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,HESI EXIT EXAM
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, two weeks later to evaluate his blood pressure (BP). His BP is
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158/106 and he admits that he has not been taking the prescribed
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medication because the drugs make him “feel bad”. In explaining
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the need for hypertension control, the nurse should stress that an
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elevated BP places the client at risk for which pathophysiological
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condition?
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a- Blindness secondary to cataracts v v v
b- Acute kidney injury due to glomerular damage
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c- Stroke secondary to hemorrhage v v v
d- Heart block due to myocardial damage
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Rationale: Stroke related to cerebral hemorrhage is major risk for
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uncontrolled hypertension.
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3. The nurse observes an unlicensed assistive personnel (UAP)
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positioning a newly admitted client who has a seizure disorder.
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The client is supine and the UAP is placing soft pillows along the
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side rails. What action should the nurse implement?
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a- Ensure that the UAP has placed the pillows effectively to protect the
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client.
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b- Instruct the UAP to obtain soft blankets to secure to the side rails
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instead of pillows.
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, a- Assume responsibility for placing the pillows while the UAP
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completes another task.
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b- Ask the UAP to use some of the pillows to prop the client in a side
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lying position.
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Rationale: The nurse should instruct the UAP to pad the side rails with
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soft blankest because the use of pillows could result in suffocation and
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would need to be removed at the onset of the seizure. The nurse can
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delegate paddling the side rails to the UAP
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4. An adolescent with major depressive disorder has been taking
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duloxetine (Cymbalta) for the past 12 days. Which assessment
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finding requires immediate follow-up?
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a- Describes life without purpose v v v
b- Complains of nausea and loss of appetite v v v v v v
c- States is often fatigued and drowsy
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d- Exhibits an increase in sweating. v v v v
Rationale: Cymbalta is a selective serotonin and norepinephrine
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reuptake inhibitor that is known to increase the risk of suicidal
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thinking in adolescents and young adults with major depressive
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disorder. B, C and D are side effects
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