. Tomato soup with a ham sandwich Rationale: Foods that are lower in sodium include fruits and vegetables, which do not contain physiologic saline. Fresh poultry and pastas are also low in sodium. Highly processed and refined foods and luncheon meats are high in sodium unless they are specifically labeled “low sodium.” Saltwater fish and shellfish are higher in sodium. Test-Taking Strategy: Focus on the subject, selecting low-sodium foods. Begin to answer this question by eliminating boiled lobster with baked potato, because saltwater fish and shellfish are high in sodium. Next eliminate the options that contain processed foods and luncheon meats. Review: foods that are high and low in sodium Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Nutrition Giddens Concepts: Client Education, Nutrition HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education References: Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 141). St. Louis: Mosby. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby. Awarded 2.0 points out of 2.0 possible points. 2. 2.ID: 9477010158 A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate to the nurse that the client needs additional instruction? Select all that apply. A. Carrots B. Tapioca C. Scallops CorrectExtra Credit HESI Module 7 D. Broccoli E. Chicken liver Correct Rationale: Organ meats such as liver, as well as certain sea foods, including scallops, sardines, and herring, should be omitted from the diet of the client who with gout because of the high purine content. The foods identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout. Test-Taking Strategy: Note the strategic words “needs additional instruction,” which indicate a negative event query and the need to select foods that are unacceptable for this client. Recalling foods that are high in purines will direct you to the correct options. Review: dietary measures for the client with gout Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Client Education, Nutrition HESI Concepts: Health, Wellness, and Illness,Teaching and Learning/Patient Education References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 1080, 1576). St. Louis: Mosby. Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 442-443). St. Louis: Mosby. Awarded 2.0 points out of 2.0 possible points. 3. 3.ID: 9477007734 A clear liquid diet has been prescribed for client who has just undergone surgery. Which foods should the nurse offer to the client? Select all that apply. A. Custard B. Apple juice Correct C. Orange juice D. Chicken broth Correct E. Orange gelatin Correct F. Vanilla ice cream Rationale: A clear liquid diet consists of foods, such as apple juice, chicken broth, and gelatin, which are relatively transparent. Custard, orange juice, and vanilla ice cream are components of a full liquid diet. Test-Taking Strategy: Remembering that a clear liquid diet consists of foods that are relatively transparent will direct you to the correct options. Review: the foods allowed on clear liquid and full liquid diets Level of Cognitive Ability: Applying Client Needs: Physiological IntegrityExtra Credit HESI Module 7 Integrated Process: Nursing Process/Implementation Content Area: Nutrition Giddens Concepts: Caregiving, Nutrition HESI Concepts: Caregiving, Health, Wellness, and Illness Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 4. 4.ID: 9477011622 Triamterene has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client are acceptable to eat while taking this medication? Select all that apply. A. Prunes B. Apples Correct C. Peaches Correct D. Avocados E. Nectarines F. Cranberries Correct Rationale: Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally high in potassium include dried prunes, avocado, bananas, fresh oranges and mangoes, nectarines, and papayas. Test-Taking Strategy: Focus on the subject, fruits that are acceptable to eat.To answer this question correctly, you need to recall that triamterene is a potassium-retaining diuretic, then identify the low-potassium foods. This will direct you to the correct options. Review: triamterene and food items high and low in potassium. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Client Education, Fluids and Electrolytes HESI Concepts: Teaching and Learning/Patient Education, Fluids and Electrolytes References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. 1233-1235) St. Louis: Saunders. Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 138). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 5. 5.ID: 9477000383Extra Credit HESI Module 7 Diverticulitis has been diagnosed in a client who has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet, during the asymptomatic period? A. Low in fat B. High in fiber Correct C. Low in residue D. High in carbohydrates Rationale: When a client’s diverticulitis is asymptomatic, a soft high-fiber diet containing fruits, vegetables, and whole grains is recommended. The client is also instructed to consume a small amount of bran daily and to take bulkforming laxatives, if prescribed, to increase stool mass and softness. Increasing fluid intake to 2500 to 3000 mL daily (unless contraindicated) is also important. A low-fat diet may be healthy but is not specific to this disorder. A highcarbohydrate diet is not helpful for the client with this condition. Test-Taking Strategy: Focus on the subject, the “asymptomatic period.” Recalling the pathophysiology of this disorder and the effects of the diets identified in the options will assist you in answering correctly. Review: dietary treatment for diverticulitis Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 995). St. Louis: Mosby. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477011688 A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the nurse tell the client are acceptable to eat? Select all that apply. A. Avocados B. Baked tuna Correct C. Green olives D. Baked potato Correct E. Fresh cherries Correct F. Cream cheeseExtra Credit HESI Module 7 Rationale: Fruits and vegetables tend to be lower in fat because they do not come from animal sources, although olives, though technically a fruit, are high in fat (as are avocados), and fish is also naturally lower in fat. Meats and dairy products (e.g., cream cheese) are higher in fat, although modifications can be made to these foods to reduce their fat content. Test-Taking Strategy: Focus on the subject, low-fat foods. Recalling that dairy products are high in fat will eliminate cream cheese. Remembering that some fruits and vegetables are high in fat will help you eliminate green olives and avocados. Review: foods high and low in fat Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 715-716). St. Louis: Mosby. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 7. 7.ID: 9477003558 A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does the nurse tell the client are acceptable to eat? Select all that apply. A. Lettuce B. Cherries Correct C. Broccoli D. Cabbage E. Potatoes Correct F. Spaghetti Correct Rationale: Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green leafy vegetables such as lettuce, broccoli, spinach, Brussels sprouts, cabbage, and turnip greens. Cherries, potatoes, and spaghetti are foods that are low in vitamin K. Test-Taking Strategy: Focus on the subject, dietary measures for the client on warfarin sodium. Recall that when a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Knowledge regarding theseExtra Credit HESI Module 7 food items will direct you to the correct options. Review: foods high and low in vitamin K Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education References: Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 105). St. Louis: Mosby. Rosenjack Burchum, Rosenthal (2016) pp. 607, 622-623 Awarded 3.0 points out of 3.0 possible points. 8. 8.ID: 9477012954 A regular diet has been prescribed for a client with a leg fracture who has been placed in skeletal traction. Which foods that will promote wound healing does the nurse encourage the client to select from the hospital menu? A. Spare ribs, rice, gelatin, tea B. Pasta, garlic bread, ginger ale C. Chicken breast, broccoli, strawberries, milk Correct D. Peanut butter and jelly sandwich, chocolate cake, tea Rationale: Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Gelatin, jelly, tea, and ginger ale have no nutritional value. Pasta, rice, and bread deliver complex carbohydrates. Spare ribs may contain some protein but are high in fat. Test-Taking Strategy: Focus on the subject, food items that promote wound healing. Eliminate pasta, garlic bread, and ginger ale first because it contains no fruits or vegetables. Review the food item presented in each option and recall that protein and vitamin C are necessary for wound healing. This will assist in answering correctly. Review: foods high in protein and vitamin C Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Nutrition Giddens Concepts: Client Education, Tissue Integrity HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 183-184). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points.Extra Credit HESI Module 7 9. 9.ID: 9476999160 A client who experienced a stroke (brain attack) is experiencing residual dysphagia. Which foods should the nurse remove from the client’s meal tray? A. Peas Correct B. Scrambled eggs C. Cheese casserole D. Mashed potatoes Rationale: In general, flavorful, warm, or well-chilled foods with texture stimulate the swallow reflex. Moist pastas, casseroles, egg dishes, and potatoes are usually well tolerated. Raw vegetables, chunky vegetables such as diced beets, stringy vegetables, and those with skin, such as corn and peas are foods commonly excluded from the diet of a client with dysphagia. Test-Taking Strategy: Focus on the subject, that the client has dysphagia. Select the food that would be most difficult to swallow; this is the correct option. Review dietary measures for a client with dysphagia. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Giddens Concepts: Intracranial Regulation, Safety HESI Concepts: Intracranial Regulation, Safety References: Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 354-355). St. Louis: Mosby. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 769-770). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9477007710 A client recovering from acute kidney injury (AKI) is being discharged home. The nurse determines that the client understands the therapeutic dietary regimen when the client states that he will plan to eat foods that are low in which substance? A. Fats B. Vitamins C. Potassium Correct D. Carbohydrates [Show Less]
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HESI Extra Credit Module 7 Exam [NEW!!] 2022 (73 Pages) 100% CORRECT - DOWNLOAD TO SCORE A+
Module 7 Exam 1. 1.ID: 22266446341 A nurse is providing information to a mother of a 1-year-old who has asked about bladder-training her child. The nurs... [Show More] e should provide which information to the mother? A. That a child cannot begin to control urination until approximately the age of 24 months Correct B. That her child is too young and that she should not yet be worrying about it C. That bowel training should be started immediately and then begin bladder training in about 1 month D. That she may start bladder training at any time Rationale: A child cannot control micturition voluntarily until he or she is approximately 24 months old. A child must be able to recognize the feeling of bladder fullness, to hold urine for 1 to 2 hours, and to communicate the sense of urgency to an adult. Telling the mother that her child is too young and to not be worrying about bladder training is a nontherapeutic response because it provides false reassurance and places the mother’s issue on hold. Bowel control develops before bladder control; however, 1 year of age is too early for the mother to begin elimination training. Test-Taking Strategy: Use therapeutic communication techniques to eliminate the option that tells the mother that her child is too young and to not be worrying about bladder training. To select from the remaining options, recall the concepts related to growth and development and elimination, which will direct you to the correct option. Review: growth and development concepts related to elimination. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Elimination Giddens Concepts: Development, Elimination HESI Concepts: Developmental, Elimination Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., p. 147). St. Louis: Mosby. Awarded 100.0 points out of 100.0 possible points. 2. 2.ID: 22266446734 A client with renal calculi is instructed to follow an alkaline ash diet. Which menu choice by the client indicates to the nurse that the client understands the prescribed regimen? A. Linguini with shrimp, tossed salad, and a plumB. Chicken, potatoes, and cranberries C. Spinach salad, milk, and a banana Correct D. Peanut butter sandwich, milk, and prunes Rationale: In an alkaline ash diet, all fruits are allowed except cranberries, prunes, and plums. The incorrect options represent components of an acid ash diet. Test-Taking Strategy: Focus on the subject, foods allowed on an alkaline ash diet. Knowledge of foods that are either included or restricted in an alkaline ash diet is necessary to answer this question. Remembering that cranberries, prunes, and plums are not allowed in an alkaline ash diet will direct you to the correct option. Review: the foods allowed in an alkaline-ash and an acid-ash diet. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Nutrition Giddens Concepts: Elimination, Nutrition HESI Concepts: Metabolism, Teaching and Learning-Patient Education Reference: Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 443-444). St. Louis: Mosby. Awarded 100.0 points out of 100.0 possible points. 3. 3.ID: 22266441990 The nurse is assigned to care for four clients. Which client does the nurse expect is likely to experience chronic pain? A. A client with a leg fracture who is in skeletal traction B. A client who has undergone appendectomy C. A client with osteoarthritis Correct D. A client with angina pectoris Rationale: Chronic pain is associated with chronic disease. The pain is prolonged, varies in intensity, and lasts longer than 6 months. The incorrect options are clients who are likely to experience acute pain. Test-Taking Strategy: Focus on the subject, chronic pain. Think about the word “chronic and note that the correct option is the only one that identifies a chronic problem. Review: the characteristics of acute and chronic pain Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Vital Signs Giddens Concepts: Caregiving, Pain HESI Concepts: Assessment, ComfortReference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 41). St. Louis: Saunders. Awarded 100.0 points out of 100.0 possible points. 4. 4.ID: 22266441971 A client arrives at the emergency department after sustaining an ankle injury, and the health care provider (HCP) prescribes the application of a cold compress to the ankle. The nurse, preparing to apply the compress, assesses the ankle and notes that it is extremely edematous. The nurse should take which action? A. Apply the cold compress for 20 minutes, and then apply a hot compress for 20 minutes B. Elevate the ankle and place cold compresses under and on top of the ankle C. Apply the cold compress to the ankle D. Consult with the HCP before applying the cold compress Correct Rationale: Cold is usually contraindicated if the site of injury is extremely edematous because it further retards circulation to the area and prevents absorption of the interstitial fluid. For this reason, applying the cold compress to the ankle and elevating the ankle and placing a cold compress under and on top of the ankle are both incorrect. The nurse would not place heat on an injury without a prescription to do so. The nurse would consult with the HCP about the prescription for cold application. Test-Taking Strategy: Eliminate the comparable or alike options that involve applying cold. To select from the remaining options, eliminate the option that involves the application of heat, because the nurse would not apply heat to an injury without a prescription to do so. Review: the principles of heat and cold applications Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making-Clinical Judgment-Critical Thinking, Perfusion Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., p. 1212). St. Louis: Mosby. Awarded 100.0 points out of 100.0 possible points. 