HESI MEDSURGE VERSION 2 EXAM | VERIFIED EXAM

HESI MEDSURGE VERSION 2 EXAM A client arrives in the ED with slurred speech and right-sided weakness Onset of symptoms The community mental health nurse is planning to visit 4 clients with schizophrenia..see first The father who took his children from school because aliens were after them The nurse is assessing several clients at a homeless shelter. Which client should the nurse refer for involuntary admission to a psych facility A young adult who has lost his appetite because the communists are asking him to kill all conservative Catholics An adult male who has not eaten for 3 days and says he is Jesus Christ and that God loves all people A middle-aged woman who sits for long periods of time and mumbles to herself about wanting to die A 7-year-old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history, which finding should the nurse expect to obtain A recent strep throat infection Beginning with the vena cava, what is the normal sequence of blood circulation through the heart (arrange from entry of the heart on top to exit of the heart on the bottom) Right atrium, tricuspid valve, right ventricle, pulmonary semilunar valve, left atrium, mitral valve, left ventricle, aortic semilunar valve The nurse is assessing the emotional status of a client with Parkinson’s disease. Which client finding is most helpful in planning goals to meet the client’s emotional needs Cries frequently during the interview What nursing intervention is particularly indicated for the second stage of labor Assisting the client to push effectively so that expulsion of the fetus can be achieved A newborn is apneic for 20 seconds. What action should the nurse implement Stimulate by gently rubbing infant’s trunk The nurse is completing a neurological assessment. Which observation indicates an abnormal pupil response When shining the light into the right eye, the left pupil does not constrict The nurse manager is concerned about the number of falls that have occurred on the unit in the last month. Which action is most likely to decrease the number of falls Obtain the evidence based practice guidelines for falls prevention The healthcare provider prescribes diltiazem (Cardizem ) for a child with hypertension who weighs 66 pounds. Based on the recommended dose of 3.5 mg/kg/day, how many mg should the child receive per day One year after being diagnosed with Pneumocystic carinii pneumonia, a client is admitted with respiratory failure. Respirations are shallow with periods of apnea. After the HCP delivers a grim prognosis to the client’s family, which intervention should the nurse implement first Clarify client’s end of life wishes When preparing to start change-of-shift report, the charge nurse observes an unlicensed assistive personnel (UAP) walking in the hallway with a urine specimen that is not covered. After telling the UAP to cover the specimen, what intervention should the charge nurse implement Review infection control guidelines with the UAP at the next opportunity In monitoring a client’s respiratory status, which symptom is characteristic of early acute (adult) respiratory distress syndrome (ARDS) Increased respiratory rate A client’s serum potassium test level is 6 mEq/L. The laboratory indicates, “Specimen is hemolyzed.” What action should the nurse take Draw a new blood specimen Which action should the nurse implement to reduce a clients risk for nosocomial infection Replace continuous tube feeding bag and tubing at least daily During the admission interview, the nurse leader learns that a newly admitted adult client has a six month history if recurring somatic pain. Which problem is most important for the nurse to further explore with the client Feelings of depression An older male adult resident of an extended care facility receives a prescription for diphenhydramine (Benadryl) 25 mg PO to treat generalized pruritis. Two hours after administration of the drug, he continues to experience itching, is confused, and has an unsteady gait. Which actions should the nurse implement first Place the client on fall precautions A female resident of a long-term care facility is being admitted to the medical department. The client has a fractured humerous and methicillin-resistant staphylococcus aureus (MRSA). Which room should the charge nurse assign this client A semi-private room with another client who also has MRSA The healthcare provider is working with a client who was recently diagnosed with asthma. Which statement by the client indicates to the nurse that further teaching is needed “I should always use my beclomethasone inhaler first, then follow it with my albuterol inhaler.” The nurse is preparing to conduct discharge teaching for a client who had an anaphylactic reaction following administration of ampicillin (Omnipen-N). What instruction is essential for the nurse to provide this client prior to discharge Instruct the client to wear a medic-alert bracelet so penicillin will not be given again