(Test Bank) 2022 HESI Health Assessment Exam - Brand New Questions & Answers With Rationales

Unknown, 1

Medicine

Test Bank

1st Edition

• $15.00 $50.00

---

Description

Test Bank for 2022 HESI Health Assessment Exam - Brand New Questions & Answers With Rationales, The downloadable file consists of 515 pages, and the total size of the file is 2.26 MB. Purchase now only for highly discounted price.

---

---

Study Note Preview

HESI Health Assessment Exam 2022 Test Bank Correct 100% Be sure of Pass ing your exam with this test bank because it have covered (The All Hesi Health A ssessment test bank is 100% Verified with all correct Answers) pass your 2022 hesi health Assessment with Grade A+ Mult iple Choices For which clinical indicator associated with a complication of portal hypertension would the nurse assess the client? A. liver abscess B. intestinal obstruction C. perforation of the duodenum D. hemorrhage from esophageal varices {{Ans - c. The increased pressure within the portal circulatory system causes increased pressure in areas of portal systemic collateral circulation (most imp ortantly, in the distal esophagus and proximal stomach). Hemorrhage is a possible complication. Liver abscesses may occur as a complication of intestinal infections, not portal hypertension. Intestinal obstruction may be caused by manipulation of the bowel during surgery, peritonitis, neurological disorders, or organic obstruction, not portal hypertension. Perforation of the duodenum usually is caused by peptic ulcers; it is not a direct result of portal hypertension or cirrhosis. A client with schizophren ia takes ziprasidone. Which conditions in the client may indicate a need to discontinue the medication? Select all that apply. One, some, or all responses may be correct. A. leukopenia B. tachycardia C. hypokalemia D. hypomagnesemia E. prolonged QT interv al {{Ans - a, c, e Ziprasidone is a second -generation antipsychotic medication indicated for schizophrenia. The medication may cause leukopenia, hypokalemia, and hypomagnesemia. This medication may cause a prolonged QT interval, which indicates torsades de pointes. Bradycard ia may occur in torsades de pointes but not tachycardia. A client is prone to hyponatremia. Which factors would the nurse identify that can precipitate hyponatremia? Select all that apply. One, some, or all responses may be correct. A. wound drainage B. diuretic therapy C. GI suction D. parenteral infusion of 0.9% sodium chloride E. inappropriate anti -diuretic hormone (ADH) secretions {{Ans - a, b, c, e Wound drainage can result in hyponatremia from loss of sodium ions. Most diuretics interfere with sodium reabsorption in the nephrons and have the side effect of hyponatremia. Gastrointestinal fluids are rich in sodium ions, which are lost by GI suction. With the syndrome of inappropriate antidiuretic hormone (SIADH), high levels of the antidiuretic hormone (ADH) are produced, causing the body to retain water instead of excreting it normally in the urine. Parenteral infusion of 0.9% sodium chloride, an isotonic solution, should be compatible with body fluids; if given in excess, it may lead to hypernatremia. Which statements made by the client identify regulatory functions of the kidney? Select all that apply. One, some, or all responses may be correct. A. erythropoiesis B. acid base balance C. vitamin D activation D. blood pressure control E. fluid and elect rolyte balance {{Ans - b, e Maintaining the acid -base balance of the body by selectively reabsorbing and secreting certain substances from the blood is a regulatory function of the kidneys. The kidneys also perform the regulatory function of electrolyte balance by regulating the reabsorption of certain electrolytes while eliminating others depending on their levels in the serum. The kidneys perform hormonal function by secreting a hormone called erythropoietin that aids in synthesis of red blood cells (eryth ropoiesis). Activation of vitamin D is a hormonal function of the kidneys. The kidneys perform hormonal function by secreting the hormone renin that assists in blood pressure control. Which signs would the nurse expect to observe in a client with small ce ll carcinoma of the lung who develops syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply. One, some, or all responses may be correct. 