5. 5.ID: 22266441974A client has been told to apply cold packs to a knee injury, and the client asks the nurse how this will help the injury. The nurse hould provide the clent with which information about a cold pack? A. Reduces muscle tension B. Dilates the blood vessels C. Promotes muscle relaxation D. Reduces blood flow to the extremity Correct Rationale: The application of cold reduces blood flow through its vasoconstriction action and eases localized pain. Cold also reduces the oxygen need of the tissues and promotes blood coagulation at the site of injury. The incorrect options are the effects of heat application. Test-Taking Strategy: Eliminate the comparable or alike options that are effects of heat application. Also, recall the effects of heat and cold on the blood vessels; this will help you eliminate the option that states that cold packs dilate the blood vessels. Review: the effects of heat and cold application Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Giddens Concepts: Perfusion, Pain HESI Concepts: Perfusion, Pain Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 986-987). St. Louis: Mosby. Awarded 100.0 points out of 100.0 possible points. 6. 6.ID: 22266446338 A client has been found to have a bladder infection. When planning care, which area of dysfunction would cause the nurse to monitor the client most closely for signs of a kidney infection? A. Glomerulus B. Urethra C. Nephron D. Ureterovesical junction Correct Rationale: The ureterovesical junction is the point where the ureters enter the bladder. At this junction, the ureter runs obliquely for 1.5 to 2 cm through the bladder wall before opening into the bladder. This pathway prevents the reflux of urine back into the ureter, in essence acting as a valve to prevent urine from traveling back into the ureter and up to the kidney. The urethra extends from the bladder to the opening of the body where urine is excreted. The nephrons and glomeruli are located in the kidneys. Test-Taking Strategy: Note the strategic words, most closely. Note that theclient has a bladder infection and focus on the subject, extension of the infection to the kidneys. Visualizing the anatomy of the renal system will direct you to the correct option. Review: the anatomy of the kidney Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Elimination Giddens Concepts: Elimination, Infection HESI Concepts: Elimination, Infection Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1049). St. Louis: Mosby. Awarded 100.0 points out of 100.0 possible points. 7. 7.ID: 22266447025 A nurse has administered a dose of furosemide to a client with diminished urine output. How does the nurse BEST determine effectiveness? A. The client reports less thirst as compared with yesterday B. The client reports socks which seem less tight on the ankle area C. The client’s weight remains stable, over the past two to three days D. The client’s urine output is 1500 ml more than the fluid intake Correct Rationale: Furosemide works by inducing excretion of sodium, potassium and chloride. Body fluid is also excreted. The best way to determine if the medication is effective is if the urine output is more than the fluid intake. Thirst is subjective, and not the best determinate of fluid status. Many clients can detect a change in the tightness of their socks over the ankle area, but this is subjective, not objective data. The client should lose some weight when furosemide causes fluid and sodium excretion. Test Taking Strategy: Note the strategic words “best determine effectiveness”. Use data in the question (diminished urine output) and search the options for related information regarding an increasing urine output. Eliminate the comparable or alike options that depict non-objective ways of determining effectiveness. Review: effects of furosemide Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: PharmacologyGiddens Concepts: Elimination,Fluids and Electrolytes HESI Concepts: Elimination, Fluid & Electrolyte Awarded 100.0 points out of 100.0 possible points. 8. 8.ID: 22266441987 A nurse develops a plan of care for a postoperative client who is receiving intravenous morphine sulfate every 4 hours as needed for pain. Which priority intervention does the nurse include in the plan? A. Administering the morphine sulfate around the clock B. Encouraging oral fluid intake C. Encouraging coughing and deep breathing Correct D. Maintaining the client in a supine position Rationale: Morphine sulfate can depress respiration and suppress the cough reflex, putting the postoperative client at greater risk for atelectasis and subsequent pneumonia. The client should be encouraged to cough and deepbreathe to prevent these postoperative complications. Keeping the client supine is counterproductive and could lead to atelectasis. Adequate fluid intake helps liquefy secretions, making their expulsion easier, but does not prevent atelectasis unless coughing and deep breathing is also performed. Because the medication is prescribed as needed, it would not be administered around the clock. Test-Taking Strategy: Note the strategic word “priority.” Also note that the client has just undergone surgery and is receiving morphine sulfate. Use the ABCs — airway, breathing, and circulation — to find the correct option. Review: nursing considerations related to the use of morphine sulfate Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Gas Exchange, Safety HESI Concepts: Oxygenation/Gas Exchange, Safety Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 813) St. Louis: Saunders. Awarded 100.0 points out of 100.0 possible points. 9. 9.ID: 22266447013 A nurse is instructing a client about the foods that will acidify the urine and inhibit the growth of microorganisms. Which foods does the nurse tell the client are most likely to acidify the urine? Select all that apply. A. Cabbage B. Cranberries Correct C. Broccoli D. ApplesE. Plums Correct F. Prunes Correct Rationale: Meats, eggs, whole-grain breads, cranberries, plums, and prunes increase urine acidity. These foods are metabolized into acid end-products that eventually enter the urine. The incorrect options are not food items that will acidify the urine. Test-Taking Strategy: Note the strategic words, most likely. Focus on the subject, foods that acidify the urine. Use your knowledge of the metabolism of the foods identified in the options to direct you to the correct options. Review: foods that will acidify the urine. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Renal and Urinary Giddens Concepts: Elimination, Nutrition HESI Concepts: Elimination, Teaching and Learning-Patient Education References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1494). St. Louis: Saunders. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1069). St. Louis: Mosby. Awarded 100.0 points out of 100.0 possible points. 10. 10.ID: 22266446725 A client with heart failure and hypertension who has been admitted to the hospital is unable to make own selections from the menu. Which meal does the nurse select for the client’s supper on the day of admission? A. Smoked ham, fresh carrots, boiled potato B. Shrimp, baked potato, salad with blue cheese dressing C. Turkey, baked potato, salad with oil and vinegar Correct D. Hot dog in a bun, sauerkraut, baked beans [Show Less]
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HESI Extra Credit Module 7 Exam [NEW!!] 2022 (73 Pages) 100% CORRECT - DOWNLOAD TO SCORE A+
Extra Credit HESI Module 7 1. Questions 1. 1.ID: 9477003586 The nurse is instructing a client with hypertension about foods that are low in sodium. Whi... [Show More] ch menu selections by the client indicate to the nurse that the client understands what has been taught? Select all that apply. A. Spaghetti with fresh tomatoes Correct B. Boiled lobster with baked potato C. Grilled chicken with turnip greens Correct D. Instant hot cereal with bacon E. Tomato soup with a ham sandwich Rationale: Foods that are lower in sodium include fruits and vegetables, which do not contain physiologic saline. Fresh poultry and pastas are also low in sodium. Highly processed and refined foods and luncheon meats are high in sodium unless they are specifically labeled “low sodium.” Saltwater fish and shellfish are higher in sodium. Test-Taking Strategy: Focus on the subject, selecting low-sodium foods. Begin to answer this question by eliminating boiled lobster with baked potato, because saltwater fish and shellfish are high in sodium. Next eliminate the options that contain processed foods and luncheon meats. Review: foods that are high and low in sodium Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Nutrition Giddens Concepts: Client Education, Nutrition HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education References: Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 141). St. Louis: Mosby. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby. Awarded 2.0 points out of 2.0 possible points. 2. 2.ID: 9477010158 A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate to the nurse that the client needs additional instruction? Select all that apply. A. Carrots B. Tapioca C. Scallops CorrectExtra Credit HESI Module 7 D. Broccoli E. Chicken liver Correct Rationale: Organ meats such as liver, as well as certain sea foods, including scallops, sardines, and herring, should be omitted from the diet of the client who with gout because of the high purine content. The foods identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout. Test-Taking Strategy: Note the strategic words “needs additional instruction,” which indicate a negative event query and the need to select foods that are unacceptable for this client. Recalling foods that are high in purines will direct you to the correct options. Review: dietary measures for the client with gout Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Client Education, Nutrition HESI Concepts: Health, Wellness, and Illness,Teaching and Learning/Patient Education References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 1080, 1576). St. Louis: Mosby. Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 442-443). St. Louis: Mosby. Awarded 2.0 points out of 2.0 possible points. 3. 3.ID: 9477007734 A clear liquid diet has been prescribed for client who has just undergone surgery. Which foods should the nurse offer to the client? Select all that apply. A. Custard B. Apple juice Correct C. Orange juice D. Chicken broth Correct E. Orange gelatin Correct F. Vanilla ice cream Rationale: A clear liquid diet consists of foods, such as apple juice, chicken broth, and gelatin, which are relatively transparent. Custard, orange juice, and vanilla ice cream are components of a full liquid diet. Test-Taking Strategy: Remembering that a clear liquid diet consists of foods that are relatively transparent will direct you to the correct options. Review: the foods allowed on clear liquid and full liquid diets Level of Cognitive Ability: Applying Client Needs: Physiological IntegrityExtra Credit HESI Module 7 Integrated Process: Nursing Process/Implementation Content Area: Nutrition Giddens Concepts: Caregiving, Nutrition HESI Concepts: Caregiving, Health, Wellness, and Illness Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 4. 4.ID: 9477011622 Triamterene has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client are acceptable to eat while taking this medication? Select all that apply. A. Prunes B. Apples Correct C. Peaches Correct D. Avocados E. Nectarines F. Cranberries Correct Rationale: Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally high in potassium include dried prunes, avocado, bananas, fresh oranges and mangoes, nectarines, and papayas. Test-Taking Strategy: Focus on the subject, fruits that are acceptable to eat.To answer this question correctly, you need to recall that triamterene is a potassium-retaining diuretic, then identify the low-potassium foods. This will direct you to the correct options. Review: triamterene and food items high and low in potassium. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Client Education, Fluids and Electrolytes HESI Concepts: Teaching and Learning/Patient Education, Fluids and Electrolytes References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. 1233-1235) St. Louis: Saunders. Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 138). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 5. 5.ID: 9477000383Extra Credit HESI Module 7 Diverticulitis has been diagnosed in a client who has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet, during the asymptomatic period? A. Low in fat B. High in fiber Correct C. Low in residue D. High in carbohydrates Rationale: When a client’s diverticulitis is asymptomatic, a soft high-fiber diet containing fruits, vegetables, and whole grains is recommended. The client is also instructed to consume a small amount of bran daily and to take bulkforming laxatives, if prescribed, to increase stool mass and softness. Increasing fluid intake to 2500 to 3000 mL daily (unless contraindicated) is also important. A low-fat diet may be healthy but is not specific to this disorder. A highcarbohydrate diet is not helpful for the client with this condition. Test-Taking Strategy: Focus on the subject, the “asymptomatic period.” Recalling the pathophysiology of this disorder and the effects of the diets identified in the options will assist you in answering correctly. Review: dietary treatment for diverticulitis Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 995). St. Louis: Mosby. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477011688 A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the nurse tell the client are acceptable to eat? Select all that apply. A. Avocados B. Baked tuna Correct C. Green olives D. Baked potato Correct E. Fresh cherries Correct F. Cream cheeseExtra Credit HESI Module 7 Rationale: Fruits and vegetables tend to be lower in fat because they do not come from animal sources, although olives, though technically a fruit, are high in fat (as are avocados), and fish is also naturally lower in fat. Meats and dairy products (e.g., cream cheese) are higher in fat, although modifications can be made to these foods to reduce their fat content. Test-Taking Strategy: Focus on the subject, low-fat foods. Recalling that dairy products are high in fat will eliminate cream cheese. Remembering that some fruits and vegetables are high in fat will help you eliminate green olives and avocados. Review: foods high and low in fat Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 715-716). St. Louis: Mosby. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 7. 7.ID: 9477003558 A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does the nurse tell the client are acceptable to eat? Select all that apply. A. Lettuce B. Cherries Correct C. Broccoli D. Cabbage E. Potatoes Correct F. Spaghetti [Show Less]
