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BSN 246 HESI HEALTH ASSESSMENT EXAM VERSION 1 WITH 100 QUESTIONS AND CORRECT VERIFIED ANSWERS WITH RATIONALES/ 2024/2025 HEALTH ASSESSMENT EXAM NIGHTINGALE/ BSN 246 EXAM$27.99
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BSN 246 HESI HEALTH ASSESSMENT EXAM VERSION 1 WITH 100 QUESTIONS AND CORRECT VERIFIED ANSWERS WITH RATIONALES/ 2024/2025 HEALTH ASSESSMENT EXAM NIGHTINGALE/ BSN 246 EXAM
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Course
BSN 246 HESI HEALTH ASSESSMENT
Institution
BSN 246 HESI HEALTH ASSESSMENT
BSN 246 HESI HEALTH ASSESSMENT EXAM VERSION 1 WITH 100 QUESTIONS AND CORRECT VERIFIED ANSWERS WITH RATIONALES/ 2024/2025 HEALTH ASSESSMENT EXAM NIGHTINGALE/ BSN 246 EXAM
BSN 246 HESI HEALTH ASSESSMENT EXAM
VERSION 1 WITH 100 QUESTIONS AND
CORRECT VERIFIED ANSWERS WITH
RATIONALES/ 2024/2025 HEALTH ASSESSMENT
EXAM NIGHTINGALE/ BSN 246 EXAM
1. The nurse is evaluating a client with hyperthyroidism who is taking
Propylthiouracil (PTU) 100 mg/day in three divided doses for maintenance
therapy.
Which of the following statements from the client indicates the desired outcome of
the drug?
1. "I have excess energy throughout the day."
2. "I am able to sleep and rest at night."
3. "I have lost weight since taking this medication."
4. "I do perspire throughout the entire day."
2. PTU is a prototype of thioamide antithyroid drugs. It inhibits production of
thyroid hormones and peripheral conversion of T4 to the more active T3. A client
taking this antithyroid drug should be able to sleep and rest well at night since the
level of
thyroid hormones is reduced in the blood. Excess energy throughout the day, loss
of weight and perspiring through the day are symptoms of hyperthyroidism
indicating the drug has not produced its outcome.
CN: Pharmacological and parenteral therapies; CL: Evaluate.
2. A client with suspected gastric cancer undergoes an endoscopy of the stomach.
Which of the following assessments made after the procedure would indicate the
development of a potential complication?
1. The client has a sore throat.
2. The client displays signs of sedation.
3. The client experiences a sudden increase in temperature.
4. The client demonstrates a lack of appetite.
3. The most likely complication of an endoscopic procedure is perforation. A
sudden temperature spike within 1 to 2 hours after the procedure is indicative of a
pg. 1
,perforation and should be reported immediately to the physician. A sore throat is to
be anticipated after an endoscopy. Clients are given sedatives during the procedure,
so it is expected that they will display signs of sedation after the procedure is
completed. A lack of appetite could be the result of many factors, including the
disease process.
CN: Reduction of risk potential; CL: Analyze
3. A 34-year-old female is diagnosed with hypothyroidism. The nurse should
assess
the client for which of the following? Select all that apply.
1. Rapid pulse.
2. Decreased energy and fatigue.
3. Weight gain of 10 lb (4.5 kg).
4. Fine, thin hair with hair loss.
5. Constipation.
6. Menorrhagia.
2, 3, 5, 6. Clients with hypothyroidism exhibit symptoms indicating a lack of
thyroid hormone. Bradycardia, decreased energy and lethargy, memory problems,
weight gain, coarse hair, constipation, and menorrhagia are common signs and
symptoms of hypothyroidism.
CN: Physiological adaptation; CL: Analyze
4. The nurse is discussing medications with a client with hypertension who has a
prescription for furosemide (Lasix) daily. The client needs further education when
the client states which of the following?
1. "I know I should not drive after taking my Lasix."
2. "I should be careful not to stand up too quickly when taking Lasix."
3. "I should take the Lasix in the morning instead of before bed."
4. "I need to be sure to also take the potassium supplement that the doctor
prescribed along with my Lasix."