1 Oliguria 2 Seizures 3 Vomiting 4 Polydipsia 5 Polyphagia {{Ans - 1, 2, 3 Cancerous cells of sm all cell lung cancer can produce antidiuretic hormone, which causes fluid retention, resulting in increased blood volume and decreased urine volume. Fluid retention associated with SIADH can cause cerebral edema, resulting in confusion and seizures. Fluid retention resulting in hyponatremia causes nausea and vomiting. The client will have nausea and vomiting, resulting in a decreased oral fluid and food intake. Which urinary diagnostic test does not require any dietary or activity restrictions for the clie nt before or after the test? 1 Renal scan 2 Renal biopsy 3 Renal arteriogram 4 Concentration test {{Ans - 1 A renal scan does not require any dietary or activity restrictions. A renal biopsy requires bed rest for 24 hours after the procedure. A renal arteriogram requires the client to maintain bed rest with affected leg straight. A concentration test requires th e client to fast after a given time in the evening. The nurse identifies that a client's urinary output is less than 40 mL/h over the past 3 hours. Which action would the nurse take? 1 Assess breath sounds and obtain vital signs. 2 Decrease the intravenou s flow rate and increase oral fluids. 3 Insert an indwelling catheter to facilitate emptying of the bladder. 4 Check for dependent edema by assessing the lower extremities {{Ans - 1 The imbalance in intake and output, with a decreasing urinary output, may i ndicate kidney failure. The retention of excess body fluid can precipitate the development of heart failure. Assessing breath sounds and obtaining the vital signs are necessary when monitoring for these complications. In the presence of hypervolemia, oral and intravenous fluid intake should be decreased. There are no data to support a problem with the excretion of urine; the problem is with insufficient production. The insertion of a urinary retention catheter requires a health care provider's prescription. Checking for dependent edema by assessing the lower extremities is an appropriate assessment after respirations and vital signs are assessed. A client had a laparoscopic cholecystectomy. Postoperatively, the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What would the nurse include in the teaching plan when preparing this client for discharge? Select all that apply. One, some, or all responses may be correct. 1 Wash the puncture sites with strong soap and hot water daily. 2 Call the health care provider for a fever of 100°F (37.8°C) or higher more for 2 days. 3 Remove the tape strips over the puncture sites 1 week after surgery. 4 Check the puncture sites daily for redness, tenderness, swelling, heat, or dr ainage. 5 Ease the discomfort from the gas used to insufflate the abdomen during surgery by applying a heating pad to the left shoulder. {{Ans - 2, 4 Which complication is most likely to occur in the immediate postoperative period after a client has had a splenectomy? 1 Infection 2 Peritonitis 3 Hemorrhage 4 Intestinal obstruction {{Ans - 3 Because the spleen is highly vascular, hemorrhage may occur in the immediate postoperative period. Although risk for some types of infection is higher after splenectomy because of lower immunoglobulin levels, risk for immediate postoperative infection is not higher than usual after splenectomy. Peritonitis is possible after splenectomy, but it would not be apparent in the immediate postoperative period and is not a common complication. The incidence of intestinal obstruction is not higher than for other abdominal surgery, and symptoms would not be apparent in the immediate postoperative period. A high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. Which would the nurse instruct the student to do? 1 Breathe into cupped ha nds. 2 Pant using rapid, shallow breaths. 3 Use a rapid deep -breathing pattern. 4 Hold the breath for as long as possible. {{Ans - 1 Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. Which major group of substances in human milk a re of special importance to the newborn and cannot be reproduced in a bottle formula? 1 Amino acids 2 Gamma globulins 3 Essential electrolytes 4 Complex carbohydrates {{Ans - 2 The gamma globulin antibodies in human milk provide the infant with immunity ag ainst all or most of the pathogens that the mother has encountered. Amino acids and essential electrolytes are present in commercial formulas. Complex carbohydrates are not required by the infant. Which instruction on infection prevention would the nurse include when providing discharge education to a client who received a cadaveric renal transplant? Select all that apply. One, some, or all responses may be correct. 1 Avoid eating from buffets. 2 Obtain annual flu vaccinations. 3 Perform regular hand hygie ne. 4 Stay away from crowded areas. 