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HESI Extra Credit Module 8 Exam Pharmacology and Intravenous Therapies [NEW!!] 2022 (65 Pages)100%
HESI MODULE 8 QUESTIONS 1. Questions 1. 1.ID: 9476967734 A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, ... [Show More] warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse should take which action first? A. Remove the IV catheter Correct B. Slow the rate of infusion C. Notify the health care provider D. Check for loose catheter connections Rationale: Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may be indicated by client discomfort at the site or by redness, warmth, and swelling in the area of the catheter. The IV catheter should be removed and a new IV line inserted at a different site. Slowing the rate of infusion and checking for loose catheter connections are not correct responses. The health care provider would be notified if phlebitis were to occur, but this is not the initial action. Test-Taking Strategy: Note the strategic word, first. Focus on the data in the question. Eliminate slowing the rate of infusion and checking the connection, because they are comparable or alike in that they indicate continuation of IV therapy. Although the health care provider would be notified of this occurrence, the word “first” should direct you to select the option of removing the IV catheter. Review the signs of phlebitis and the actions to be taken when it occurs Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Intravenous Therapy Giddens Concepts: Clinical Judgment, Inflammation HESI Concepts: Clinical Decision-Making/Clinical Judgment, Inflammation Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 707). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9476963098 A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which action should the nurse take first? A. Remove the IV B. Sit the client up in bed C. Shut off the IV infusion Correct D. Slow the rate of infusionRationale: The client’s symptoms are indicative of speed shock, which results from the rapid infusion of drugs or a bolus infusion. In this case, the nurse would note that 400 mL has infused over 60 minutes. The first action on the part of the nurse is shutting off the IV infusion. Other actions may follow in rapid sequence: The nurse may elevate the head of the bed to aid the client’s breathing and then immediately notify the health care provider. Slowing the infusion rate is inappropriate because the client will continue to receive fluid. The IV does not need to be removed. It may be needed to manage the complication. Test-Taking Strategy: Note the question contains the strategic word “first.” Recognizing the signs of speed shock and recalling the appropriate interventions should also direct you to the option of shutting off the IV infusion. Review the initial nursing actions for speed shock Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care Giddens Concepts: Fluid and Electrolytes, Perfusion HESI Concepts: Fluid and Electrolytes, Perfusion Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 230). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9476961248 A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which action should the nurse take next? A. Remove the IV catheter B. Contact the health care provider Correct C. Change the solution to 5% dextrose in water D. Obtain a culture of the tip of the catheter device removed from the client Rationale: If the nurse suspects a transfusion reaction, the transfusion is stopped and normal saline solution infused at a keep-vein-open rate pending further health care provider prescriptions. The nurse then contacts the health care provider.. Dextrose in water is not used, because it may cause clotting or hemolysis of blood cells. Normal saline solution is the only type of IV fluid that is compatible with blood. The nurse would not remove the IV catheter, because then there would be no IV access route through which to treat the reaction. There is no reason to obtain a culture of the catheter tip; this is done when an infection is suspected. Test-Taking Strategy: Note the strategic word “next.” Knowing that the IV should not be removed will assist you in the elimination process. Recalling that normal saline solution is the only type of IV fluid that is compatible with blood will also help you answer correctly. To select from the remaining options, note that infection is not the concern; this will help you eliminate the option of obtaining a culture of the catheter tip. Review care of the client experiencing a transfusion reaction Level of Cognitive Ability: Applying Client Needs: Physiological IntegrityIntegrated Process: Nursing Process/Implementation Content Area: Blood administration Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 740-741). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9476963017 The nurse determines that the client is exhibiting signs of a hemolytic transfusion reaction while receiving a blood transfusion. The nurse should perform these actions in which priority order? Arrange the actions in the order that they should be performed. All options must be used. Correct A. Stopping the infusion of blood B. Hanging an IV bag of normal saline solution (NS) at a keep-vein-open (KVO) rate C. Notifying the health care provider D. Obtaining vital signs/oxygen saturation E. Documenting the findings Rationale: If a transfusion reaction is suspected, the transfusion is immediately stopped and NS infused, pending further primary health care provider prescriptions. Ensuring patent IV access also helps maintain the client’s intravascular volume. NS is the solution of choice, rather than solutions containing dextrose, because red blood cells do not clump with NS. Next, the primary health care provider should be notified because this is an emergency situation. Vital signs and oxygen saturation are monitored closely. Finally, the nurse documents the findings and the client’s response to the interventions. Test-Taking Strategic: Note the strategic word, priority. Note that the client is experiencing a hemolytic transfusion reaction an emergency condition. The question sets forth the problem; the nurse must determine the order in which interventions should be performed. First, the blood transfusion is stopped and an isotonic solution infused. Next the nurse should notify the primary healthcare provider, check vital signs and oxygen saturation data, and assess the client closely. Once prescriptions from the primary healthcare provider have been initiated, the nurse should document the event and client’s response. Review the prioritization of interventions for a transfusion reaction Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Blood Administration Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 740-741). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points.2. 5.ID: 9476964571 A client with heart failure is being given furosemide and digoxin. The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first? A. Administer an antiemetic B. Administer the daily dose of digoxin C. Discontinue the morning dose of furosemide D. Checkthe result of laboratory testing for potassium on the sample drawn 3 hours ago Correct Rationale: Anorexia and nausea are symptoms commonly associated with digoxin toxicity, which is compounded by hypokalemia. Early clinical manifestations of digoxin toxicity include anorexia and mild nausea, but they are frequently overlooked or not associated with digoxin toxicity. Hallucinations and any change in pulse rhythm, color vision, or behavior should be investigated and reported to the health care provider. The nurse should first check the results of the potassium level, which will provide additional when the nurse calls the health care provider,an important follow-up action. The nurse should also check the digoxin reading if one is available. The nurse would not administer an antiemetic without further investigating the client’s problem. Because digoxin toxicity is suspected, the nurse would withhold the digoxin until the health care provider has been consulted. The nurse would not discontinue a medication without a prescription to do so. Test-Taking Strategy: Note the strategic word “first” and use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Review nursing interventions for suspected digoxin toxicity Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Giddens Concepts: Cellular Regulation, Clinical Judgment HESI Concepts: Cellular Regulation, Clinical Decision-Making/Clinical Judgment References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 363) St. Louis: Saunders. Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 753). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 2. 6.ID: 9476961282 The health care provider (HCP)prescribes the administration of totalparenteral nutrition (TPN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the TPN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse should take which immediate action? A. Obtain blood for culture B. Clamp the TPN infusion line Correct C. Obtain an electrocardiogram (ECG) D. Obtain a sample for blood glucose testingRationale: One complication of a subclavian central line is embolism, caused by air or thrombus. Sudden onset of chest pain shortly after the initiation of TPN may mean that this complication has developed. The infusion is clamped (the line should not be discontinued, however), the client turned on the left side with the head down, and the HCP notified immediately. Depending on agency protocol, the rapid response team would also be called. Blood cultures are not necessary in this situation, because infection is not the concern. Likewise, there is no useful reason for checking the blood glucose level. An ECG may be obtained, but this is not the immediate priority. If the client shows signs of an air embolism, the nurse should examine the catheter to determine whether an open port has allowed air into the circulatory system. Test-Taking Strategy: Note the strategic word “immediate.” Focus on the data provided in the question to determine that an embolus has occurred. Eliminate blood cultures and blood glucose testing, which, respectively, relate to infection and hyperglycemia, which is not likely to occur during the first 2 hours of TPN administration. To select from the remaining options, focus on the strategic word “immediate”; this will direct you to the correct option. Review the complications of TPN and the associated nursing interventions Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: TotalParenteral Nutrition Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion-Clotting Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 311). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 3. 7.ID: 9476957598 The health care provider prescribes 2000 mL of 5% dextrose and normal saline 0.45% for infusion over 24 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number). Correct Correct Responses A. 21 Rationale: Use the IV flow rate formula: Test-Taking Strategy: Focus on the information in the question. Use the formula for calculatingIV flow rates when answering the question. Remember to convert 24 hours to minutes and to round the answer to the nearest whole number. Review IV infusion rates Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Intravenous Therapy Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 710-711). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 2. 8.ID: 9476963091 A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the insertion site. What should the nurse do first? A. Remove the IV Correct B. Apply a warm compress C. Check for blood return D. Measure the area of infiltration [Show Less]
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HESI Extra Credit Module 8 Exam Pharmacology and Intravenous Therapies [NEW!!] 2022 (78 Pages)100%
Module 8
Questions
1. 1.ID: 383694396
A physician’s prescription reads, “Phenytoin (Dilantin) 0.1 g by mouth twice daily.”
The medication label i... [Show More] ndicates that the bottle contains 100-mg capsules. How
many capsules does the nurse prepare for administration of one dose?
Correct
Correct Responses: "1"
Rationale: Convert 0.1 g to milligrams: 1000 mg = 1 g; therefore 0.1 g =
100 mg. Next use the medication
formula:
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IMG src="/objects/NCLEX/silvestri1e_v1/mod_08/images/exam/M08Q044E02.gif"
border=0>
Test-Taking
Strategy: First, convert 0.1 g to mg. Next. follow the formula for the calculation
of the correct dose. Recheck your work and ensure that the answer makes sense. If
you had difficulty with this question, review medication calculation
problems.
Level
of Cognitive Ability:
Applying
<
i>
Client
Needs: Physiological
Integrity
<
i>
Integrat
ed Process: Nursing
Process/Implementation
Content Area: Medication
Calculations
Refe
rence: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.,
pp. 695-699). St. Louis: Mosby.
Awarded 1.0 out of 1.0 possible points.
2. 2.ID: 383694320A client has a prescription for short-term therapy with enoxaparin (Lovenox). The
nurse explains to the client that this medication is being prescribed to:
A. Prevent pain
B. Relieve back spasms
C. Increase the client’s energy level
D. Reduce the risk of deep vein thrombosis Correct
Rationale: Enoxaparin is an anticoagulant that is administered to prevent deep
vein thrombosis and thromboembolism in selected at-risk clients. It is not used to
prevent pain, relieve back spasms, or increase the energy level.
Test-Taking Strategy: To answer this question accurately, it is necessary to be
familiar with this medication and its intended effects. Recalling that this medication
is an anticoagulant will direct you to the correct option. Review the action of this
medication if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Reference: Lehne, R. (2010). Pharmacology for nursing care (7th ed., p. 602). St.
Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 383695637
A client receiving parenteral nutrition (PN) requires fat emulsion (lipids), which will
be piggybacked to the PN solution. On obtaining a bottle of fat emulsion, the nurse
notes that fat globules are floating at the top of the solution. Which of these
actions should the nurse take?
A. Shaking the bottle vigorously
B. Requesting a new bottle from the pharmacy Correct
C. Rotating the bottle gently back and forth to mix the globules
D. Running the bottle under warm water until the globules disappear
Rationale: The nurse should not hang a fat emulsion that contains visible fat
globules. Another bottle of solution should be obtained and used in its place. When
PN is combined with fat emulsion, the solution should not be used if there is a
visible “ring” noted in the container of solution. The actions in the other options are
incorrect.
Test-Taking Strategy: Remember that options that are comparable or alike are not
likely to be correct. With this in mind, eliminate rotating the bag and shaking thebottle first. To select from the remaining options, think about the significance of
seeing fat globules in the solution and imagine the potential adverse effect of fat
globules in the client’s bloodstream. This will direct you to the correct option.
Review the procedures for administration of fat emulsion if you had difficulty with
this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Parenteral Nutrition
Reference: Gahart, B., & Nazareno, A. (2010). 2010 intravenous medications (26th
ed., p. 576). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 383695130
Risperidone (Risperdal) is prescribed for a client with a diagnosis of schizophrenia.
Which laboratory study does the nurse expect to see among the physician’s
prescriptions?
