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HESI MEDSURG III FINAL EXAM ACTUAL EXAM 100 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+$18.99
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Based on the clinical A. Monitor Blood Glucose Levels
manifestations of Cushing
syndrome, which nursing Cushing syndrome results from a hypersecretion of
intervention would be glucocorticoids in the adrenal cortex. Clients with
appropriate for a client Cushing syndrome often develop diabetes mellitus.
who is newly diagnosed Monitoring of serum glucose levels assesses for
with Cushing syndrome? increased blood glucose levels so that treatment can
begin early. A common finding in Cushing syndrome is
A. Monitor blood glucose generalized edema. Although potassium is needed, it is
levels daily. generally obtained from food intake, not by offering
B. Increase intake of potassium-enhanced fluids. Fatigue is usually not an
fluids high in potassium. overwhelming factor in Cushing syndrome, so an
C. Encourage adequate emphasis on the need for rest is not indicated A low-
rest between activities. calorie, low-carbohydrate, low-sodium diet is not
D. Offer the client a recommended.
sodium-enriched menu.
,The nurse is assessing a B.While the nurse is taking the client's blood pressure, he
male client with acute has a carpal spasm.
pancreatitis. Which Rationale:
finding requires the most A positive Trousseau sign indicates hypocalcemia and
immediate intervention by always requires further assessment and intervention,
the nurse? regardless of the cause (40% to 75% of those with acute
pancreatitis experience hypocalcemia, which can have
serious, systemic effects). A key diagnostic finding of
A. The client's amylase pancreatitis is serum amylase and lipase levels that are
level is three times higher two to five times higher than the normal value. Severe
than the normal level. boring pain is an expected symptom for this diagnosis,
B.While the nurse is but dealing with the hypocalcemia is a priority over
taking the client's blood administering an analgesic. Long-term planning and
pressure, he has a carpal teaching do not have the same immediate importance as
spasm. a positive Trousseau sign.
C.On a 1 to 10 scale, the
client tells the nurse that
his epigastric pain is at 7.
D.The client states that he
will continue to drink
alcohol after going home.
,The nurse is completing C. Have you ever been frozen in one spot, unable to
an admission interview move?"
for a client with Parkinson Rationale:
disease. Which question Clients with Parkinson disease frequently experience
will provide additional difficulty in initiating, maintaining, and performing motor
information about activities. They may even experience being rooted to the
manifestations that the spot and unable to move. Parkinson disease does not
client is likely to typically cause option A, B, or D.
experience?
A. "Have you ever
experienced any paralysis
of your arms or legs?"
B. "Do you have frequent
blackout spells?"
C."Have you ever been
frozen in one spot,
unable to move?"
D. "Do you have
headaches, especially
ones with throbbing
pain?"
, The nurse notes that the D.Assess for kinks or dependent loops in the tubing.
client's drainage has Rationale:
decreased from 50 to 5 The least invasive nursing action should be performed
mL/hr 12 hours after first to determine why the drainage has diminished.
chest tube insertion for Option A is completed after assessing for any problems
hemothorax. What is the causing the decrease in drainage. Option B is no longer
best initial action for the considered standard protocol because the increase in
nurse to take? pressure may be harmful to the client. Option C is an
appropriate nursing action after the tube has been
A. Document this assessed for kinks or dependent loops.
expected decrease in
drainage.
B. Clamp the chest tube
while assessing for air
leaks. C. Milk the tube to
remove any excessive
blood clot buildup.
D. Assess for kinks or
dependent loops in the
tubing.
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