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Adult health hesi v1 Exam with complete solution
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10/18/24, 4:13 PMAdult health hesi v1 Exam with complete solution
Terms in this set (67)
Which method elicits the most accurate A. use reliable assessment tools for older adults
information during a physical assessment of
an older adult? Specific assessment tools (D) for an older adult, such as Older Adult Resource
A. use reliable assessment tools for older Services Center Instrument, mini-mental assessment, fall risk, depression, or skin
adults breakdown risk, consider age-related physiologic and psychosocial changes related
B. Review the past medical record for to aging and provide the most accurate and complete information. A and B are
medications subjective and may vary in reliability based on the client's memory and caregiver's
C. Ask the client to recount one's health current involvement. Although C is a good resource to identify polypharmacy, a
history written record may not be available or currently accurate.
D. Obtain the client's information from a
caregiver
A client who has just tested positive for HIV B. discuss retesting to verify results, which will ensure continuing contact
does not appear to hear what the nurse is
saying during post-test counseling. Which encouraging retesting supports hope and gives the client time to cope with the
information should the nurse offer to diagnosis. Although post-test counseling should include education about A, B, and
facilitate the client's adjustment to HIV C, retesting encourages the client to maintain medical follow-up and management.
infection?
A. teach the client about the medications
that are available for treatment
B. discuss retesting to verify the results,
which will ensure continuing contact
C. identify the need to test others who
have had risky contact with the client
D. inform the client how to protect sexual
and needle-sharing partners
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D. return to pre-illness weight
The nurse is caring for a client with HIV
infection who develops Mycobacterium MAC is an opportunistic infection that presents as a TB like pulmonary process. MAC
avium complex (MAC). what is the most is a major contributing factor to the development of wasting syndrome, so the most
significant desired outcome for this client? significant desired outcome is the client's return to a pre-illness weight. drug
A. free from injury of drug side effects schedules and side effects remain a life-long management problem. Client
B. maintenance of intact perineal skin outcomes for adequate oxygenation are often dependent on management of
c. adequate oxygenation anemia, maintenance of activities without fatigue, and supplemental oxygen to
D. return to pre-illness weight prevent hypoxia. Skin integrity is dependent upon resolution of diarrhea, which is not
as significant as optimal nutrition.
A client who had abdominal surgery two a. assist the client to ambulate in the hall
days ago has prescriptions for intravenous
morphine sulfate 4 mg every 2 hours and a Post-operative abdominal distention is caused by decreased peristalsis as a result of
clear liquid diet. the client complains of handling the intestine during surgery, limited dietary intake before and after surgery,
feeling distended and has sharp, cramping and anesthetic and analgesic agents. Peristalsis is stimulated and distention
gas pains. What nursing intervention should minimized by implementing early and frequent ambulation. Based on the client's
be implemented? status, laxatives or withholding dietary progression are not indicated at this time.
A. assist the client to ambulate in the hall although pain management should be implemented, another analgesic prescription
B. obtain a prescription for a laxative may be needed because morphine reduces intestinal motility and contributes to the
C. administer the prescribed morphine client's gas pains.
sulfate
D. withhold all oral fluid and food
A client with Meniere's disease is B. turn off the television and darken the room
incapacitated by vertigo and is lying in bed
grasping the side rails and staring at the to decrease the client's vertigo during an acute attack of Meniere's disease, any
television. Which nursing intervention visual stimuli or rotational movement, such as sudden head movements or position
should the nurse implement? changes, should be minimized. Turning off the television and darkening the room
A. keep the head of the bed elevated 30 minimize fluorescent lights, flickering television lights, and distracting sound. The
degrees other are ineffective in managing the client's symptoms.
B. turn off the television and darken the
room
c. encourage fluids to 3000 mL per day
D. change the client's position every two
hours
a client who has a chronic cough with B. allow the client nothing by mouth until the gag reflex returns
blood-tinged sputum returns to the unit
after a bronchoscopy. What nursing the nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior
interventions should be implemented in the to bronchoscopy, and the bronchoscope is coated with lidocaine gel to inhibit the
immediate post-procedural period? gag reflex and prevent laryngeal spasm during insertion. The client should be NPO
A. check vital signs every 15 minutes for 2 until the client's gag reflex returns to prevent aspiration from any oral intake or
hours secretions. The others are not indicated after bronchoscopy
B. allow the client nothing by mouth until
the gag reflex returns
C. encourage fluid intake to promote
elimination of the contrast media
D. keep the client on bed rest for 8 hours
Adult health hesi v1
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The nurse is assessing a client with a cuffed A. observe the client four coughing colored sputum after drinking a small amount of
tracheostomy tube in place who is colored water
breathing spontaneously. to evaluate if the
client can tolerate cuff deflation to to evaluate the risk for aspiration after the cuff is deflated, the client should be
promote speaking and swallowing, what instructed to swallow a small amount of colored water, then be observed for
action should the nurse implement? coughing up colored sputum, or the tracheostomy should be suctioned for the
A. observe the client for coughing colored presence of colored water.
sputum after drinking a small amount of
colored water
B. ask the client to try to speak
C. auscultate for pulmonary crackles after
the client drinks a small amount of clear
water
D. assess for respiratory distress
What assessment finding should the nurse B. wheezing becomes louder
identify that indicates a client with an acute
asthma exacerbation is beginning to In an acute asthma attack, air flow may be so significantly restricted that wheezing is
improve after treatment? diminished. If the client is successfully responding to bronchodilators and respiratory
A. vesicular breath sounds decrease treatments, wheezing becomes louder as air flow increases in the airways. As the
B. wheezing becomes louder airways open and mucous is mobilized in response to treatment, the cough becomes
C. bronchodilators stimulate coughing more productive. vesicular sounds are soft, low-pitched, gentle, rustling sounds
D. cough remains unproductive heard over lung fields.
A client with sickle cell anemia is admitted C. evaluate the effectiveness of narcotic analgesics
with severe abdominal pain and the
diagnosis is sickle cell crisis. What is the Pain management is the priority for a client during sickle cell crisis. Continuous
most important nursing action to narcotic analgesics are the mainstay of pain control, which should be evaluated
implement? frequently to determine if the client's pain is adequately controlled.
A. limit the client's intake of oral fluids
B. teach the client about prevention of
crises
C. evaluate the effectiveness of narcotic
analgesics
D. encourage the client to ambulate as
tolerated
The nurse is caring for a client with non- D. check stools for occult blod
Hodgkin's lymphoma who is receiving
chemotherapy. Laboratory results reveal a Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a
platelet count of 10,000/mL. What action common side effect of chemotherapy. A client with thrombocytopenia should be
should the nurse implement? assessed frequently for occult bleeding in the emesis, sputum, feces, urine,
A. provide oral hygiene every 2 hours nasogastric secretions, or wounds.
B. check for fever every 4 hours
C. encourage fluids to 3000 mL/day
D. check stools for occult blood
Adult health hesi v1
https://quizlet.com/742081465/adult-health-hesi-v1-flash-cards/ 3/19
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