A. Platelet count Correct
B. Creatinine level
C. Sedimentation rate
D. Red blood cell count
Rationale: Baseline assessment includes renal and liver function parameters.
Risperidone is used with caution — often at a reduced dosage — in clients with
renal or hepatic impairment, clients with underlying cardiovascular disorders, and
in older or debilitated clients. The laboratory tests identified in the other options
are not necessary.
Test-Taking Strategy: Use the process of elimination. Recalling that this medication
is used with caution in clients with renal or hepatic failure will direct you to the
correct option. Review this medication if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: PharmacologyReference: Kee, J., Hayes, E., & McCuistion, L. (2009). Pharmacology: A nursing
process approach (6th ed., p. 402). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 383695122
The serum theophylline level of a client who is taking the medication (Theo-24) is
16 mcg/mL. On the basis of this result, the nurse will initially:
A. Document the normal value on the chart Correct
B. Call the healthcare provider immediately
C. Call the rapid response team to help with the emergency
D. Call the pharmacy to alert the pharmacist regarding the client’s
theophylline level
Rationale: The normal therapeutic range for theophylline is 10 to 20 mcg/mL. A
level above 20 mcg/mL is considered toxic. A value of 16 mcg/mL is within the
therapeutic range.
Test-Taking Strategy: Specific knowledge regarding the therapeutic range for this
medication is necessary to answer this question. Recalling that the normal
therapeutic range for theophylline levels is 10 to 20 mcg/mL will direct you to the
correct option. Review the nursing considerations related to this medication if you
had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Reference: Kee, J., Hayes, E., & McCuistion, L. (2009). Pharmacology: A nursing
process approach (6th ed., p. 608). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 383695614
A nurse has obtained a unit of blood from the blood bank and properly checked the
blood bag with another nurse. Which of the following parameters does the nurse
assess just before hanging the transfusion?
A. Skin color
B. Vital signs Correct
C. Latest platelet count
D. Urine output over the last 24 hours
Rationale: A change in vital signs may indicate that a transfusion reaction is
occurring. This is why the nurse assesses vital signs before the procedure, every
15 minutes for the first half-hour, and every half-hour thereafter. The other optionsdo not need to be assessed just before the start of a transfusion. The nurse should
be aware of fluid volume status, as well as weight. to help identify fluid volume
overload, but this is not the priority before start of a blood infusion.
Test-Taking Strategy: The strategic words in the question are “just before,” which
tell you that the correct option must be assessed for possible comparison during
the transfusion. Use the ABCs (airway, breathing, and circulation) to find the
correct option. Review the procedure for administering blood if you had difficulty
with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Blood administration
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
Patient-centered collaborative care (6th ed., p. 918). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 383694391
At 1300, the nurse is documenting the receipt of a unit of packed blood cells at the
hospital blood bank. The nurse calculates that the transfusion must be started by:
A. 1315
B. 1330 Correct
C. 1345
D. 1400
Rationale: Blood must be hung within 30 minutes after obtaining it from the blood
bank. After that time, the temperature of the blood becomes warm and could be
unsafe for use. Therefore 1345 and 1400 are incorrect. It is not necessary to hang
the blood within 15 minutes of receiving it from the blood bank.
Test-Taking Strategy: Knowledge of the standard procedures related to blood
administration is needed to answer this question correctly. Remember that blood
must be hung within 30 minutes after obtaining it from the blood bank. Review this
procedure if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/PlanningContent Area: Blood Administration
References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
Patient-centered collaborative care (6th ed., p. 918). St. Louis: Saunders.
Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 792).
St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
8. 8.ID: 383697107
A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One
hour later the client complains of chest tightness, is dyspneic and apprehensive,
and has an irregular pulse. The IV bag has 100 mL remaining. Which of the
following actions should the nurse take first?
A. Removing the IV
B. Sitting the client up in bed
C. Shutting off the IV infusion Correct
D. Slowing the rate of infusion
Rationale: The client’s symptoms are indicative of speed shock, which results from
the rapid infusion of drugs or a bolus infusion. In this case, the nurse would note
that 400 mL has infused over 60 minutes. The first action on the part of the nurse
is shutting off the IV infusion. Other actions may follow in rapid sequence: The
nurse may elevate the head of the bed to aid the client’s breathing and then
immediately notify the healthcare provider. Slowing the infusion rate is
inappropriate because the client will continue to receive fluid. The IV does not need
to be removed. It may be needed to manage the complication.
Test-Taking Strategy: Use the process of elimination, focusing on the data in the
question. Note the question contains the strategic word “first.” Recognizing the
signs of speed shock and recalling the appropriate interventions should also direct
you to the option of shutting off the IV infusion. Review the initial nursing actions
for speed shock if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
Patient-centered collaborative care (6th ed., p. 230). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.9. 9.ID: 383694370
A client taking hydrochlorothiazide reports to the clinic for follow-up blood tests.
For which side effect of the medication does the nurse monitor the client’s
laboratory results?
A. Hypokalemia Correct
B. Hypocalcemia
C. Hypernatremia
D. Hypermagnesemia
Rationale: The client taking a potassium-wasting diuretic such as
hydrochlorothiazide must be monitored for reductions in the potassium level. Other
fluid and electrolyte imbalances that may occur with use of this medication are
hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia. The
nurse should also educate the client about foods that are rich in potassium.
Test-Taking Strategy: Use the process of elimination, recalling that most thiazide
diuretics names end with -zide. Remembering that hypokalemia is a concern when
a client is taking a potassium-wasting diuretic will direct you to the correct option.
If this question was difficult for you, review the side effects of this medication.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Reference: Edmunds, M. (2010). Introduction to clinical pharmacology (6th ed., p.
236). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
10. 10.ID: 383697122
A nurse is caring for a client with a diagnosis of chronic renal failure who is
receiving dialysis. Epoetin alfa (Epogen), to be administered subcutaneously, has
been prescribed, and the nurse is drawing the medication from a single-use vial.
The nurse should prepare the medication by:
A. Shaking the vial before drawing up the medication
B. Drawing up the medication and discarding the unused portion Correct
C. Obtaining the medication from the medication freezer and allowing it to
thaw
D. Mixing the medication with 0.1 mL of heparin before administration to
prevent clotting [Show Less]
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HESI Extra Credit Module 8 Exam Pharmacology and Intravenous Therapies [NEW!!] 2022 (55 Pages)100%
A client is receiving total parenteral nutrition (TPN) with fat emulsion (lipids) piggybacked to the TPN solution. For which signs of an adverse reaction ... [Show More] to the fat emulsion should the nurse monitor the client? Select all that apply. A. Chest and back pain Correct B. Nausea and vomiting Correct C. Chills Correct D. Headache Correct E. Pallor F. Subnormal temperature Rationale: Signs of an adverse reaction to fat emulsion include chest and back pain, chills, fever, dyspnea, cyanosis, diaphoresis, flushing, headache, nausea and vomiting, pressure over the eyes, vertigo, and thrombophlebitis at the infusion site. Test-Taking Strategy: Focus on the subject, adverse effects of fat emulsion. Recalling that fever and flushing occur will assist you in answering correctly. Specific knowledge about these adverse effects is needed to select the remaining correct options. Review: the signs of an adverse reaction to fat emulsion Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Total Parenteral Nutrition Giddens Concepts: Clinical Judgment, Immunity HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Immunity Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p. 528). St. Louis: Mosby. Awarded 99.0 points out of 99.0 possible points. 2.ID: 21553033022 A nurse has just hung a transfusion of packed red blood cells and stayed with the client for the appropriate amount of time. Before leaving the room, the nurse tells the client that it is most important to immediately report which specific signs if it occurs? Select all that apply. A. Fatigue B. TirednessC. Rash Correct D. Chills Correct E. Backache Correct Rationale: The nurse should instruct the client to report signs of a transfusion reaction, such as a backache, chills, itching, or rash, immediately. If a transfusion reaction occurs, the nurse would stop the transfusion immediately. Fatigue and tiredness are not specifically related to a transfusion reaction. Test-Taking Strategy: Note the strategic words “most important” and “immediately.” Eliminate the comparable or alike options (fatigue and tiredness). Review: the signs of a transfusion reaction Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Blood Administration Giddens Concepts: Immunity, Perfusion HESI Concepts: Immunity, Perfusion Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 749). St. Louis: Mosby. Awarded 99.0 points out of 99.0 possible points. 3.ID: 21553032642 Disulfiram is prescribed for a client. Which questions does the nurse make a priority of asking the client before administering this medication? Select all that apply. A. “Do you have a history of thyroid problems?” Correct B. “Do you have a history of cancer in your family?” C. “Do you have a history of diabetes insipidus?” D. “When was your last drink of alcohol?” Correct E. “When did you have your last full meal?” Rationale: Disulfiram is used as an adjunct treatment for selected clients with alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important question is when the client had his last drink of alcohol. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in cases of severe heart disease, psychosis, or hypersensitivity to the medication. Test-Taking Strategy: Note the strategic word, priority. Recalling that the medication is used as an adjunct treatment for selected clients with alcoholism will help direct you to the option in which the client is asked when he consumed his last alcoholic drink. To find the other correct options, it is necessary to know the contraindications to the use of disulfiram. Review: the effects of disulfiram. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology Giddens Concepts:Addiction, Safety HESI Concepts: Behaviors, Safety Reference: Rosenjack Burchum, Rosenthal (2016) pp. 421-422 Awarded 99.0 points out of 99.0 possible points.4.ID: 21553033015 A client who needs to receive a blood transfusion has experienced a pruritic rash during previous transfusions. The client asks the nurse whether it is safe to receive the transfusion. Which medication does the nurse anticipate will most likely be prescribed before the transfusion? A. Acetaminophen B. Diphenhydramine Correct C. Ibuprofen D. Acetylsalicylic acid Rationale: An urticarial reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine, such as diphenhydramine. Acetaminophen and acetylsalicylic acid are analgesics; ibuprofen is a nonsteroidal antiinflammatory medication. Test-Taking Strategy: Note the strategic words, most likely. To answer this question correctly, it is necessary to be familiar with this particular type of reaction and the medication that may be used in its prevention. Recalling that diphenhydramine is an antihistamine will direct you to the correct option. Review: the procedure for administering a blood transfusion Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Blood Administration Giddens Concepts: Clinical Judgment, Immunity HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Immunity Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 900). St. Louis: Saunders. Awarded 99.0 points out of 99.0 possible points. 5.ID: 21553033533 Zidovudine is prescribed for an adult client with HIV infection. The nurse should provide which instruction to the client about the medication? A. That the medication must be taken with milk B. That aspirin can be taken to treat headache C. To discontinue the medication if nausea occurs D. To space the doses evenly around the clock Correct Rationale: The adult dosage of zidovudine is usually 200 mg every 8 hours or 300 mg every 12 hours. The client is instructed to space doses of the medication evenly around the clock. Food or milk does not affect the gastrointestinal absorption of the medication. The client is instructed to continue therapy for the full prescribed duration of treatment. The client is also instructed not to take any medication, including aspirin, without the health care provider’s approval. Test-Taking Strategy: Focus on the subject, client instructions for taking zidovudine. Knowledge of the basic principles of medication administration will assist you in eliminating the option referring to discontinuation of the medication. To select from the remaining options, recall that this medication is an antiviral, which will direct you to the correct option. Remember that evenly spaced doses are necessary to maintain virustatic concentrations of the medication. Review: client teaching points for zidovidine Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Giddens Concepts:Immunity, SafetyHESI Concepts: Immunity, Safety Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. 1294- 1295) St. Louis: Saunders. Awarded 99.0 points out of 99.0 possible points. 6.ID: 21553033518 A client with a thoracic spinal cord injury is receiving dantrolene sodium. Which statement by the client indicates to the nurse that the client is experiencing an adverse effect of the medication? A. “I’m feeling really drowsy.” Correct B. “I urinate about the same amount as I always did.” C. “My legs are very relaxed.” D. “I can’t seem to get enough to eat.” Rationale: Drowsiness, diarrhea, and hepatotoxicity are the adverse effects of this muscle relaxant, which is used to treat the chronic spasticity seen with spinal cord injury. The drowsiness may interfere with the client’s rehabilitation. Relaxed legs are a desired effect. Some clients experience anorexia and urinary frequency. Test-Taking Strategy: Focus on the subject, an adverse effect of a medication. Relaxed legs are a desired effect, so eliminate this option. To select from the remaining options, recall that this medication is a muscle relaxant. This will direct you to the correct option. Review: the adverse effects of dantrolene sodium Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Intracranial Regulation HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Intracranial Regulation Reference: Rosenjack Burchum, Rosenthal (2016) p. 244 Awarded 99.0 points out of 99.0 possible points. 7.ID: 21553033578 A home care nurse has been assigned a client who has been discharged home with a prescription for total parenteral nutrition (TPN). Which parameters does the nurse plan to check at each visit as a means of identifying complications of the TPN therapy? Select all that apply. A. Weight Correct B. Glucose test Correct C. Temperature Correct D. Peripheral pulses E. Hemoglobin and hematocrit Rationale: When a client is receiving TPN therapy, the nurse monitors the client’s weight to determine the effectiveness of the therapy. The nurse should weigh the client at each visit to make sure that the client has not gained or lost an excessive amount of weight. Because the formula contains a large amount of dextrose, the health care provider should check the client’s glucose level frequently. The nurse caring for a client receiving TPN at home should also monitor the temperature to detect infection, which is a potential complication of this therapy. An infection in the intravenous line could result in sepsis, because the catheter is in a blood vessel. The peripheral pulses andhemoglobin and hematocrit readings may provide data but are unrelated to complications associated with TPN therapy. Test-Taking Strategy: Focus on the subject, complications associated with TPN therapy. Think about the procedures involved with the administration of TPN and the associated complications to answer correctly. Review: the priority assessments in the client receiving TPN Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Total Parenteral Nutrition Giddens Concepts: Fluids and Electrolytes, Nutrition HESI Concepts: Fluid & Electrolyte, Metabolism Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 800). St. Louis: Mosby. Awarded 99.0 points out of 99.0 possible points. 8.ID: 21553032611 Phenelzine sulfate is being administered to a client with depression. The client suddenly complains of a severe frontally radiating occipital headache, neck stiffness and soreness, and vomiting. On further assessment, the client exhibits signs of hypertensive crisis. Which medication should the nurse prepare to administer, anticipating that it will be prescribed as the antidote to treat phenelzine-induced hypertensive crisis? A. Protamine sulfate B. Phentolamine Correct C. Acetylcysteine D. Calcium gluconate Rationale: The antidote to treat phenelzine-induced hypertensive crisis is phentolamine. Hypertensive crisis may manifest as hypertension, frontally radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia or bradycardia and constricting chest pain may also be present. Test-Taking Strategy: Focus on the subject, the antidote to treat phenelzine-induced hypertensive crisis. Protamine sulfate and calcium gluconate may be easily eliminated, because protamine sulfate is the antidote to heparin and calcium gluconate is used in cases of magnesium overdose. To select from the remaining options, it is necessary to recall that acetylcysteine is the antidote to acetaminophen. Review: the antidote to treat phenelzine-induced hypertensive crisis Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Mood and Affect, Safety HESI Concepts: Mood & Affect, Safety Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 952) St. Louis: Saunders. Awarded 99.0 points out of 99.0 possible points.9.ID: 21553033010 The health care provider prescribes 1000 mL of 5% dextrose in water to be infused over 8 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number). _______ Correct Correct Responses 1. 31 .//assessment[9]/question[62]/question_correct_feedback/text() Awarded 99.0 points out of 99.0 possible points. 10.ID: 21553033097 The first bag of total parenteral nutrition (TPN) solution has arrived on the clinical unit for a client beginning this nutritional therapy. The solution is to be infused by way of a central line. Which essential piece of equipment should the nurse obtain before hanging the solution? A. Electronic infusion device Correct B. Pulse oximeter C. Noninvasive blood pressure monitor D. Blood glucose meter [Show Less]
