Exam (elaborations)
Hesi level 2 (Nsg 170)
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- BCH 462 Urea Cycle, Fatty Acid Synthesis
Hesi level 2 (Nsg 170)
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Hesi level 2 (Nsg 170)A client with acute appendicitis is experiencing anxiety and loss of sleep about
missing final examination week at college. Which outcome is most important for
the nurse to include in the plan of care?
A. Sleeping six to eight hours.
B. Achieve a sense of control.
C. Utilize problem solving skills.
D. Increased focus of attention. - CORRECT ANSWER-B. Achieve a sense of
control.
The experience of psychological discomfort may be as real as physical pain for
the client and
should be seen as a priority in care. Because the client is experiencing anxiety,
achieving a sense of control is a key need (B) before (A, C and D) are
addressed.
A 57-year-old male client is scheduled to have a stress-thallium test the following
morning and is NPO after midnight. At 0130, he is agitated because he cannot
eat and is demanding food. Which response is best for the nurse to provide to
this client?
A) I'm sorry sir, you have a prescription for nothing by mouth from midnight
tonight.
B) I will let you have one cracker, but that is all you can have for the rest of
tonight.
C) What did the healthcare provider tell you about the test you are having
tomorrow?
D) The test you are having tomorrow requires that you have nothing by mouth
tonight. - CORRECT ANSWER-D. "The test you are having tomorrow requires
that you have nothing by mouth tonight."
Being direct and explaining to the client that the test requires him to be NPO, is
the most therapeutic statement because the nurse is responding to the client's
question and providing him the reason why.
,A male client who smokes two packs of cigarettes a day states he understands
that smoking cigarettes is contributing to the difficulty that he and his wife are
having in getting pregnant and wants to know if other factors could be
contributing to their difficulty. What information is best for the nurse to provide?
(Select all that apply.)
A.Marijuana cigarettes do not affect sperm count.
B.Alcohol consumption can cause erectile dysfunction.
C.Low testosterone levels affect sperm production.
D.Cessation of smoking improves general health and fertility.
E.Obesity has no effect on sperm production. - CORRECT ANSWER-B, C, D
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is
also negatively affected by low testosterone levels and obesity.
Which response by a client with a nursing diagnosis of Spiritual distress indicates
to the nurse that a desired outcome measure has been met?
A.Expresses concern about the meaning and importance of life.
B.Remains angry at God for the continuation of the illness.
C.Accepts that punishment from God is not related to illness.
D.Refuses to participate in religious rituals that have no meaning. - CORRECT
ANSWER-C.Accepts that punishment from God is not related to illness
Acceptance that her illness is not God punishing her, indicates a desired
outcome for some degree of resolution of spiritual distress
A mother brings her 4-month-old infant to the clinic for a well-child checkup. She
asks if she should go back to work now or stay at home with the baby. How
should the nurse respond to the mother?
A.Mothers can promote healthy bonding by staying at home during the child's
first years.
B.Determine if other family relatives can stay at home with the baby.
C.Ask the mother to talk about the options she has been considering.
D.Returning to work when an infant is young helps the baby to adjust to other
children. - CORRECT ANSWER-C.Ask the mother to talk about the options she
has been considering.
,It is common for mothers to feel ambivalent about returning to work and caring
full time for children at home. The nurse should assist the mother to explore her
feelings on the subject while focusing on the optimal, appropriate, safe, and
available options for her child
A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks
the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which
response is best for the nurse to provide?
A. "It may hurt a little because of the incision made in your throat."
B. "It won't hurt because you're such a big boy."
C. "It won't hurt because we put you to sleep."
D. "It may hurt but we'll give you medicine to help you feel better." - CORRECT
ANSWER-D. "It may hurt but we'll give you medicine to help you feel better."
Answering questions simply and directly provides comfort for the preschool-age
child and builds confidence in the healthcare team.
A postoperative client has been receiving a continuous IV infusion of meperidine
(Demerol) 35 mg/hr for four days. The client has a PRN prescription for Demerol
100 mg PO q3h. The nurse notes that the client has become increasingly
restless, irritable and confused, stating that there are bugs all over the walls.
What action should the nurse take first?
A..Administer a PRN dose of the PO meperidine (Demerol).
B.Administer naloxone (Narcan) IV per PRN protocol.
C.Decrease the IV infusion rate of the meperidine (Demerol) per protocol.
D.Notify the healthcare provider of the client's confusion and hallucinations. -
CORRECT ANSWER-C.Decrease the IV infusion rate of the meperidine
(Demerol) per protocol.
The client is exhibiting symptoms of Demerol toxicity which is consistent with the
large doses of Demerol received over four days. Decreasing the infusion rate of
the Demerol as per protocol is the most effective action to immediately decrease
the amount of serum Demerol. The next nursing action is for the nurse to notify
the healthcare provider.
, A couple trying to cope with an infertility problem wants to know what can be
done to preserve emotional equilibrium. What is the best response for the nurse
to provide?
A. "Tell your friends and family so that they can help you."
B. "Get involved with a support group. I will give you some names."
C. "Talk only to other friends who are infertile since only they can help."
D. "Start adoption proceedings immediately since obtaining an infant is very
difficult." - CORRECT ANSWER-B: "Get involved with a support group. I will give
you some names."
A support group provides a safe haven for the couple to share their feelings and
experience, gain insight from others dealing with the same experience, and
assure the couple that they are not alone in their situation.
A 17-year-old unmarried, pregnant client with drug addiction is a high school
dropout, homeless, and has a history of past abuse arrives at the clinic for her
first prenatal visit. Which findings should the nurse document as health risk
factors for the client? (Select all that apply.)
A.Age.
B.Drug addiction.
C.History of abuse.
D.Pregnancy.
E.Homelessness.
F.Unmarried. - CORRECT ANSWER-A, B, C, D, E
Health risk factors for this client include age, drug addiction, pregnancy, history of
abuse and homelessness. Each factor should be considered individually. The
client, as an adolescent mother, is at high risk for nutritional deficits, anemia,
gestational diabetes and hypertension, which also impact the fetus' risk for small
for gestational age, fetal anomalies, and fetal demise.
Which nursing intervention should the nurse implement with parents who
experience a fetal demise and express the wish not to see the baby?
A.Tell them there is nothing to fear.
B. Insist that they hold infant so they can grieve.
C.Respect their wishes and release the body to the morgue.
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