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HESI_Med_Surg_E 1. Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing?  Respiratory effort.  Unsteady gait.  Intensity of pain.  Ability to eat. Guillain-Barre syndrome causes paralys...

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hesimedsurgexamdocx 1 which assessment is most important for the nurse to perform on a client who is hospitalized for guillain barre syndrome that is rapidly progressing

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1.
Which assessment is most important for the nurse to perform on a client who is
hospitalized for Guillain-Barre syndrome that is rapidly progressing?
 Respiratory effort.
 Unsteady gait.
 Intensity of pain.
 Ability to eat.

Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet
and progresses upwards. As the condition progresses, the nurse must ensure that the
client is able to breathe effectively.

Heuther, Understanding Pathophysiology, 6th ed. p. 412

2.
A male client comes into the clinic with a history of penile discharge with painful,
burning urination. Which action should the nurse implement?
 Collect a culture of the penile discharge.
 Palpate the inguinal lymph nodes gently.
 Observe for scrotal swelling and redness.
 Express the discharge to determine color.

Penile discharge with painful urination is commonly associated with gonorrhea. The
nurse should collect a culture of the penile discharge to determine the cause of these
symptoms. The cause must be determined or confirmed through culture to identify the
organism and ensure effective treatment.

Jarvis Physical Examination and Health Assessment, 6th edition

3.
A client with history of atrial fibrillation is admitted to the telemetry unit with sudden
onset of shortness of breath. The nurse observes a new irregular heart rhythm and
should perform which assessment at this time?
 Check for a pulse deficit.
 Palpate the apical impulse.
 Inspect jugular vein pulse.
 Examine for a carotid bruit.

A client with a past history of atrial fibrillation may return to that rhythm. Any signs
of atrial fibrillation, such as sudden onset shortness of breath, requires further
investigation. The nurse should assess this client for a pulse deficit because this
condition occurs with atrial fibrillation.

,Jarvis. (2016); Physical Examination and Health Assessment, (Chap 19) 7th ed., p.
481

4.
Which client should be further assessed for an ectopic pregnancy?
 A 24-year-old with shoulder and lower abdominal quadrant pain.
 A 33-year-old with intermittent lower abdominal cramping.
 A 20-year-old with fever and right lower abdominal colic.
 A 40-year-old with jaundice and right lower abdominal pain.

A 24-year-old with sudden onset of lower abdominal quadrant pain should be
assessed for an ectopic pregnancy. The pain can also be referred to the shoulder and
may be associated with vaginal bleeding.

Health Assessment for Nursing Practice, Wilson and Giddens. p.269

5.
Which dietary assessment finding is most important for the nurse to address when
caring for a client with diabetic nephropathy?
 Drinks a six pack of beer every day.
 Enjoys a hamburger once a month.
 Eats fortified breakfast cereal daily.
 Consumes beans and rice every day.

Drinking six beers every day is the dietary assessment finding most important for the
nurse to address when caring for a client with diabetic nephropathy. The usual can of
beer is 12 ounces (355 mL). Clients with diabetes are recommended to drink no more
than 12 ounces of beer per day because beer contains carbohydrates that can create
unhealthy fluctuations in blood glucose and promote poor glucose control.
Nephropathy is exacerbated by poor blood glucose control.
6.
Which assessment finding is of greatest concern to the nurse who is caring for a client
with stomatitis?
 Cough brought on by swallowing.
 Sore throat caused by speaking.
 Painful and dry oral cavity.
 Unintended weight loss.

A cough brought on by swallowing is a sign of dysphagia, which is a finding of
particular concern in a client with stomatitis. Dysphagia can cause numerous
problems, including airway obstruction, and should be reported to the healthcare
provider immediately.

,Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative care,
eight edition., Ch. 53, p. 1100.

7.
The nurse is teaching a client diagnosed with peripheral arterial disease. Which
genitourinary system complication should the nurse include in the teaching?
 Altered sexual response.
 Sterility.
 Urinary incontinence.
 Decreased pelvic muscle tone.

Peripheral arterial disease (PAD) is a cardiovascular condition characterized by
narrowing of the arteries and reduced blood flow to the extremities. PAD is known to
alter the blood flow to the male's penis and is associated with erectile dysfunction in
men.

Ignatavicius,. (2016). Medical-surgical nursing: Patient-centered collaborative care,
eight edition., Ch. 69, p. 1452.

8.
A 40-year-old female client has a history of smoking. Which finding should the nurse
identify as a risk factor for myocardia infarction?
 Oral contraceptives.
 Senile osteopenia.
 Levothyroxine therapy.
 Pernicious anemia.

Women older than 35 years old who smoke and take oral contraceptives have an
increased risk of myocardial infarction or stroke.

Ignatavicius, (2013). Medical-surgical nursing: Patient-centered collaborative care,
7th ed.., Ch. 35, p. 694.

9.
A client has been told that there is cataract formation over both eyes. Which finding
should the nurse expect when assessing the client?
 Decreased color perception.
 Presence of floaters.
 Loss of central vision.
 Reduced peripheral vision.

Decreased color perception occurs with cataract formation. Cataract formation is also
associated with blurred vision and a global loss of vision so gradual that the client
may not be aware of it.

, Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative care,
eight edition., Ch. 47,

10.
Which assessment finding should most concern the nurse who is monitoring a client
two hours after a thoracentesis?
 New onset of coughing.
 Low resting heart rate.
 Distended neck veins.
 Decreased shallow respirations.

A pneumothorax (partial or complete lung collapse) is the potential complication of a
thoracentesis. Manifestations of a pneumothorax include new onset of a nagging
cough, tachycardia, and an increased shallow respiration rate.

Ignatavicius,(2016). Medical-surgical nursing: Patient-centered collaborative care,
eight edition., Ch. 27, pp. 511-13.

11.
While caring for a client who has esophageal varices, which nursing intervention is
most important for the registered nurse (RN) to implement?
 Monitor infusing IV fluids and any replacement blood products.
 Prepare for esophagogastroduodenoscopy (EGD).
 Maintain the client on strict bedrest.
 Insert a nasogastric tube (NGT) for intermittent suction.

Maintaining hemodynamic stability in a client with esophageal varices can precipitate
a life-threatening crisis if esophageal varies leak or rupture and can result in
hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any
replacement blood products.

12.
The registered nurse (RN) is caring for a client who developed oliguria and was
diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding
indicates to the RN that the client is stabilizing?
 Urine output of 40 mL/hour.
 Apical pulse 100 and blood pressure 76/42.
 Urine specific gravity 1.001.
 Tented skin on dorsal surface of hands.

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