5 Report a temperature greater than 100.5°F. {{Ans - 1,2,3,4,5 Clients who receive an organ transplant need to take immunosuppressant medications for the rest of their lives to prevent organ rejection. These medications p ut the client at increased risk for infection. The nurse would provide infection prevention teaching to the client after renal transplant, which would include instructions to avoid eating from buffets, get an annual flu vaccine, practice regular hand hygie ne, and avoid crowded areas. Clients would also be instructed to report a temperature greater than 100.5°F to their health care provider as it could indicate infection or organ rejection and requires treatment. Which malnourished condition may predispose a client to secondary immunodeficiency? 1 Cachexia 2 Cirrhosis 3 Diabetes mellitus 4 Hodgkin lymphoma {{Ans - 1 Cachexia is a nutrition disorder that may occur because of wasting of muscle mass and weight, resulting in a secondary immunodeficiency disorder. Cirrhosis, diabetes mellitus, and Hodgkin lymphoma also lead to secondary immunodeficiency disorder, but these are not malnutrition disorders. Which dietary modifications help improve the nutritional status of a client with acquired immunodeficiency synd rome (AIDS)? 1 Refraining from consuming fatty foods 2 Refraining from consuming frequent meals 3 Refraining from consuming high -calorie foods 4 Refraining from consuming high -protein foods {{Ans - 1 Many clients with AIDS become intolerant to fat due to the disease and the antiretroviral medications. The client should be instructed to refrain from consuming fatty foods. The client should be encouraged to eat small and frequent meals to improve nutriti onal status. High -calorie and high -protein foods are beneficial to clients with AIDS because they provide energy and build immunity. Which statement describes a client's tidal volume? 1 Tidal volume is the volume of air inhaled and exhaled with each breat h. 2 Tidal volume is the amount of air remaining in the lungs after forced expiration. 3 Tidal volume is the additional air forcefully inhaled after normal inhalation. 4 Tidal volume is the additional air forcefully exhaled after normal exhalation. {{Ans - 1 Which hormone is released from the posterior pituitary gland? 1 Oxytocin 2 Prolactin 3 Growth hormone 4 Luteinizing hormone {{Ans - 1 Oxytocin is released from the posterior pituitary gland, which acts on the uterus and mammary glands. Prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland. Which clinical manifestation is associated with hypernatremia in burns? 1 Fatigue 2 Seizures 3 Paresthesias 4 Cardiac dysrhythmias {{Ans - 2 Seizures are the clinical manifestat ion of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia. A client with laryngeal cancer is receiving chemotherapy. Which laboratory report is most important for the nurse to monitor when c onsidering the effects of chemotherapy? 1 Platelets 2 Hemoglobin level 3 Red blood cell count 4 White blood cell count {{Ans - 4 Antineoplastic medications depress bone marrow, which results in leukopenia; the client must be protected from infection, which is a primary cause of death in the client with cancer. Platelets may decrease rapidly, but complications may be limited by infusions of platelets. Although the hemoglobin level diminishes, a transfusion with packed red blood cells (PRBCs) will alleviate th e anemia. RBCs diminish slowly and may be replaced with a transfusion of PRBCs. Which type of hepatitis virus spreads through contaminated food and water? 1 Hepatitis A virus 2 Hepatitis B virus 3 Hepatitis C virus 4 Hepatitis D virus {{Ans - 1 Hepatitis A virus spreads through contaminated food and water. Hepatitis B, C, and D viruses spread through contaminated needles, syringes, and blood products. Which organism is a common opportunistic infection in a client infected with human immunodefici ency virus (HIV)? 1 Oropharyngeal candidiasis 2 Cryptosporidiosis 3 Toxoplasmosis encephalitis 4 Pneumocystis jiroveci pneumonia {{Ans - 1 Oropharyngeal candidiasis is the most common infection associated with HIV because the immune system can no longer con trol Candida fungal growth. Pneumocystis jiroveci pneumonia (PCP) is more common in a client infected with acquired immunodeficiency syndrome (AIDS). It causes tachypnea and persistent dry cough. Cryptosporidiosis, an intestinal infection caused by Cryptos poridium organisms, presents in clients with AIDS as does toxoplasmosis encephalitis, which is caused by Toxoplasma gondii and is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat. Which effect has resulted in the avoidance of tetracycline use in children under 8 years old? 1 Birth defects 2 Allergic responses 3 Severe nausea and vomiting 4 Permanent tooth discoloration {{Ans - 4 Tetracycline use in children under the age of 8 years has been discontinued because it causes permanent tooth discoloration. Birth defects, allergic responses, and severe nausea and vomiting are not prevalent reasons for the discontinuation of tetracycline medications in children under 8 years old. The nurse understands which medication increases the risk of Reye syndrome in children? 