HSEI PRACTICE EXAM 3 | 126 QUESTIONS |
WITH COMPLETE SOLUTIONS!!
The nurse instills an atropine ophthalmic solution into both eyes for a client
who is having a routine eye examination. Which side effects should the nurse
tell the client to anticipate?
Blurred vision.
Halos around objects.
Inability to see at night.
Itching of the conjunctiva. Answer - Blurred vision.
Atropine ophthalmic solution is used during eye examinations to dilate the
pupil (mydriasis) and paralyze the ciliary muscle (cycloplegic refraction), which
prevents accommodation and causes blurred vision.
The nurse is teaching a client who is newly diagnosed with Type 1 diabetes
mellitus about diet and insulin. The client should be instructed to perform
glucose self-monitoring when which symptom occurs after exercising?
Shakiness.
Unusual thirst.
Sudden anorexia.
Excessive urination. Answer - Shakiness.
The primary response to acute exercise is an increase in glucose utilization, so
the client should recognize shakiness as an early sign of hypoglycemia.
,Excessive urination (polyuria) and unusual thirst (polydipsia) are manifestations
of hyperglycemia related to excess dietary intake or stressors, such as infection.
Anorexia may be experienced with hyperglycemia, but serum glucose should
be evaluated if the client demonstrates signs of hypoglycemia, which is more
likely after exercising.
The nurse identifies the nursing diagnosis of, "Visual sensory/perceptual
alterations related to increased intraocular pressure (IOP)" for a client with
glaucoma. Which nursing intervention should the nurse include in the plan of
care?
Encourage compliance with drug therapy to prevent loss of vision.
Develop pain management strategies associated with ocular nerve atrophy.
Identify coping mechanisms related to the eventual loss of peripheral vision.
Recognize that damage to the eye can be reversed until late stages Answer -
Encourage compliance with drug therapy to prevent loss of vision.
Glaucoma is characterized by a silent increase in IOP, optic nerve atrophy, and
visual field loss that is managed with eyedrop instillation of beta-blocker, alpha-
adrenergic, or carbonic anhydrase inhibitors. The retinal damage caused by the
increased IOP is irreversible and can lead to blindness, so the client's drug
therapy compliance addresses the nursing diagnosis.
A primiparous client has been in labor for 15 hours. Two hours ago, vaginal
examination revealed the cervix dilated to 5 cm, 100% effaced, and the
presenting part at station 0. Five minutes ago, the vaginal examination reveals
no change in the cervix or decent of the fetus. Which labor pattern should the
nurse document to describe the client's progress?
Protracted descent.
Arrest of active phase.
,Prolonged latent phase.
Protracted active phase. Answer - Arrest of active phase.
Arrest of active phase is indicated if there is no change in the dilation of the
cervix for 2 hours or more in a primigravida. Prolonged latent phase is labor
lasting longer than 20 hours in a primigravida. Protracted active phase occurs
when dilatation of the cervix is less than 1.2 cm/hour. Protracted descent
occurs when the fetus descends less than 1 cm/hour into the pelvis
A nurse gives a client a narcotic for pain and must now leave the unit. To whom
should the nurse delegate the task of evaluating the client's response to the
pain medication?
Unit clerk.
Student nurse.
Nurse-manager.
Unlicensed assistive personnel. Answer - Nurse-manager.
Pain assessment and evaluation of analgesia are components in the scope of
nursing practice and are determined by a licensed nurse, so the nurse-manager
should assume this responsibility. Although some client care tasks may be
delegated to unlicensed personnel evaluation of analgesia is a component of
the nursing process that requires the expertise of a nurse.
A male client with degenerative arthritis of the knees and hips takes an over-
the-counter (OTC) nonsteroidal antiinflammatory drug (NSAID) for pain. During
a routine clinic visit, the client tells the nurse, "For the past month I've been
having a lot of trouble sleeping. I can't seem to fall asleep, and when I finally do
get to sleep, I find that I wake up a number of times during the night." Which
information should the nurse obtain first?
, Does the client snore or experience sleep apnea?
How intense does the client rate his pain on a scale of 1 to 10?
What type of medications does the client take before bedtime?
Are there any white noise or lights on during the night? Answer - How intense
does the client rate his pain on a scale of 1 to 10?
A client with degenerative arthritis may have sleep disturbances related to
chronic pain, so the client's pain intensity should be determined. Other factors
that may affect the client's sleep patterns and should be considered after
assessing the client's arthritic pain and how it is managed.
