HESI/Saunders Online Review- Module 10-Physiological Health Problems (all solved)

A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client's personal care items: correct answers B. Within the client's reach on the right side Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is not there. The client does not look at the paralyzed limb when moving about. Unilateral neglect results in increased risk for injury. It is possible for the client to relearn to look for and to move the affected limb(s). Therefore in this condition the client's personal care items are placed within the client's reach on the right side. Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This reduces client frustration and aids in ensuring client safety because the client does not have to strain and reach for needed items. The nurse adapts the client's environment to the deficit by focusing on the client's unaffected side and by placing the client's personal care items on the affected side within reach. Placing items out of the client's reach presents a risk of injury. The emergency department nurse assesses a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note? Select all that apply. correct answers E. Crackles on auscultation of the lungs. Rationale: Signs of left-sided heart failure result from decreased cardiac output and increased pulmonary venous congestion, and the nurse would note signs related to the respiratory system, such as cough, dyspnea, and crackles and wheezes on auscultation of the lungs. Right-sided heart failure is associated with increased systemic venous pressure and congestion, and the nurse would note signs such as neck vein distention, dependent edema, abdominal distention, and weight gain. A home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction? correct answers A. "I should put a steam vaporizer in her room." Rationale: Steam from running water in a closed bathroom and cool mist from a bedside humidifier or a freezer are effective in reducing mucosal edema. A cool mist humidifier is recommended over a steam vaporizer, which presents a danger of scald burns. Taking the child out into the cool humid night air may also relieve mucosal swelling. A mother calls the clinic and tells the nurse that her newborn's umbilical cord site looks red and swollen. The nurse should tell the mother: correct answers B.To bring the newborn to the clinic. Rationale: Symptoms of cord infection include moistness, oozing, discharge, swelling, and a reddened base. If symptoms of infection occur, the newborn must be seen by the healthcare provider. Telling the mother to increase the number of times that the cord is cleansed each day or