1 Aspirin 2 Naloxone 3 Ibuprofen 4 Acetaminophen {{Ans - 1 Aspirin increases the risk of Reye syndrome in children. Naloxone, ibuprofen, and acetaminophen can be used, but the child should be assessed for ren al and liver functioning before prescribing. Which immunomodulatory agent is beneficial for the treatment of clients with multiple sclerosis? 1 Interleukin 2 2 Interleukin 11 3 Beta interferon 4 Alpha interferon {{Ans - 3 A normal calcium level is {{Ans - 9-10.5 A normal magnesium level is {{Ans - 1.8-2.6 Normal phosphate levels {{Ans - 3-4.5 Which foods would the nurse recommend to a client who is concerned with ensuring that her diet is not deficient in folic acid (folate )? Select all that apply. One, some, or all responses may be correct. 1 Lean ground beef 2 Milk and cheese 3 Chicken breast meat 4 Black and pinto beans 5 Enriched bread and pasta {{Ans - 4, 5 Which teaching would the nurse include for parents of an infant with phenylketonuria (PKU)? 1 Testing for PKU is done immediately after birth. 2 Cognitive impairment occurs if PKU is untreated. 3 Treatment for PKU includes lifelong medications. 4 PKU is transmitted by an autosomal dominant gene. {{Ans - 2 In PKU, the a bsence of the hepatic enzyme phenylalanine hydroxylase prevents metabolism (hydroxylation to tyrosine) of the amino acid phenylalanine. The increased fluid level of phenylalanine in the body and the alternate metabolic by -products (phenylketones) are assoc iated with severe cognitive impairment if PKU is not identified and treated early. Testing for PKU cannot be done until after several days of milk ingestion. Medications are not part of therapy for PKU. PKU is transmitted by an autosomal recessive gene. A health care provider prescribes B -complex vitamins. Which information will the nurse teach the client? 1 The vitamins may turn the urine bright yellow. 2 The daily fluid intake should be increased. 3 The vitamins should be taken on an empty stomach. 4 Taking the vitamins with a high -fat meal will increase absorption. {{Ans - 1 Bright yellow urine is an expected, insignificant side effect of vitamin B complex. There is no need to increase oral fluids; the client may consume the usual daily intake of flu id. Taking the vitamins on an empty stomach may precipitate nausea; therefore they should be taken with food. Vitamin B complex is a water -soluble vitamin, and excess amounts are excreted in urine. Taking the vitamins with a fatty meal will not improve abs orption. Chemotherapy via regional perfusion is the treatment of choice for a client's malignant sarcoma of the liver. Which reason would the nurse provide to explain to the client why this method of medication administration probably was selected? 1 Medi cation therapy can be continued at home with little difficulty. 2 Larger doses of medications can be delivered to the actual site of the tumor. 3 Toxic effects of the chemotherapeutic medications are confined to the area of the tumor. 4 Combinations of med ications are used to attack neoplastic cells at various stages of the cell cycle. {{Ans - 2 Regional perfusion therapy permits relative isolation of the tumor area and saturation with the medication(s) selected. This method of medication administration requ ires medical and nursing supervision and cannot be continued at home. Although toxic effects are confined mainly to the treated area, some migration may still occur. Combinations of chemotherapeutic medications are administered via intravenous or oral rout es, not via regional perfusion. Which nursing actions best promote communication when obtaining a nursing history? Select all that apply. One, some, or all responses may be correct. 