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HESI Extra Credit Module 9 Exam Monitoring for Health Problems [NEW!!] 2022 (75 Pages) 100% CORRECT
Extra Credit HESI Module 9 1. Questions 1. 1.ID: 9477047208 A client who has undergone abdominal surgery calls the nurse and reports that she just felt... [Show More] “something give way” in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? A. Document the findings B. Contact the health care provider C. Place the client in a supine position with the legs flat D. Cover the abdominal wound with a sterile dressing moistened with sterile saline solution Correct Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in a low Fowler’s position or supine with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The health care provider is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response. Test-Taking Strategy: Note the strategic word “immediate.” Visualize this occurrence and recall that the primary concern when wound dehiscence occurs is the protrusion of underlying tissues. This will direct you to the correct option. Review the nursing actions to be taken immediately in the event of wound dehiscence Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care Giddens Concepts: Caregiving, Tissue Integrity HESI Concepts: Caregiving, Tissue Integrity Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9477054249 A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The nurse should take which immediate action? A. Notify the surgeon Correct B. Continue the assessmentExtra Credit HESI Module 9 C. Check the client’s blood pressure D. Obtain a flashlight, gauze, and a curved hemostat Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the client vomits a large amount of bright-red blood or the pulse rate increases and the patient is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse should also gather additional assessment data, but the surgeon must be contacted immediately. Test-Taking Strategy: Note the strategic word, immediate. Noting the words “bright-red blood” will assist in directing you to the correct option. Remember that the presence of bright-red blood indicates active bleeding. Review the nursing actions to be taken immediately when bleeding occurs after a tonsillectomy and adenoidectomy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situation/Management Giddens Concepts: Collaboration, Clotting HESI Concepts: Collaboration/Managing Care, Perfusion-Clotting Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 644). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9477051455 A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? A. Preparing the client for a perfusion scan B. Attaching the client to a cardiac monitor C. Administering oxygen by way of nasal cannula Correct D. Ensuring that the intravenous (IV) line is patent Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the health care provideris notified. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for arterial blood gas determinations drawn. The immediate priority, however, is the administration of oxygen. Test-Taking Strategy: Focus on the client’s diagnosis and use the skills ofExtra Credit HESI Module 9 prioritizing. Use the ABCs (airway, breathing, and circulation) to find the correct option. Review the nursing actions to be taken immediately in the event of pulmonary embolism Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situation/Management Giddens Concepts: Perfusion, Clotting HESI Concepts: Oxygenation/Gas Exchange, Perfusion-Clotting Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 552). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9477051498 A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). A. Clamp the chest tube B. Chang the drainage system C. Assess the system for an external air leak Correct D. Reduce the degree of suction being applied E. Document assessment findings, actions taken, and client response Correct Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not present and the air leak is a new occurrence, the health care provider is notified immediately, because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped unless this has been specifically prescribed in the agency’s policies and procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of suction being applied will not affect the bubbling in the water seal chamber and could be harmful. The nurse would document the assessment findings and interventions taken in the client’s medical record. Test-Taking Strategy: Focus on the data in the question, noting that there is bubbling in the water seal chamber. Use knowledge regarding the priority actions in the care of a closed chest tube drainage system. Recalling that this may indicate an air leak will direct you to the correct options. Review theExtra Credit HESI Module 9 nursing actions to be taken immediately in the event that complications of a closed chest tube drainage system occur Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situation/Management Giddens Concepts: Care Coordination, Gas Exchange HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby. Awarded 2.0 points out of 2.0 possible points. 5. 5.ID: 9477055619 A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? A. Reinsert the chest tube B. Contact the health care provider C. Transfer the client back to bed D. Cover the insertion site with a sterile occlusive dressing Correct Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the client back into bed, and contacts the health care provider. The nurse does not reinsert the chest tube. The health care provider will reinsert the chest tube as necessary. Test-Taking Strategy: Note the strategic word “immediate.” Eliminate the option that involves reinsertion of the chest tube first, because a nurse is not trained to insert a chest tube. To select from the remaining options, focus on the subject, dislodgment of a chest tube from its insertion site, and recall the complications associated with this occurrence; this will direct you to the correct option. Review the nursing actions to be taken immediately in the event of complications associated with a closed chest tube drainage system Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situation/Management Giddens Concepts: Care Coordination, Gas ExchangeExtra Credit HESI Module 9 HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477047967 A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? A. Continue suctioning to remove the blood B. Check the degree of suction being applied Correct C. Encourage the client to cough out the bloody secretions D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth [Show Less]
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HESI Extra Credit Module 9 Exam Monitoring for Health Problems [NEW!!] 2022 (71 Pages) 100% CORRECT
A client who has undergone abdominal surgery calls the nurse and reports that she just felt ID: 18630135763 “something give way” in the abdominal inci... [Show More] sion. The nurse checks the incision and notes the presence of wound dehiscence. The nurse immediately takes which action? A. Contacts the health care provider B. Documents the findings C. Places the client in a supine position with the legs flat D. Covers the abdominal wound with a sterile dressing moistened with sterile saline solution C Co or rr re ec ct t Rationale: Rationale: W Wound dehiscence is the disruption of a surgical incision or wound. When ound dehiscence is the disruption of a surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in a low Fowler position or supine dehiscence occurs, the nurse immediately places the client in a low Fowler position or supine with the knees bent and instructs the client to lie quietly with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion . These actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The health care provider is notified, and the nurse documents the occurrence with sterile saline. The health care provider is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response. and the nursing actions that were implemented in response. T Test-T est-Taking Strategy: aking Strategy: Use Use the process of elimination and note the strategic word “immediately the process of elimination and note the strategic word “immediately.” .” V Visualize this occurrence and recall that the primary concern when wound dehiscence occurs is isualize this occurrence and recall that the primary concern when wound dehiscence occurs is the protrusion of underlying tissues. This will direct you to the correct option. Review the nursing the protrusion of underlying tissues. This will direct you to the correct option. Review the nursing actions to be taken immediately in the event of wound dehiscence if you had dif actions to be taken immediately in the event of wound dehiscence if you had difficulty with this ficulty with this question. question. Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying Client Needs: Client Needs: Physiological Integrity Physiological Integrity Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Perioperative Care Perioperative Care A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. 1.A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is ID: 18630135725 restless and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. Which is the immediate nursing action? A. Notify the surgeon. C Co or rr re ec ct t Rationale: Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the . If the client vomits a large amount of bright-red blood or the pulse rate increases and the patient is client vomits a large amount of bright-red blood or the pulse rate increases and the patient is restless, the nurse must notify the surgeon immediately restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror . The nurse should obtain a light, mirror, , gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse should also gather additional data, but the surgeon must be contacted immediately should also gather additional data, but the surgeon must be contacted immediately. . T Test-T est-Taking Strategy: aking Strategy: Focus on the data in the question. Noting the words “bright-red blood” will Focus on the data in the question. Noting the words “bright-red blood” will assist in directing you to the correct option. Remember that the presence of bright-red blood assist in directing you to the correct option. Remember that the presence of bright-red blood indicates active bleeding. Review the nursing actions to be taken immediately when bleeding indicates active bleeding. Review the nursing actions to be taken immediately when bleeding occurs after a tonsillectomy and adenoidectomy if you had dif occurs after a tonsillectomy and adenoidectomy if you had difficulty with this question. ficulty with this question. Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying Client Needs: Client Needs: Physiological Integrity Physiological Integrity Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Delegating/Prioritizing Delegating/Prioritizing B. Auscultate the lungs. C. Check the client’s blood pressure. D. Obtain a flashlight, gauze, and a curved hemostat. A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. 2. A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and ID: 18630135170 tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately takes which action? A. Preparing the client for a perfusion scan B. Attaching the client to a cardiac monitor C. Administering oxygen by way of nasal cannula C Co or rr re ec ct t Rationale: Rationale: Pulmonary embolism is a life-threatening emergency Pulmonary embolism is a life-threatening emergency. Oxygen is immediately . Oxygen is immediately administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the health care provider is notified. IV infusion lines are needed to administer medications or fluids. health care provider is notified. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for A perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for the presence of dysrhythmias. Additionally the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for , a urinary catheter may be inserted and blood for arterial blood gas determinations drawn. The immediate priority arterial blood gas determinations drawn. The immediate priority, however , however, is the administration , is the administration of oxygen. of oxygen. 3.T Test-T est-Taking Strategy: aking Strategy: Focus on the client’ Focus on the client’s diagnosis and use the skills of prioritizing. Apply the s diagnosis and use the skills of prioritizing. Apply the ABCs (airway ABCs (airway, breathing, and circulation) to find the correct option. Review the nursing actions , breathing, and circulation) to find the correct option. Review the nursing actions to be taken immediately in the event of pulmonary embolism if you had dif to be taken immediately in the event of pulmonary embolism if you had difficulty with this ficulty with this question. question. Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying Client Needs: Client Needs: Physiological Integrity Physiological Integrity Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Delegating/Prioritizing Delegating/Prioritizing D. Ensuring that the intravenous (IV) line is patent A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes ID: 18630135190 constant bubbling in the water seal chamber. What actions should the nurse take? Select all that apply. A. Clamping the chest tube B. Changing the drainage system C. Assessing the system for an external air leak C Co or rr re ec ct t D. Reducing the degree of suction being applied E. Documenting assessment findings, actions taken, and client response C Co or rr re ec ct t Rationale: Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber an external air leak if constant bubbling were noted in this chamber. If an external air leak is not present . If an external air leak is not present and the air leak is a new occurrence, the health care provider is notified immediately because an air and the air leak is a new occurrence, the health care provider is notified immediately because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped , a chest tube is not clamped unless this has been specifically prescribed in the agency’ unless this has been specifically prescribed in the agency’s policies and procedures. Changing the s policies and procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of suction being applied will not drainage system will not alleviate the problem. Reducing the degree of suction being applied will not af affect the bubbling in the water seal chamber and could be harmful. The nurse would document the fect the bubbling in the water seal chamber and could be harmful. The nurse would document the assessment findings and interventions taken in the client’ assessment findings and interventions taken in the client’s medical record. s medical record. T Test-T est-Taking Strategy: aking Strategy: Use the process of elimination and your knowledge regarding the priority actions Use the process of elimination and your knowledge regarding the priority actions in the care of a closed chest tube drainage system. Focus on the data in the question, noting that there in the care of a closed chest tube drainage system. Focus on the data in the question, noting that there is bubbling in the water seal chamber is bubbling in the water seal chamber. Recalling that this may indicate an air leak will direct you to the . Recalling that this may indicate an air leak will direct you to the correct options. Review the nursing actions to be taken immediately in the event that complications of a correct options. Review the nursing actions to be taken immediately in the event that complications of a closed chest tube drainage system occur if you had dif closed chest tube drainage system occur if you had difficulty with this question. ficulty with this question. Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying 4.Client Needs: Client Needs: Physiological Integrity Physiological Integrity Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Adult Health/Respiratory Adult Health/Respiratory A Awarded 2.0 points out of 2.0 possible points. warded 2.0 points out of 2.0 possible points. A nurse is helping a client with a closed chest tube drainage system get out of bed and into a ID: 18630135172 chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. The immediate priority on the part of the nurse is which action? A. Contacting the health care provider B. Reinserting the chest tube C. Transferring the client back to bed D. Covering the insertion site with a sterile occlusive dressing C Co or rr re ec ct t Rationale: Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the If a chest tube is dislodged from the insertion site, the nurse immediately covers the site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the client back into bed, and contacts the health care provider client back into bed, and contacts the health care provider. The nurse does not reinsert the . The nurse does not reinsert the chest tube. The health care provider will reinsert the chest tube as necessary chest tube. The health care provider will reinsert the chest tube as necessary. . T Test-T est-Taking Strategy: aking Strategy: Use the process of elimination, noting the strategic word “immediate.” Use the process of elimination, noting the strategic word “immediate.” Eliminate the option that involves reinsertion of the chest tube first because a nurse does not Eliminate the option that involves reinsertion of the chest tube first because a nurse does not have the required education to insert a chest tube. T have the required education to insert a chest tube. To select from the remaining options, focus o select from the remaining options, focus on the subject, dislodgment of a chest tube from its insertion site, and recall the complications on the subject, dislodgment of a chest tube from its insertion site, and recall the complications associated with this occurrence; this will direct you to the correct option. Review the nursing associated with this occurrence; this will direct you to the correct option. Review the nursing actions to be taken immediately in the event of complications associated with a closed chest actions to be taken immediately in the event of complications associated with a closed chest tube drainage system if you had dif tube drainage system if you had difficulty with this question. ficulty with this question. Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying Client Needs: Client Needs: Physiological Integrity Physiological Integrity Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Adult Health/Respiratory Adult Health/Respiratory A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. 5. A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody ID: 18630136407 secretions. The nurse should take which action first? 6.A. Continue suctioning to remove the blood. B. Check the degree of suction being applied. C Co or rr re ec ct t Rationale: Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, the nurse should first assess the client and then determine the degree of suction being applied. the nurse should first assess the client and then determine the degree of suction being applied. The degree of suction pressure may need to be decreased. The nurse must also remember to The degree of suction pressure may need to be decreased. The nurse must also remember to apply intermittent suction and perform catheter rotation during suctioning. Continuing the apply intermittent suction and perform catheter rotation during suctioning. Continuing the suctioning or performing vigorous suctioning through the mouth will result in increased trauma suctioning or performing vigorous suctioning through the mouth will result in increased trauma and therefore increased bleeding. Suctioning is normally performed on clients who are unable to and therefore increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody secretions. secretions. T Test-T est-Taking Strategy: aking Strategy: Use knowledge of the subject, the technique for nasopharyngeal Use knowledge of the subject, the technique for nasopharyngeal suctioning. Eliminate the options of continuing the suctioning to remove the blood and removing suctioning. Eliminate the options of continuing the suctioning to remove the blood and removing the suction catheter from the nose to begin vigorous suctioning through the mouth, because the suction catheter from the nose to begin vigorous suctioning through the mouth, because they are comparable or alike. Next eliminate the option that involves encouraging the client to they are comparable or alike. Next eliminate the option that involves encouraging the client to cough out the bloody secretions because it is unlikely that the client will be able to do so. cough out the bloody secretions because it is unlikely that the client will be able to do so. Review the nursing actions to be taken immediately in the event of a complication during Review the nursing actions to be taken immediately in the event of a complication during suctioning if you had dif suctioning if you had difficulty with this question. ficulty with this question. Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying Client Needs: Client Needs: Physiological Integrity Physiological Integrity Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Adult Health/Respiratory Adult Health/Respiratory C. Encourage the client to cough out the bloody secretions. D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth. A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client ID: 18630135741 begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client’s trachea but is unable to do so. The nurse would take which action first? A. Call a code. B. Contact the health care provider. C. Administer a bronchodilator. D. Disconnect the suction source from the catheter. C Co or rr re ec ct t 7.Rationale: Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the Inability to remove a suction catheter is a critical situation. This finding, along with the client’ client’s symptoms presented in the question, indicates the presence of bronchospasm and s symptoms presented in the question, indicates the presence of bronchospasm and bronchoconstriction. The nurse immediately disconnects the suction source from the catheter bronchoconstriction. The nurse immediately disconnects the suction source from the catheter but leaves the catheter in the trachea. The nurse then connects the oxygen source to the but leaves the catheter in the trachea. The nurse then connects the oxygen source to the catheter catheter. The health care provider is notified and will most likely prescribe an inhaled . The health care provider is notified and will most likely prescribe an inhaled bronchodilator bronchodilator. The nurse also prepares for emergency resuscitation if the bronchospasm is not . The nurse also prepares for emergency resuscitation if the bronchospasm is not relieved. relieved. T Test-T est-Taking Strategy: aking Strategy: Use the process of elimination, noting the strategic word “first.” Eliminate Use the process of elimination, noting the strategic word “first.” Eliminate the option of administering a bronchodilator because this action requires a health care provider the option of administering a bronchodilator because this action requires a health care provider’’s s prescription. T prescription. To select from the remaining options, visualize the situation presented in the o select from the remaining options, visualize the situation presented in the question. Noting that the nurse is unable to remove the suction catheter from the client’ question. Noting that the nurse is unable to remove the suction catheter from the client’s trachea s trachea will direct you to the correct option. Review the nursing actions to be taken immediately in the will direct you to the correct option. Review the nursing actions to be taken immediately in the event of a complication during suctioning if you had dif event of a complication during suctioning if you had difficulty with this question. ficulty with this question. Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying Client Needs: Client Needs: Physiological Integrity Physiological Integrity Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation Content Area: Content Area: Adult Health/Respiratory Adult Health/Respiratory A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points. A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy ID: 18630135753 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse first performs which action? A. Contacts the health care provider B. Checks for kinks in the drainage system [Show Less]
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HESI Extra Credit Module 9 Exam Monitoring for Health Problems [NEW!!] 2022 (45 Pages) 100% CORRECT
MODULE 9 Exam Questions 1.ID: 8482572285A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give... [Show More] way” in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse immediately: *Covers the abdominal wound with a sterile dressing moistened with sterile saline solution Correct Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in a low Fowler’s position or supine with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The physician is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response. 2.ID: 8482572275A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The immediate nursing action is to: *Notify the surgeon Correct Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the client vomits a large amount of bright-red blood or the pulse rate increases and the patient is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse should also gather additional assessment data, but the surgeon must be contacted immediately. 3.ID: 8482570090A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about: *Administering oxygen by way of nasal cannula Correct Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the physician is notified. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for arterial blood gas determinations drawn. The immediate priority, however, is the administration of oxygen. 4.ID: 8482572237A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). *Assessing the system for an external air leak Correct*Documenting assessment findings, actions taken, and client response Correct Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not present and the air leak is a new occurrence, the physician is notified immediately, because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped unless this has been specifically prescribed in the agency’s policies and procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of suction being applied will not affect the bubbling in the water seal chamber and could be harmful. The nurse would document the assessment findings and interventions taken in the client’s medical record. 5.ID: 8482572257A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. The immediate priority on the part of the nurse is: *Covering the insertion site with a sterile occlusive dressing Correct Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the client back into bed, and contacts the physician. The nurse does not reinsert the chest tube. The physician will reinsert the chest tube as necessary. 6.ID: 8482568053A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. The nurse would first: *Check the degree of suction being applied Correct Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, the nurse should first assess the client and then determine the degree of suction being applied. The degree of suction pressure may need to be decreased. The nurse must also remember to apply intermittent suction and perform catheter rotation during suctioning. Continuing the suctioning or performing vigorous suctioning through the mouth will result in increased trauma and therefore increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody secretions. . 7.ID: 8482568077A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client’s trachea but is unable to do so. The nurse would first: Disconnect the suction source from the catheter Correct Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the client’s symptoms presented in the question, indicates the presence of bronchospasm and bronchoconstriction. The nurse immediately disconnects the suction sourcefrom the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter. The physician is notified and will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if the bronchospasm is not relieved. 8.ID: 8482572225A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse first: *Checks for kinks in the drainage system Correct Rationale: If a chest tube is not draining, the nurse must first check for a kink or clot in the chest drainage system. The nurse also observes the client for signs of respiratory distress or mediastinal shift; and if such signs are noted, the physician is notified. Checking the heart rate and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new drainage system to the client’s chest tube is done once the fluid drainage chamber is full. A specific procedure is followed when a new drainage system is connected to a client’s chest tube. 9.ID: 8482572259A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour was 25 mL. On the basis of this finding, the nurse first: Checks the client’s overall intake and output record Correct Rationale: Clients are at risk for becoming hypovolemic after surgery, and often the first sign of hypovolemia is decreasing urine output. However, the nurse needs additional data to make an accurate interpretation. Neither an increase in the rate of the IV infusion nor administration of a 250-mL bolus of normal saline (0.9%) would be implemented without a prescription from the physician. The physician is called once the nurse has gathered all necessary assessment data, including the overall fluid status and vital signs. 10.ID: 8482572277A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which of the following actions should the nurse take first? Lowering the head of the bed slowly until the dizziness is relieved Correct Rationale: Dizziness or a feeling of faintness is not uncommon when a client is positioned upright for the first time after surgery. If this occurs, the nurse lowers the head of the bed slowly until the dizziness is relieved. The nurse then checks the client’s pulse and blood pressure. Because the problem is circulatory, not respiratory, checking the oxygen saturation level and having the client take some deep breaths are not the first actions to be taken. 11.ID: 8482570020A nurse is preparing for intershift report when a nurse’s aide pulls an emergency call light in a client’s room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60 mm Hg. Which action should the nurse take first? Placing the client in a modified Trendelenburg position [Show Less]
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HESI Extra Credit Module 9 Exam Monitoring for Health Problems [NEW!!] 2022 (39 Pages) 100% CORRECT
