Hesi Fundamentals
A nurse is teaching staff members about the legal terminology used in child abuse.
What definition of battery should the nurse include
... [Show More] in the teaching?
1
Maligning a person's character while threatening to do bodily harm.
2
A legal wrong committed by one person against property of another.
Correct3
The application of force to another person without lawful justification.
4
Behaving in a way that a reasonable person with the same education would not.
Battery means touching in an offensive manner or actually injuring another person. Battery
refers to actual bodily harm rather than threats of physical or psychological harm. Battery
refers to harm against persons instead of property. Behaving in a way that a reasonable
person with the same education would not is the definition of negligence.
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Issue with this question? 3.
Which nursing interventions require a nurse to wear gloves? (Select all that
apply.)
1
Giving a back rub.
Correct2
Cleaning a newborn immediately after delivery.
Correct3
Emptying a portable wound drainage system.
4
Interviewing a client in the emergency department.
5
Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive
Personal protective equipment (PPE) should be used because the newborn is covered with
amniotic fluid and maternal blood. PPE should be used because the nurse may be exposed
to blood and fluid that are contained in the portable wound drainage system. PPE is not
required for a back rub; there is no indication that the nurse is in contact with body
secretions. PPE is not necessary when conducting an interview because it is unlikely that the
nurse will come in contact with the client's body fluids. PPE is not necessary when obtaining
the blood pressure of a client, even if the client is HIV positive.
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A nurse is caring for a client with hemiplegia who is frustrated. How can the nurse
motivate the client toward independence?
1
Establish long-range goals for the client.
2
Identify errors that the client can correct.
Correct3
Reinforce success in tasks accomplished.
4
Demonstrate ways to promote self-reliance.
Success is a basic motivation for learning. People receive satisfaction when a goal is
reached. Progress toward long-range goals often is not apparent readily and may be
discouraging. Constructive criticism is an important aspect of client teaching, but if it is not
tempered with praise, it is discouraging. Demonstrating ways to promote self-reliance is an
important part of teaching, but it probably will not motivate the client.
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5.
A health care provider prescribes a standard walker (pick-up walker with rubber tips
on all four legs). The nurse identifies what clinical findings that indicate the client is
capable of using a standard walker?
1
Weak upper arm strength and impaired stamina
2
Weight bearing as tolerated and unilateral paralysis
3
Partial weight bearing on the affected extremity and kyphosis
Correct4
Strong upper arm strength and non–weight bearing on the affected extremity
A walker with four rubber tips on the legs requires more upper body strength than a rolling
walker. A client who is non–weight bearing on the affected extremity is able to use
a standard walker. A rolling walker is more appropriate for a client with weak upper arm
strength and impaired stamina who is less able to lift up and move a walker with four rubber
tips. A client with unilateral paralysis is not a candidate for a standard walker; the client
must be able to grip and lift the walker with both upper extremities and move the walker
forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able
to lift up and move a walker with four rubber tips.
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Issue with this question? 6.
To prevent footdrop in a client with a leg cast, the nurse should:
1
Encourage complete bed rest to promote healing of the foot.
2
Place the foot in traction.
Correct3
Support the foot with 90 degrees of flexion.
4
Place an elastic stocking on the foot to provide support.
To prevent footdrop (plantar flexion of the foot due to weakness or paralysis of the anterior
muscles of the lower leg) in a client with a cast, the foot should be supported with 90
degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to
prevent footdrop . Applying an elastic stocking for support also will not prevent footdrop; a
firmer support is required.
Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late
in the morning, take a high-protein snack with you to eat 20 minutes before the
examination. The brain works best when it has the glucose necessary for cellular function.
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Issue with this question? 7.
What should the nurse include in dietary teaching for a client with a colostomy?
1
Liquids should be limited to 1 L per day.
2
Non-digestible fiber and fruits should be eliminated.
3
A formed stool is an indicator of constipation.
Correct4
The diet should be adjusted to include foods that result in manageable stools.
Each person will need to experiment with diet after a colostomy to determine what foods are
best tolerated and also produce stools that are manageable, depending on the type of
colostomy. Liquids are typically not limited unless there is a specific reason such as cardiac
or renal disease. Food high in fiber such as fruit should be included in the diet as tolerated.
Depending on the type of colostomy and the diet, a formed stool is acceptable and does not
indicate a constipating diet.
STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However,
being smart involves more than just intelligence. Being practical and applying common
sense are also part of the learning experience.
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A client with respiratory difficulties asks why the percussion procedure is being
performed. The nurse explains that the primary purpose of percussion is to:
1
Relieve bronchial spasm.
2
Increase depth of respirations.
Correct3
Loosen pulmonary secretions.
4
Expel carbon dioxide from the lungs.
Percussion (chest physiotherapy) loosens pulmonary secretions by mechanical means. This
is accomplished by vibrations over the lung fields on the client's posterior, anterior, and
lateral chest. Percussion does not relieve bronchial spasms. Once pulmonary secretions are
loosened by percussion and the client has a clearer airway, the depth of respirations may
increase and facilitate removal of carbon dioxide from the lungs.
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Issue with this question? 10.
A 2-year-old child admitted with a diagnosis of pneumonia was administered
antibiotics, fluids, and oxygen. The child's temperature increased until it reached
103° F. When notified, the health care provider determined that there was no need
to change treatment, even though the child had a history of febrile seizures.
Although concerned, the nurse took no further action. Later, the child had a seizure
that resulted in neurological impairment. Legally, who is responsible for the child's
injury?
1
Health care provider, because this decision took precedence over the nurse's concern
2
Health care provider, because of total responsibility for the child's health and treatment
regimen
Correct3
Nurse, because failure to further question the health care provider about the child's status
placed the child at risk
4
Neither, because high fevers are common in children and the health care provider had little
cause for concern
It is the nurse's responsibility to foresee potential harm and prevent risks by acting as a
client advocate. This is not acceptable as a rationale for inaction. The nurse and health care
provider share interdependent roles in the assessment and care of clients. High
temperatures are common in children but are nonetheless a valid cause for concern.
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On the third postoperative day following a below-the-knee amputation, a client is
refusing to eat, talk, or perform any rehabilitative activities. What is the best initial
approach that the nurse should take when interacting with this client?
1
Explain why there is a need to increase activity.
2
Emphasize that with a prosthesis, there will be a return to the previous lifestyle.
3
Appear cheerful and non-critical regardless of the client's response to attempts at
intervention.
Correct4
Acknowledge that the client's withdrawal is an expected and necessary part of initial
grieving.
The withdrawal provides time for the client to assimilate what has occurred and integrate
the change in body image. The client is not ready to hear explanations about why there is a
need to increase activity until assimilation of the surgery has occurred. Emphasizing a return
to the previous lifestyle does not acknowledge that the client must grieve; it also does not
allow the client to express any feelings that life will never be the same again. In addition, it
may be false reassurance. The client might feel that the nurse has no comprehension of the
situation or understanding of feelings if the nurse appears cheerful and noncritical
regardless of the client's response to attempts at intervention.
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Issue with this question? 12. [Show Less]