1 Establishing eye contact 2 Paraphrasing the client's message 3 Asking " why" and "how" questions 4 Using broad, open -ended statements 5 Reassuring the client that there is no cause for alarm 6 Asking questions that can be answered with a "yes" or "no" {{Ans - 1, 2, 4 Eye contact indicates to the client that the nurse is listeni ng and interested. Paraphrasing is an effective interviewing technique; it indicates to the client that the message was heard and invites the client to elaborate further. Open -ended statements provide a milieu in which people can verbalize their problems r ather than be placed in a situation of providing a forced response. Asking "why" and "how" questions can be threatening to the client, who may not have the answer to these questions. False reassurance is detrimental to the nurse -client relationship and doe s not promote communication. Direct questions do not open or promote communication. Which actions would the nurse take to help a client with obsessive -compulsive disorder discuss how anxiety influences feelings and the ability to function? Select all that apply. One, some, or all responses may be correct. 1 Identify manipulative behaviors. 2 Explore anxiety -provoking situations. 3 Introduce the client to socializing situations. 4 Assist the client in examining coping mechanisms. 5 Assess the quality of int erpersonal relationships. {{Ans - 2, 4 Which statement will the nurse include when teaching the family of a child with asthma about peak flow meters (PFMs)? 1 "This device measures the peak amount of air that your child can inhale." 2 "This device will improve medication delivery to the lungs when it's used with an inhaler." 3 "Your child should make sure to use a short -acting bronchodilator before using the PFM." 4 "A PFM can help you identify when asthma is getting worse even before your child has symptoms." {{Ans - 4 The PFM is used to measure the maximal amount of exhalation. In doing this, it can identify when airway obstruction is occurring before the obstruction is sufficient to cause symptoms. PFMs are used to measure exhalation , not inhalation. PFMs are not used for medication administration. The use of a PFM should not be preceded by administration of a bronchodilator. Oral iron supplements patient education should include... {{Ans - - should be given on an empty stomach betwee n meals for best absorption - if a child is old enough, the supplements should be offered with citrus fruit juice as vitamin C will increase absorption - milk and products and antacids also decrease absorption of oral iron and should be avoided for 2 hour s after administration - iron supplements may cause constipation and dark green, tarry stools - liquid iron can stain teeth and so are administered with a medicine dropper toward the back of the infants cheek Cushing's triad {{Ans - Signs of increased int racranial pressure: 1. hypertension w/ widened pulse pressure 2. bradycardia 3. irregular respiration's Where is the nurse positioned when performing a Romberg test? 1 Sitting next to the client 2 Standing behind the client 3 Standing in front of the clie nt 4 Standing to the side of the client {{Ans - 4 The nurse would be standing to the side of the client when performing a Romberg test because the client is most likely to sway side to side. Sitting does not safely position the nurse to rescue an unbalanced client. Standing behind or in front of the client is not optimal for safety because the client is most likely to sway side to side. Which point requires correction regarding the use of restraints? 1 Less restrictive interventions must have been unsuccess ful before applying restraints. 2 All other alternatives must have been tried and exhausted before applying restraints. 3 Restraints may be applied to ensure the physical safety of the resident or other residents. 4 A written order for restraints is not re quired. {{Ans - 4 Restraints can be used only on the written order of a health care provider. Restraints can be used when less restrictive interventions are not successful. Restraints may be used after all available alternatives have been tried and exhaust ed. Restraints can be used only to ensure the physical safety of the resident or other residents. A child is prescribed intravenous mannitol. The nurse understands mannitol belongs to which classification of diuretics? 1 Loop 2 Osmotic 3 Potassium sparing 4 Carbonic anhydrase inhibitor {{Ans - 2 Osmotic diuretics, such as mannitol, increase the osmotic pressure of glomerular filtrate and thus decrease absorption of sodium; they are used to treat cerebral edema and increased intraocular pr essure. A medical -surgical nurse completes the admission assessment on a client diagnosed with a urinary tract infection. The client's admitting weight is 165 lb (74.8 kg). The vital signs are: temperature 96°F (35.6°C), pulse 110 beats per minute, respir ations 20 per minute, and blood pressure 88/56 mm Hg. The client received 3 L of normal saline in the emergency department. The total urine output for the past 2 hours was 20 mL via a urinary drainage system. Which intervention would the nurse recommend to the primary health care provider? 