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ADULT HEALTH 2 HESI TEST BANK EXAM NEWEST ACTUAL EXAM COMPLETE 250 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+||BRAND NEW VERSION!!£19.13
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ADULT HEALTH 2 HESI TEST BANK EXAM NEWEST ACTUAL EXAM COMPLETE 250 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+||BRAND NEW VERSION!!
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Module
ADULT HEALTH 2 HESI
Institution
ADULT HEALTH 2 HESI
ADULT HEALTH 2 HESI TEST BANK
EXAM NEWEST ACTUAL EXAM
COMPLETE 250 QUESTIONS AND
CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY
GRADED A+||BRAND NEW VERSION!!
ADULT HEALTH 2 HESI TEST BANK EXAM NEWEST ACTUAL EXAM COMPLETE 250 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+||BRAND NEW VERSION!! When planning care for a patient with a C5 spinal cord injury, which nursing dia gnosis is the highest priority? A. Risk for impairment of tissue integrity caused by paralysis B. Altered patterns of urinary elimination caused by quadriplegia C. Altered family and individual coping caused by the extent of trauma D. Ineffective airway clearance caused by high cervical spinal cord injury Correct Answer d. Maintaining a patent airway is the most important goal for a patient with a high cervical f racture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs. The nurse is providing care for a patient who has been diagnosed with Guillain -Barré syndrome. Which of the following assessments should the nurse prioritize? A. Pain assessment B. Glasgow Coma Scale C. Respiratory assessment D. Musculoskeletal assessment Correct Answer c. Although all of the assessments are necessary in the care of patients with Guillain -Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status. Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nur se to the possibility of autonomic dysreflexia? A. Headache and rising blood pressure B. Irregular respirations and shortness of breath C. Decreased level of consciousness or hallucinations D. Abdominal distention and absence of bowel sounds Correct Answer a. Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic. Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Administration of benzodiazepines C. Suctioning of the patient's upper airway D. Placement of the patient in the Trendelenburg position Correct Answer a. Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepine s are contraindicated and suctioning is likely unnecessary. Which of the following characteristics of a patient's recent seizure is congruent with a partial seizure? A. The patient lost consciousness during the seizure. B. The seizure involved lip smack ing and repetitive movements. C. The patient fell to the ground and became stiff for 20 seconds. D. The etiology of the seizure involved both sides of the patient's brain. Correct Answer b. The most common complex partial seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity. Which of the following measures should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? A. Vigilant infection contro l and adherence to standard precautions B. Careful monitoring of neurologic vital signs and frequent reorientation C. Maintenance of a calorie count and hourly assessment of intake and output D. Assessment of blood pressure and monitoring for signs of orthostatic hypotension Correct Answer a. Infection control is a priority in the care of patients with MS, since infection is the most common precipitator of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not ty pically result in hypotension or fluid volume excess or deficit. A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long -term care facility. Which of the following actions should the health care team take in order to promote adequate nutrition for this patient? A. Provide multivitamins with each meal. B. Provide a diet that is low in complex carbohydrates and high in protein. C. Provide small, frequent meals throughout the day that are easy to chew and swallow. D. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium. Correct Answer c. Nutritional support is a priority in the care of individuals with PD. Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow. Multivitamins are not necessary at each meal, and vitamin intake, along with protein intake, must be monitored to prevent contraindications with medications. It is likely premature to introduce a minced o r pureed diet, and a low carbohydrate diet is not indicated.
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