Questions 1.ID: 8482572285A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the a... [Show More] bdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse immediately: Contacts the physician Documents the findings Places the client in a supine position with the legs flat Covers the abdominal wound with a sterile dressing moistened with sterile saline solution Correct Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in a low Fowler’s position or supine with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The physician is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response. Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately.” Visualize this occurrence and recall that the primary concern when wound dehiscence occurs is the protrusion of underlying tissues. This will direct you to the correct option. Review the nursing actions to be taken immediately in the event of wound dehiscence if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 291, 292, 296). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 2.ID: 8482572275A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The immediate nursing action is to: Notify the surgeon Correct Continue the assessment Check the client’s blood pressure Obtain a flashlight, gauze, and a curved hemostat Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the client vomits a large amount of bright-red blood or the pulse rate increases and the patient is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse should also gather additional assessment data, but the surgeon must becontacted immediately. Test-Taking Strategy: Focus on the data in the question. Noting the words “brightred blood” will assist in directing you to the correct option. Remember that the presence of bright-red blood indicates active bleeding. Review the nursing actions to be taken immediately when bleeding occurs after a tonsillectomy and adenoidectomy if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 657). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 3.ID: 8482570090A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about: Preparing the client for a perfusion scan Attaching the client to a cardiac monitor Administering oxygen by way of nasal cannula Correct Ensuring that the intravenous (IV) line is patent Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the physician is notified. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for arterial blood gas determinations drawn. The immediate priority, however, is the administration of oxygen. Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Apply the ABCs (airway, breathing, and circulation) to find the correct option. Review the nursing actions to be taken immediately in the event of pulmonary embolism if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 680). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 4.ID: 8482572237A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). Clamping the chest tube Changing the drainage system Assessing the system for an external air leak Correct Reducing the degree of suction being applied Documenting assessment findings, actions taken, and client response Correct Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not present and the air leak is a new occurrence, the physician is notified immediately, because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped unless this has been specifically prescribed in the agency’s policies and procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of suction being applied will not affect the bubbling in the water seal chamber and could be harmful. The nurse would document the assessment findings and interventions taken in the client’s medical record. Test-Taking Strategy: Use the process of elimination and your knowledge regarding the priority actions in the care of a closed chest tube drainage system. Focus on the data in the question, noting that there is bubbling in the water seal chamber. Recalling that this may indicate an air leak will direct you to the correct options. Review the nursing actions to be taken immediately in the event that complications of a closed chest tube drainage system occur if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 648, 649). St. Louis: Saunders. Awarded 2.0 points out of 2.0 possible points. 5.ID: 8482572257A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. The immediate priority on the part of the nurse is:Contacting the physician Reinserting the chest tube Transferring the client back to bed Covering the insertion site with a sterile occlusive dressing Correct Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the client back into bed, and contacts the physician. The nurse does not reinsert the chest tube. The physician will reinsert the chest tube as necessary. Test-Taking Strategy: Use the process of elimination, noting the strategic word “immediate.” Eliminate the option that involves reinsertion of the chest tube first, because a nurse is not trained to insert a chest tube. To select from the remaining options, focus on the subject, dislodgment of a chest tube from its insertion site, and recall the complications associated with this occurrence; this will direct you to the correct option. Review the nursing actions to be taken immediately in the event of complications associated with a closed chest tube drainage system if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 648, 649). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 6.ID: 8482568053A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. The nurse would first: Continue suctioning to remove the blood Check the degree of suction being applied Correct Encourage the client to cough out the bloody secretions Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth [Show Less]
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HESI Extra Credit Module 10 Exam Physiological Health Problems [NEW!!] 2022 (105 Pages)100% CORRECT
Hesi Study Module 10 Physiological Health Problems Questions 1.ID: 383719769 A nurse is assigned to care for four clients on the medical-surgical unit. ... [Show More] Which client should the nurse see first on the shift assessment? A client admitted with pneumonia with a fever of 100° F and some diaphoresis Incorrect A client with congestive heart failure with clear lung sounds on the previous shift A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In light of such a history, SOB could indicate that fluid-volume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority. Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, the client who should be seen first. Recall the rule of assessment of the ABCs — airway, breathing, and circulation — which means that the client experiencing SOB should take precedence over the other clients on the unit. This client’s condition could progress to respiratory arrest if the client were not assessed immediately on the basis of the signs and symptoms. Read each option and think about the client in most critical condition and review the disorders to determine which clients have the most critical needs. If you had difficulty with this question, review the various disease processes presented in this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care. (6th ed., p. 176). St. Louis: Saunders. Level of Cognitive Ability: Analyzing SendClient Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Delegating/Prioritizing Awarded 0.0 points out of 1.0 possible points. 2.ID: 383719781 A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. Decreased pulse Decreased urine output Correct Increased blood pressure Increased respiratory rate Correct Decreased respiratory depth Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluidvolume overload. Test-Taking Strategy: Use the process of elimination and focus on the subject, dehydration (deficient fluid volume). Think about the pathophysiology of deficient fluid volume. Remember that the body will increase the respiratory rate in an attempt to maintain the oxygen level. If you had difficulty with this question, review the signs of insufficient fluid volume.Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 179). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Awarded 0.0 points out of 1.0 possible points. 3.ID: 383720547 A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am–7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume? A 48-year-old client receiving diuretics to treat hypertension A 35-year old client who is vomiting undigested food after eating An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr Correct A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for deficient fluid volume. Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk for excessive fluid volume. Read each option and think about the fluid imbalance that could occur in each situation; in the case of the incorrect options, it is fluid-volume deficiency; the only option reflecting conditions that could result in an excess is the correct option. If you had difficulty with this question, review the causesof excessive fluid volume. References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 2202). St. Louis: Saunders. Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 183). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Awarded 0.0 points out of 1.0 possible points. 4.ID: 383721964 A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client’s condition has improved? Dyspnea 1+ edema in the legs Moist crackles in the lower lobes of the lungs Weight loss of 4 lb in 24 hours Correct Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is retaining fluid. Assessment findings associated with excessive fluid volume include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse, increased central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. These symptoms must be reversed if the fluid-volume excess is to be resolved.Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign that the client’s condition is improving. The only such finding is decreasing body weight. If you had difficulty with this question, review the assessment findings noted in excessive fluid volume and the signs that the condition is resolving. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 182, 183). St. Louis: Saunders. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fluid and Electrolytes Awarded 0.0 points out of 1.0 possible points. 5.ID: 383719771 A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which of the following serum potassium readings does the nurse associate this finding? 3.1 mEq/L Correct 4.2 mEq/L 4.5 mEq/L 5.4 mEq/L Rationale: A serum potassium level below 3.5 mEq/L is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L and 4.2 mEq/L are normal potassium levels; 5.4 mEq/L indicates hyperkalemia. Test-Taking Strategy: Begin to answer this question by recalling the normal range of values for serumpotassium. Next it is necessary to know that ST-segment depression occurs in hypokalemia. If you had difficulty with this question, review the ECG changes that occur in hypokalemia. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 184, 188). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fluid and Electrolytes Awarded 0.0 points out of 1.0 possible points. 6.ID: 383721958 A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? Insert a Foley catheter in the client Prepare the client for insertion of a central IV line Administer the medication with the use of a macrodrip IV tubing set Ensure that the medication is diluted in an appropriate amount of normal saline solution Correct Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. The intramuscular and subcutaneous routes of administration are not recommended because the medication cannot be adequately diluted for these routes; toxicity could result if the medication is not adequately diluted. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Saline dilution is recommended, but dextrose is avoided because it increases intracellular potassium shifting. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. The physician is notified if theurinary output is less than 30 mL/hr. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line. Test-Taking Strategy: Use the process of elimination and note the strategic words “intravenous potassium chloride.” Recalling that the medication must be diluted will direct you to the correct option. If you had difficulty with this question, review the guidelines for the administration of potassium chloride. References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 154). St. Louis: Saunders. Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 188, 189). St. Louis: Saunders. Lehne, R. (2010). Pharmacology for nursing care (7th ed., pp. 457, 458). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Awarded 0.0 points out of 1.0 possible points. 7.ID: 383719761 A nurse notes that a client’s serum potassium level is 5.8 mEq/L. The nurse interprets this as an expected finding in the client with: Diarrhea Wound drainage Addison disease Correct Heart failure being treated with loop diuretics [Show Less]
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HESI Extra Credit Module 10 Exam Physiological Health Problems [NEW!!] 2022 (74 Pages) 100% CORRECT
1. 1.ID: 18630147534 A nurse is assigned to care four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessme... [Show More] nt? A. A client admitted with pneumonia with a fever of 100°F and some diaphoresis B. A client with congestive heart failure with clear lung sounds on the previous shift C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In light of such a history, SOB could indicate that fluidvolume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority. Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, the client who should be seen first. Recall the rule of assessment of the ABCs—airway, breathing, and circulation—which means that the client experiencing shortness of breath should take precedence over the other clients on the unit. This client’s condition could progress to respiratory arrest if the client were not assessed immediately on the basis of the signs and symptoms. Read each option and think about the client in most critical condition and review the disorders to determine which clients have the most critical needs. If you had difficulty with this question, review the various disease processes presented in this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Delegating/Prioritizing D. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 18630146839 A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. A. Decreased pulse B. Decreased urine output CorrectC. Increased blood pressure D. Increased respiratory rate Correct E. Decreased respiratory depth Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-volume overload. Test-Taking Strategy: Use the process of elimination and focus on the subject, dehydration (deficient fluid volume). Think about the pathophysiology of deficient fluid volume. Remember that the body will increase the respiratory rate in an attempt to maintain the oxygen level. If you had difficulty with this question, review the signs of insufficient fluid volume. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible points. 3. 3.ID: 18630147505 A nurse is reviewing the medical records of the clients for the assigned 7 a.m.–7 p.m. shift. Which client will the nurse monitor most closely for excessive fluid volume? A. A 48-year-old client receiving diuretics to treat hypertension B. A 35-year old client who is vomiting undigested food after eating C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hrCorrect Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for deficient fluid volume.Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk for excessive fluid volume. Look for comparable or alike options that indicate fluid volume deficits. Read each option and think about the fluid imbalance that could occur in each situation; in the case of the incorrect options, it is fluid-volume deficiency; the only option reflecting conditions that could result in an excess is the correct option. If you had difficulty with this question, review the causes of excessive fluid volume. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fluid and Electrolytes D. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 18630146876 A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which finding causes the nurse to determine that the client’s condition has improved? A. Dyspnea B. 1+ edema in the legs C. Moist crackles in the lower lobes of the lungs D. Weight loss of 4 lb in 24 hours Correct Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is retaining fluid. Assessment findings associated with excessive fluid volume include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse, increased central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. These symptoms must be reversed if the fluidvolume excess is to be resolved. Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign that the client’s condition is improving. The only such finding is decreasing body weight. If you had difficulty with this question, review the assessment findings noted in excessive fluid volume and the signs that the condition is resolving.Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 18630146862 A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which potassium reading does the nurse associate this finding? A. 3.1 mEq/L Correct Rationale: A serum potassium level below 3.5 mEq/L is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially lifethreatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L and 4.2 mEq/L are normal potassium levels; 5.4 mEq/L indicates hyperkalemia. Test-Taking Strategy: Begin to answer this question by recalling the normal range of values for serum potassium. Next it is necessary to know that STsegment depression occurs in hypokalemia. Look for comparable or alike options that indicate a normal potassium reading. If you had difficulty with this question, review the ECG changes that occur in hypokalemia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fluid and Electrolytes B. 4.2 mEq/L C. 4.5 mEq/L D. 5.4 mEq/L Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 18630146885 A health care provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. The nurse should reinforce which client instructions? A. A catheter will be inserted to drain your bladder. B. A large intravenous line will be inserted into your chest vein.C. This infusion requires use of a large caliber IV tubing. D. This medication is diluted in a large bag of IV fluid and infused slowly into your vein. Correct Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line. Test-Taking Strategy: Use the process of elimination and note the strategic words “intravenous potassium chloride.” Recalling that the medication must be diluted will direct you to the correct option. If you had difficulty with this question, review the guidelines for the administration of potassium chloride. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 18630146897 A nurse notes that a client’s serum potassium level is 5.8 mEq/L. The nurse interprets this as an expected finding in the client with? A. Diarrhea B. Wound drainage C. Addison disease Correct Rationale: A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and the nurse would report the finding to the health care provider. Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia. Test-Taking Strategy: Use the process of elimination. Eliminate the comparableor alike options that indicate that the client is experiencing body fluid losses and therefore a loss of potassium. If you had difficulty with this question, review the risk factors associated with hyperkalemia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fluid and Electrolytes D. Heart failure being treated with loop diuretics Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 18630146883 A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A. Slow pulse B. Decreased urine output C. Skeletal muscle weakness Correct D. Hyperactive bowel sounds Correct E. Hyperactive deep tendon reflexes [Show Less]