1 Transfer the client to a critical care unit. 2 Discontinue the urinary catheter immediately. 3 Administer another 1 L bolus of sodium chloride. 4 Begin a dopamine hydrochloride drip for renal perfusion. {{Ans - 1 The cli ent has a known infection, is exhibiting signs of sepsis, and is unresponsive to fluid therapy as evidenced by the low blood pressure. The client is showing signs of renal failure. The client is manifesting probable signs of septic shock requiring a higher level of care. This question requires the medical/surgical nurse to synthesize the client's manifestations and make an evaluation of the need for more invasive care than is available on the admitting unit. Giving another fluid is plausible, but this clien t weighs 75 kg, requiring a maximum of 3 L of fluid to be given before a diagnosis of severe sepsis. The client requires more invasive monitoring than can be done on a medical/surgical unit to determine if more fluid or vasopressors are required. The urina ry catheter is necessary to continue monitoring the urine output in this acute client. A client has a blood pressure of 90/50 mm Hg during her first visit to the prenatal clinic. On a subsequent visit, at 34 weeks' gestation, her blood pressure is 120/76 mm Hg. Which would the nurse conclude might have caused the change? 1 The presence of chronic hypertension 2 The possible development of preeclampsia 3 An increased stroke volume during the third trimester 4 An expected increase in blood pressure as pregna ncy progresses {{Ans - 2 During the second trimester the blood pressure usually decreases and stays lower for the remainder of the pregnancy; an increase in systolic pressure of 30 mm Hg and diastolic pressure of 15 mm Hg warrants close observation for pree clampsia. The client's baseline blood pressure is low, suggesting that the increase in blood pressure is pregnancy related (i.e., gestational hypertension). Increased stroke volume during the third trimester does not cause an increase in blood pressure. An increase in blood pressure of this amount at 34 weeks' gestation is not expected. A 2-year -old child is admitted to the pediatric unit with a diagnosis of bacterial meningitis. Which is the most important safety measure for the nurse to institute immedia tely after the child has a seizure? 1 Monitoring the child's vital signs 2 Padding the side rails of the toddler's crib 3 Placing the child in the side -lying position 4 Bringing suction equipment to the bedside {{Ans - 3 The side -lying position promotes a p atent airway; the tongue can move away from the back of the pharynx, and saliva can flow out of the mouth by gravity. Although monitoring vital signs is important, a patent airway is the priority. The crib sides should have been padded as a part of seizure precautions before the seizure. If the seizure was unexpected and seizure precautions were not previously instituted, they should be instituted after the immediate respiratory and safety needs of the toddler have been met. Suctioning may be unnecessary; t he child should not be left alone while equipment is obtained. A blood transfusion is prescribed for a child with acute lymphocytic leukemia (ALL). Which intervention will the nurse implement during the administration of the blood product? 1 Infuse the blood over no more than 4 hours. 2 Take the vital signs 3 hours after the transfusion. 3 Check the vital signs 15 minutes after starting the transfusion. 4 Have the blood warm at room temperature for 1 hour before administration. {{Ans - 1 Bloo d should be administered within 4 hours; the risk for bacterial proliferation increases over time and exposure to room temperature. Taking the vital signs 3 hours after the transfusion is too long to wait; the vital signs should be checked every 5 minutes during the absorption of the first 50 mL of blood and then routinely thereafter (every 15 minutes to 1 hour, depending on hospital policy). Vital signs must be checked every 5 minutes during the administration of the first 50 mL of blood to detect a transf usion reaction. Blood should be used within 30 minutes after its arrival from the blood bank; the risk for bacterial proliferation increases over time and exposure to room temperature. Which clinical finding in a newly delivered client requires immediate investigation? 