1 Furosemide (Lasix) is a diuretic often prescribed for clients with hypertension
or heart failure; the drug should not affect a client's ability to drive safely. Lasix
may cause orthostatic hypotension and clients should be instructed to be careful
when changing from supine to sitting to standing position. Diuretics should be
taken in the morning if possible to prevent sleep disturbance due to the need to get
up to void. Lasix is a loop diuretic that is not potassium sparing; clients should take
potassium
pg. 2
,supplements as prescribed and have their serum potassium levels checked at
prescribed intervals.
CN: Pharmacological and parenteral therapies; CL: Evaluate
5. A client with thyrotoxicosis says to the nurse, "I am so irritable. I am having
problems at work because I lose my temper very easily." Which of the following
responses by the nurse would give the client the most accurate explanation of her
behavior?
1. "Your behavior is caused by temporary confusion brought on by your illness."
2. "Your behavior is caused by the excess thyroid hormone in your system."
3. "Your behavior is caused by your worrying about the seriousness of your
illness."
4. "Your behavior is caused by the stress of trying to manage a career and cope
with illness."
2. A typical sign of thyrotoxicosis is irritability caused by the high levels of
circulating thyroid hormones in the body. This symptom decreases as the client
responds to therapy. Thyrotoxicosis does not cause confusion. The client may be
worried about her illness, and stress may influence her mood; however, irritability
is a common symptom of thyrotoxicosis and the client should be informed of that
fact rather than blamed.
CN: Psychosocial integrity; CL: Synthesize
6. The nurse is completing a health assessment of a 42-year-old female with
suspected Graves' disease. The nurse should assess this client for:
1. Anorexia.
2. Tachycardia.
3. Weight gain.
4. Cold skin.
2. Graves' disease, the most common type of thyrotoxicosis, is a state of
hypermetabolism. The increased metabolic rate generates heat and produces
tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism.
Loss of weight, despite a good appetite and adequate caloric intake, is a common
feature of hyperthyroidism. Cold skin is associated with hypothyroidism.
CN: Physiological adaptation; CL: Analyze
7. The nurse should teach the client with Graves' disease to prevent corneal
irritation from mild exophthalmos by:
1. Massaging the eyes at regular intervals.
pg. 3
, 2. Instilling an ophthalmic anesthetic as prescribed.
3. Wearing dark-colored glasses.
4. Covering both eyes with moistened gauze pads.
3. Treatment of mild ophthalmopathy that may accompany thyrotoxicosis includes
measures such as wearing sunglasses to protect the eyes from corneal irritation.
Treatment of ophthalmopathy should be performed in consultation with an
ophthalmologist. Massaging the eyes will not help to protect the cornea. An
ophthalmic anesthetic is used to examine and possibly treat a painful eye, not
protect the cornea.
Covering the eyes with moist gauze pads is not a satisfactory nursing measure to
protect the eyes of a client with exophthalmos because treatment is not focused on
moisture to the eye but rather on protecting the cornea and optic nerve. In
exophthalmos, the retrobulbar connective tissues and extraocular muscle volume
are expanded because of fluid retention. The pressure is also increased.
CN: Reduction of risk potential; CL: Synthesize
8. A client with Graves' disease is treated with radioactive iodine (RAI) in the
form of sodium iodide 131I. Which of the following statements by the nurse will
explain
to the client how the drug works?
1. "The RAI stabilizes the thyroid hormone levels before a thyroidectomy."
2. "The RAI reduces uptake of thyroxine and thereby improves your condition."
3. "The RAI lowers the levels of thyroid hormones by slowing your body's
production of them."
4. "The RAI destroys thyroid tissue so that thyroid hormones are no longer
produced."
4. Sodium iodide 131I destroys the thyroid follicular cells, and thyroid hormones
are no longer produced. RAI is commonly recommended for clients with Graves'
disease, especially the elderly. The treatment results in a "medical thyroidectomy."
RAI is given in lieu of surgery, not before surgery. RAI does not reduce uptake of
thyroxine.
The outcome of giving RAI is the destruction of the thyroid follicular cells. It is
possible to slow the production of thyroid hormones with RAI.
CN: Pharmacological and parenteral therapies; CL: Synthesize
9. After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I,
the nurse teaches the client to:
pg. 4
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