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HESI Extra Credit Module 10 Exam Physiological Health Problems [NEW!!] 2022 (89 Pages) 100% CORRECT
1.ID: 9476932222 A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assess... [Show More] ment? A. A client admitted with pneumonia with a fever of 100° F (37.8°C) and some diaphoresis B. C. A client with congestive heart failure with clear lung sounds on the previous shift D. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct E. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In light of such a history, SOB could indicate that fluidvolume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority. Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, the client who should be seen first. Recall the rule of assessment of the ABCs — airway, breathing, and circulation — which means that the client experiencing SOB should take precedence over the other clients on the unit. This client’s condition could progress to respiratory arrest if the client were not assessed immediately on the basis of the signs and symptoms. Read each option and think about the client in most critical condition and review the disorders to determine which clients have the most critical needs. If you had difficulty with this question, review the various disease processes presented in this question. Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., p. 305). St. Louis: Elsevier. Level of Cognitive Ability: Analyzing Client Needs: Physiological IntegrityIntegrated Process: Nursing Process/Assessment Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Clinical Decision Making/Clinical Judgment, Collaboration/Managing Care Awarded 1.0 points out of 1.0 possible points. 2.ID: 9476924021 A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. A. Decreased pulse B. Decreased urine output Correct C. Increased blood pressure D. Increased respiratory rate Correct E. Decreased respiratory depth Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-volume overload. Test-Taking Strategy: Use the process of elimination and focus on the subject, dehydration (deficient fluid volume). Think about the pathophysiology of deficient fluid volume. Remember that the body will increase the respiratory rate in an attempt to maintain the oxygen level. If you had difficulty with this question, review the signs of insufficient fluid volume. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291-292). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment,Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible points. 3.ID: 9476934084 A nurse is reviewing the medical records of the clients to whom she is assignedon the 7 am–7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume? A. A 48-year-old client receiving diuretics to treat hypertension B. A 35-year old client who is vomiting undigested food after eating C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr Correct D. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for deficient fluid volume. Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk for excessive fluid volume. Read each option and think about the fluid imbalance that could occur in each situation; in the case of the incorrect options, it is fluid-volume deficiency; the only option reflecting conditions that could result in an excess is the correct option. If you had difficulty with this question, review the causes of excessive fluid volume. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291, 293). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Giddens Concepts: Care Coordination, Fluid and Electrolyte Balance HESI Concepts: Collaboration/Managing Care, Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 4.ID: 9476926416 A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client’s condition hasimproved? A. Dyspnea B. 1+ edema in the legs C. Moist crackles in the lower lobes of the lungs D. Weight loss of 4 lb (1.8 kg) in 24 hours E. Correct Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is retaining fluid. Assessment findings associated with excessive fluid volume include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse, increased central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. These symptoms must be reversed if the fluid-volume excess is to be resolved. Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign that the client’s condition is improving. The only such finding is decreasing body weight. If you had difficulty with this question, review the assessment findings noted in excessive fluid volume and the signs that the condition is resolving. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 292-293). St. Louis: Mosby. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 5.ID: 9476930486 A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which serum potassium reading does the nurse associate this finding? A. 3.1 mEq/L (3.1 mmol/L) CorrectB. 4.2 mEq/L (4.2 mmol/L) C. 4.5 mEq/L (4.5 mmol/L) D. 5.4 mEq/L (5.4 mmol/L) Incorrect Rationale: A serum potassium level below 3.5 mEq/L(3.5 mmol/L) is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L (4.5 mmol/L)and 4.2 mEq/L (4.2 mmol/L)are normal potassium levels; 5.4 mEq/L (5.4 mmol/L)indicates hyperkalemia. Test-Taking Strategy: Begin to answer this question by recalling the normal range of values for serum potassium. Next it is necessary to know that STsegment depression occurs in hypokalemia. If you had difficulty with this question, review the ECG changes that occur in hypokalemia. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 296, 791). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 0.0 points out of 1.0 possible points. 6.ID: 9476924035 A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? A. Insert a Foley catheter in the client B. Prepare the client for insertion of a central IV line C. Administer the medication with the use of a macrodrip IV tubing set D. Ensure that the medication is diluted in an appropriate amount of normal saline solution Correct Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. The intramuscular and subcutaneous routes of administration are not recommendedbecause the medication cannot be adequately diluted for these routes; toxicity could result if the medication is not adequately diluted. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Saline dilution is recommended, but dextrose is avoided because it increases intracellular potassium shifting. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. The health care provider is notified if the urinary output is less than 30 mL/hr. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line. Test-Taking Strategy: Use the process of elimination and note the strategic words “intravenous potassium chloride.” Recalling that the medication must be diluted will direct you to the correct option. If you had difficulty with this question, review the guidelines for the administration of potassium chloride. References: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., pp. 1009-1010). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision Making/Clinical Judgment, Evidence Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 7.ID: 9476930409 A nurse notes that a client’s serum potassium level is 5.8 mEq/L(5.8 mmol/L). The nurse interprets this as an expected finding in the client with: A. Diarrhea B. Wound drainage C. Addison disease Correct D. Heart failure being treated with loop diuretics Rationale: A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L)indicates hyperkalemia, and the nurse would report the finding to thehealth care provider. Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they all indicate that the client is experiencing body fluid losses and therefore a loss of potassium. If you had difficulty with this question, review the risk factors associated with hyperkalemia. Reference: Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 296, 1211). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 8.ID: 9476930444 A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A. Slow pulse B. Decreased urine output Incorrect C. Skeletal muscle weakness Correct D. Hyperactive bowel sounds Correct E. Hyperactive deep tendon reflexes In [Show Less]
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HESI Extra Credit Module 10 Exam Physiological Health Problems [NEW!!] 2022 (83 Pages) 100% CORRECT
Extra Credit HESI Module 10 1. Questions 1. 1.ID: 9476932222 A nurse is assigned to care for four clients on the medical-surgical unit. Which client sh... [Show More] ould the nurse see first on the shift assessment? A. A client admitted with pneumonia with a fever of 100° F (37.8°C) and some diaphoresis B. A client with congestive heart failure with clear lung sounds on the previous shift C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct D. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In light of such a history, SOB could indicate that fluid-volume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority. Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, the client who should be seen first. Recall the rule of assessment of the ABCs — airway, breathing, and circulation — which means that the client experiencing SOB should take precedence over the other clients on the unit. This client’s condition could progress to respiratory arrest if the client were not assessed immediately on the basis of the signs and symptoms. Read each option and think about the client in most critical condition and review the disorders to determine which clients have the most critical needs. If you had difficulty with this question, review the various disease processes presented in this question. Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., p. 305). St. Louis: Elsevier. Level of Cognitive Ability: Analyzing Client Needs: Physiological IntegrityIntegrated Process: Nursing Process/Assessment Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Clinical Decision Making/Clinical Judgment, Collaboration/Managing Care Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9476924021Extra Credit HESI Module 10 A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. A. Decreased pulse B. Decreased urine output Correct C. Increased blood pressure D. Increased respiratory rate Correct E. Decreased respiratory depth Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-volume overload. Test-Taking Strategy: Use the process of elimination and focus on the subject, dehydration (deficient fluid volume). Think about the pathophysiology of deficient fluid volume. Remember that the body will increase the respiratory rate in an attempt to maintain the oxygen level. If you had difficulty with this question, review the signs of insufficient fluid volume. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291-292). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment,Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible points. 3. 3.ID: 9476934084 A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am–7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume? A. A 48-year-old client receiving diuretics to treat hypertension B. A 35-year old client who is vomiting undigested food after eatingExtra Credit HESI Module 10 C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr Correct D. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for deficient fluid volume. Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk for excessive fluid volume. Read each option and think about the fluid imbalance that could occur in each situation; in the case of the incorrect options, it is fluid-volume deficiency; the only option reflecting conditions that could result in an excess is the correct option. If you had difficulty with this question, review the causes of excessive fluid volume. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291, 293). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Giddens Concepts: Care Coordination, Fluid and Electrolyte Balance HESI Concepts: Collaboration/Managing Care, Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9476926416 A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client’s condition has improved? A. Dyspnea B. 1+ edema in the legs C. Moist crackles in the lower lobes of the lungs D. Weight loss of 4 lb (1.8 kg) in 24 hours CorrectExtra Credit HESI Module 10 Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is retaining fluid. Assessment findings associated with excessive fluid volume include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse, increased central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. These symptoms must be reversed if the fluidvolume excess is to be resolved. Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign that the client’s condition is improving. The only such finding is decreasing body weight. If you had difficulty with this question, review the assessment findings noted in excessive fluid volume and the signs that the condition is resolving. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 292-293). St. Louis: Mosby. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 9476930486 A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which serum potassium reading does the nurse associate this finding? A. 3.1 mEq/L (3.1 mmol/L) Correct B. 4.2 mEq/L (4.2 mmol/L) C. 4.5 mEq/L (4.5 mmol/L) D. 5.4 mEq/L (5.4 mmol/L) Rationale: A serum potassium level below 3.5 mEq/L(3.5 mmol/L) is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L (4.5 mmol/L)and 4.2 mEq/L (4.2 mmol/L)are normal potassium levels; 5.4 mEq/L (5.4 mmol/L)indicates hyperkalemia.Extra Credit HESI Module 10 Test-Taking Strategy: Begin to answer this question by recalling the normal range of values for serum potassium. Next it is necessary to know that STsegment depression occurs in hypokalemia. If you had difficulty with this question, review the ECG changes that occur in hypokalemia. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 296, 791). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9476924035 A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? A. Insert a Foley catheter in the client B. Prepare the client for insertion of a central IV line C. Administer the medication with the use of a macrodrip IV tubing set D. Ensure that the medication is diluted in an appropriate amount of normal saline solution Correct Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. The intramuscular and subcutaneous routes of administration are not recommended because the medication cannot be adequately diluted for these routes; toxicity could result if the medication is not adequately diluted. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Saline dilution is recommended, but dextrose is avoided because it increases intracellular potassium shifting. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. The health care provider is notified if the urinary output is less than 30 mL/hr. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary;Extra Credit HESI Module 10 potassium chloride may be administered through a peripheral IV line. Test-Taking Strategy: Use the process of elimination and note the strategic words “intravenous potassium chloride.” Recalling that the medication must be diluted will direct you to the correct option. If you had difficulty with this question, review the guidelines for the administration of potassium chloride. References: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., pp. 1009-1010). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision Making/Clinical Judgment, Evidence Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9476930409 A nurse notes that a client’s serum potassium level is 5.8 mEq/L(5.8 mmol/L). The nurse interprets this as an expected finding in the client with: A. Diarrhea B. Wound drainage C. Addison disease Correct D. Heart failure being treated with loop diuretics Rationale: A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L)indicates hyperkalemia, and the nurse would report the finding to the health care provider. Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they all indicate that the client is experiencing body fluid losses and therefore a loss of potassium. If you had difficulty with this question, review the risk factors associated with hyperkalemia. Reference: Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 296, 1211). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological IntegrityExtra Credit HESI Module 10 Integrated Process: Nursing Process/Analysis Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9476930444 A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A. Slow pulse B. Decreased urine output C. Skeletal muscle weakness Correct D. Hyperactive bowel sounds Correct E. 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