1 An inflamed episiotomy 2 A slow trickle of blood from the vagina 3 An estimated blood loss of half a liter during a vaginal birth 4 A boggy fundus that becomes firm after prolonged massage {{Ans - 2 Vaginal bleeding may be an early sign of hemorrhage; hypovolemic shock can develop. An inflamed episiotomy is an expected finding; ice packs help resolve the inflammation. Expected blood loss for a vaginal birth is 300 to 500 mL. A fundus that has been overstretched or is multiparous may require prolonged massage until it becomes firm. The nurse is caring for a client with a 30% total body surface area burn. Which assessment finding indicates that the client's fluid replacement is adequate? 1 Increasing hematocrit level 2 Urinary output of 15 to 20 mL/h 3 Slowing of a previously rapid pulse rate 4 Central venous pressure progressing from 5 to 1 mm Hg {{Ans - 3 The pulse rate is one indicator of optimum vascular fluid volume; the pulse rate decreases as intravascular volume normalizes. An increasing hematocrit level indicates hemoconcentration resulting from hypovolemia. Urinary output of 0.5 to 1 mL/kg/h indicates inadequate kidney perfusion; if adequate, output should be greater than 30 mL/h. Central venous pressure decreasing from 5 to 1 mm Hg ind icates hypovolemia. Which intervention would the nurse implement for a client with Alzheimer disease who has become agitated and aggressive and is incontinent of urine and feces? 1 Manage the behavior. 2 Prevent further deterioration. 3 Focus on the needs of the spouse. 4 Establish an elimination rewards program {{Ans - 1 The nurse would manage the behavior. The client must be kept from harming self or others and needs a calm, supportive environment that meets needs and maintains dignity. After a thoracent esis for pleural effusion, a client returns to an outpatient clinic for a follow -up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? 1 "Lately I can only breathe well if I sit up." 2 "During the night I sometimes get the chills." 3 "I get a sharp, stabbing pain when I take a deep breath." 4 "I'm coughing up large amounts of thicker mucus for the past several days." {{Ans - 3 Tension is placed on the pleura at the height of inspiration and causes pain. Which of the following statements from a patient's history is it most important to investigate further? a. "I have an allergy to peanuts." b. "I have lost 30 pounds over the last 4 months." c. "I don't like many vegetables so I take multivitamins." d. "I drink 2 cups of coffee each morning." {{Ans - ANS: B The statement in option "b is most important to investigate further because any significant weight loss may indicate a serious problem. The statement about an allergy to peanuts is not the most imp ortant piece of information, although the nurse would want to investigate and document any food allergies. Option "c" is not the most significant statement; however, the nurse should investigate the types and amounts of vegetables the patient eats. Two cup s of coffee is considered fairly typical and the patient is not consuming an excessive amount of caffeine. Your patient complains of pruritus. You should examine the patient for which of the following associated signs and symptoms? a. rash and edema b. coolness and pallor c. cyanosis and coolness d. ecchymosis and purpura {{Ans - ANS: A Pruritus or itching of the skin is associated with the following manifestations: rashes, lesions, edema, angioedema, anaphylaxis, excoriation or ulcers as a result of scratching, lichenification or thickening of the skin, and systemic disease. As a result of scratching the skin due to pruritus, the skin would most likely be warm and red, not pale, cool, or cyanotic. Ecchymosis is a violaceous discoloration, also called a black -and-blue mark. Purpura is a condition characterized by the presence of confluent petechiae or confluent ecchymosis. Neither of these is associated with pruritus. ____ 3. Your patient asks you about the small, reddish purple discolorations of the s kin, less than 0.5 cm in diameter. You inform the patient that this is known as which of the following? a. ecchymoses c. purpura b. petechiae d. spider telangiectasia {{Ans - ANS: B Petechiae are violaceous (red -purple) discolorations of less than 0.5 cm in diameter. Petechiae do not blanch. They can indicate an increased bleeding tendency or embolism; causes include intravascular defects and infections. Ecchymosis is a violaceous discoloration of varying size, also called a black -and- blue mark. It is caus ed by extravasation of blood