Hesi Exit Cat Exam 3, Answered-An adult client being admitted to the psychiatric unit with a diagnosis of bipolar disorder arrives in an elated state.
... [Show More] What is the best room assignment the nurse can make for this client?
- A quiet room away from the nurse's station.
The community mental health nurse is planning to visit four clients with schizophrenia. Which client should the nurse see first?
- A mother who took her children from school because aliens were after them.
A female client, the mother of two small children, appears depressed after learning from her healthcare provider that she has multiple sclerosis. Which nursing intervention should the nurse implement first?
- Sit quietly with the client and answer questions she may ask.
Which statement by a client with emphysema indicates the best understanding of the purpose of pulmonary function testing?
- "It will measure how well my lungs are working."
An adolescent male client is admitted to the hospital. Based on Erikson's theory of psychosocial development, which nursing intervention best assists this adolescent's adjustment to his hospital stay?
- Invite him to participate in the evening group activity.
Which individual may legally sign an informed consent?
- A 16-year-old mother for her newborn.
The nurse working on a psychiatric unit is concerned about providing ethical and legally defensible care for clients on the unit. Which occurrence is an indication that a client's civil rights are being violated?
- refused to take an oral psychiatric medication is administered the same medication as an IM injection.
Which statement by the mother of a toddler girl indicates to the nurse that scheduled vaccine should not be administered?
- "Her throat closed up so bad she couldn't breathe the last time she got this shot."
Thirty-six hours after delivery, the nurse assesses a client's fundus just above the umbilicus and displaced to the right of the midline. What actions should the nurse take first?
- Palpate the bladder for distention.
10. A hospitalized 81-year-old female client has numerous complaints and uses her call button often to summon staff to help her with activities that she is capable of performing for herself. Which plan might be most beneficial in dealing with this client?
- Check on the client at designated time intervals and let the client know when the nurse will return.
11. When giving a cooling bath to reduce the fever of a 3-year-old child, which action should the nurse include?
- Pour tepid water over the child's back and chest.
The nurse determines that a client has a potential (high risk) problem. What is important for the nurse to do when planning care?
- Direct nursing actions toward reducing risk factors.
The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in these lower immunization groups?
- Designated clinics conveniently located in target neighborhoods.
The first time a male client stands at the bedside following a total hip replacement, he reports severe pain in his left calf. What intervention should the nurse take first?
- Return the client to bed and assess the lower extremities.
A client is receiving an IV of 5% dextrose in Lactated Ringer's solution at a rate of 100 ml/hour. The client tells the nurse, "I don't need to eat because I'm getting all the nutrition I need through this IV needle." What initial response would be best for the nurse to provide this client?
- "Only a very small amount of the calories you need are provided by your IV."
The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms this assessment?
- "The nurse at night is trying to poison me with pills."
A male client returns to the acute care unit following surgery with sequential compression devices in place. The nurse observes that the client dorsiflexes his feet frequently. What action should the nurse implement?
- Encourage the client to perform foot exercises regularly while his mobility is limited.
18. Which statement by a 16-year-old male client with acute osteomyelitis in his leg indicates the best understanding of the appropriate activity level for his disorder?
- "During this illness, I need to keep my leg as immobile as possible."
The nurse has conducted a cancer prevention community education program. In evaluating the participant's understanding of the carcinogens, what statement indicates an accurate understanding?
- Substances that change a cell so that it becomes cancerous are potential cause of cancer
20. A 25-year-old female client is diagnosed with endometriosis by her healthcare provider. Which nursing diagnosis has the highest priority?
- Pain related to extrauterine tissue inflammation.
The charge nurse is supervising a newly licensed practical nurse (PN) who is administering medications. The PN notes that a client with exophthalmus is scheduled to receive artificial tear drops. What action should the charge nurse implement?
- Remind the PN to evaluate the effectiveness of the medication after administration.
The charge nurse is assessing the morning lab work on four clients. Which client's laboratory findings should prompts the charge nurse to contact the healthcare provider immediately?
- c. A 29-year-old diagnosed with ulcerative colitis having a serum potassium level of 3.1 mEq/L.
When assessing a client with Raynaud's disease, which symptoms should the nurse expect the client to exhibit?
- Coldness, pain and pallor of fingertips, toes, and tip of nose.
A client is currently receiving an infusion of 25,000 units of Heparin in 500ml of normal saline at 10 ml/hour. A prescription is received to change the rate of the infusion to 700 units of Heparin per hour. The nurse should set the infusion pump to deliver how many ml/hour? (Enter numeric value only.)
- Answer: 14
An elderly client is suspected of having a cardiac dysrhythmia. The nurse knows that it is most important to obtain which information when assessing this client?
- Changes in mentation, personality, and behavior.
A client has developed drug toxicity after receiving a high dose of a medication with a prolonged half-life. After consulting with the health care provider, the nurse expects to administer which treatment plan?
- Several dose of antagonistic medication with a short half life administered at frequent time intervals.
The nurse is assigned to care for a group of clients. Based on priority of need, arrange in the order in which the nurse should assess these four clients, with the first client the nurse should assess on top and the last client the nurse should assess on the bottom. The client who has
- A T6 spinal cord injury with a blood pressure of 180/98.
Type 1 diabetes mellitus with a blood sugar of 55 mg/dl.
End stage renal disease with a serum creatinine of 10 m.
A total hip prosthesis with a 12 g hemoglobin.
28. A 22-year-old female client calls the public health clinic because her breasts are tender and she felt several small lumps during a breast self-examination (SBE). What information should the nurse elicit from the client first?
- Date of last menstrual period.
29. An adolescent female who has been a lacto-ovo-vegetarian for six months tells the nurse she is experience increased fatigue. What dietary recommendation should the nurse provide?
- Eat spinach three times a weeks.
A client who has been admitted to the Emergency Department following a sexual assault tells the nurse that she wants to use emergency contraception. Pending the results of a pregnancy test, what information is most important for the nurse to obtain from this client?
- Length of time since the rape occurred.
A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?
- Offer information about ultrasonography and genotyping to determine sex assignment.
A nurse is assessing a client who as an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. What intervention should the nurse implement?
- Document the findings.
What assessment finding places a client at risk for problems associated with impaired skin integrity?
- Capillary refill 5 seconds.
The nurse is evaluating discharge teaching of an adolescent who had a long leg cast applied in the emergency department. Which statement by the adolescent indicates an understanding of cast care?
- "I will put adhesive tape around the edges of the cast if they become sharp." [Show Less]