into the skin as a result of trauma; heparin or Coumadin use; or liver dysfunction. Purpura is a condition characterized by the presence of confluent petechiae or confluent ecchymosis over any part of the body. Purpura is cause d by hemorrhage into the skin and can be the result of decreased platelet formation. Spider angiomas, a type of telangiectasia, are bright red and star -shaped. Most often these lesions are found on the face, neck, and chest. There is often a central pulsat ion noted with pressure, and this results in blanching in the extensions. Your patient expresses concern about a mole on her right leg that has recently started itching. Which accompanying finding most likely indicates a developing cancerous lesion? a. regular and distinct border c. edema in both feet b. multiple colorations d. inflammation of periungual tissue {{Ans - ANS: B Developing cancerous lesions may have multiple colorations such as brownish, tan, red, white, blue, pink, purple, or gray. Othe r signs in potentially cancerous lesions include the following: 1) rapid change in size; 2) change in coloration; 3) irregular or butterfly -shaped border; 4) elevation in a previously flat mole; 5) multiple colorations in a lesion; 6) change in surface cha racteristics, such as oozing; 7) change in sensation, such as pain, itching, or tenderness; 8) change in surrounding skin, such as inflammation or induration; and 9) bleeding or ulcerative appearance in a mole. These lesions are not associated with edema o r inflammation of the area around the fingernails or the toenails. After releasing the pressure of your thumb on your patient's lower legs, ankles, and feet, you observe a 4 mm depression of the skin that disappears in 10 to 15 seconds. You would report t his finding as which of the following? a. 1+ pitting edema c. 3+ pitting edema b. 2+ pitting edema d. 4+ pitting edema {{Ans - ANS: B Edema is the accumulation of fluid in the intercellular spaces. Pitting edema is rated on a 4 -point scale: 0+ = no pitti ng edema. 1+ = mild pitting edema; 2 mm depression that disappears rapidly. 2+ = moderate pitting edema; 4 mm depression that disappears in 10 to 15 seconds. 3+ = moderately severe pitting edema; 6 mm depression that can last more than 1 minute. 4+ = sever e pitting edema; 8 mm depression that can last more than 2 minutes. The nurse checks the capillary refill of a new patient. The amount of time for the nail color to return after the pressure is released on the patient's nail should not exceed which of the following? a. 1-2 seconds c. 3 -4 seconds b. 2-3 seconds d. 4 -5 seconds {{Ans - ANS: B Capillary refill time is a measure used to examine arterial flow to the extremities and is an indicator of peripheral circulation. Normal capillary refill varies with a ge, but color should return to normal within 2 - 3 seconds. Options "c" and "d" indicate prolonged capillary refill time and may indicate cardiovascular or respiratory dysfunction. Option "a" would be considered within normal limits. To locate the temporoma ndibular joint, the nurse would palpate with both index and middle fingers on both sides of the face a. anterior to the tragus of the ear. c. over the temporalis muscles. b. inferior to the external meatus of the ear. d. posterior to the tragus of the ear. {{Ans - ANS: A The temporomandibular joint is just below the temporal artery and anterior to the tragus of the ear. The tragus is a small extension of the auricular cartil age of the ear, anterior to the external meatus of the ear. The temporomandibular joint is not over the temporalis muscles. The nurse can examine this joint by palpating it as the patient opens and closes the mouth and notes normally smooth movement with no limitation or tenderness. Crepitation, limited range of motion, or tenderness are abnormal findings. To perform auscultation of a patient's thyroid gland, you would place the bell of your stethoscope over the a. thyroid isthmus, then the right and left lobes. b. right thyroid lobe, then the left lobe. c. left carotid artery first. d. right temporal artery, then the left temporal artery. {{Ans - ANS: B If the thyroid is enlarged, auscultation should be performed. The nurse stands in front of the patien t, places the stethoscope over the right thyroid lobe, auscultates for bruits, and finally repeats the procedure on the left lobe. The thyroid isthmus is the band of tissue connecting the right and left thyroid lobes; however, it is not involved in auscult ation of the thyroid gland. Options "c" and "d" are included in auscultation of the thyroid gland.