Which evidence supports the application of healthcare informatics and client
care technology?
The elimination of chaos in solving informatics problems.
The emergence of new and appropriate knowledge structures.
A solution for informatics problems with data flow records and work flow
documentation.
A new sense of order to a problem that facilitates cost-effective analysis and
evaluation of care. Answer - A new sense of order to a problem that facilitates
cost-effective analysis and evaluation of care.
Chaordic theory is the mix of chaos and order that is often a harmonious
coexistence of both. This theory is seen in living organisms and its principles
have been used as guidelines for creating human organizations or businesses,
such as informatics. Electronic medical records and client care technology
produce a vast amount of data, such as client assessments, planning,
documentation of treatment, and evaluation of client care, that must be cost-
effectively organized.
WITH COMPLETE SOLUTIONS!!
The nurse instills an atropine ophthalmic solution into both eyes for a client
who is having a routine eye examination. Which side effects should the nurse
tell the client to anticipate?
Blurred vision.
Halos around objects.
Inability to see at night.
Itching of the conjunctiva. Answer - Blurred vision.
Atropine ophthalmic solution is used during eye examinations to dilate the
pupil (mydriasis) and paralyze the ciliary muscle (cycloplegic refraction), which
prevents accommodation and causes blurred vision.
The nurse is teaching a client who is newly diagnosed with Type 1 diabetes
mellitus about diet and insulin. The client should be instructed to perform
glucose self-monitoring when which symptom occurs after exercising?
Shakiness.
Unusual thirst.
Sudden anorexia.
Excessive urination. Answer - Shakiness.
The primary response to acute exercise is an increase in glucose utilization, so
the client should recognize shakiness as an early sign of hypoglycemia.
,Excessive urination (polyuria) and unusual thirst (polydipsia) are manifestations
of hyperglycemia related to excess dietary intake or stressors, such as infection.
Anorexia may be experienced with hyperglycemia, but serum glucose should
be evaluated if the client demonstrates signs of hypoglycemia, which is more
likely after exercising.
The nurse identifies the nursing diagnosis of, "Visual sensory/perceptual
alterations related to increased intraocular pressure (IOP)" for a client with
glaucoma. Which nursing intervention should the nurse include in the plan of
care?
Encourage compliance with drug therapy to prevent loss of vision.
Develop pain management strategies associated with ocular nerve atrophy.
Identify coping mechanisms related to the eventual loss of peripheral vision.
Recognize that damage to the eye can be reversed until late stages Answer -
Encourage compliance with drug therapy to prevent loss of vision.
Glaucoma is characterized by a silent increase in IOP, optic nerve atrophy, and
visual field loss that is managed with eyedrop instillation of beta-blocker, alpha-
adrenergic, or carbonic anhydrase inhibitors. The retinal damage caused by the
increased IOP is irreversible and can lead to blindness, so the client's drug
therapy compliance addresses the nursing diagnosis.
A primiparous client has been in labor for 15 hours. Two hours ago, vaginal
examination revealed the cervix dilated to 5 cm, 100% effaced, and the
presenting part at station 0. Five minutes ago, the vaginal examination reveals
no change in the cervix or decent of the fetus. Which labor pattern should the
nurse document to describe the client's progress?
Protracted descent.
Arrest of active phase.
,Prolonged latent phase.
Protracted active phase. Answer - Arrest of active phase.
Arrest of active phase is indicated if there is no change in the dilation of the
cervix for 2 hours or more in a primigravida. Prolonged latent phase is labor
lasting longer than 20 hours in a primigravida. Protracted active phase occurs
when dilatation of the cervix is less than 1.2 cm/hour. Protracted descent
occurs when the fetus descends less than 1 cm/hour into the pelvis
A nurse gives a client a narcotic for pain and must now leave the unit. To whom
should the nurse delegate the task of evaluating the client's response to the
pain medication?
Unit clerk.
Student nurse.
Nurse-manager.
Unlicensed assistive personnel. Answer - Nurse-manager.
Pain assessment and evaluation of analgesia are components in the scope of
nursing practice and are determined by a licensed nurse, so the nurse-manager
should assume this responsibility. Although some client care tasks may be
delegated to unlicensed personnel evaluation of analgesia is a component of
the nursing process that requires the expertise of a nurse.
A male client with degenerative arthritis of the knees and hips takes an over-
the-counter (OTC) nonsteroidal antiinflammatory drug (NSAID) for pain. During
a routine clinic visit, the client tells the nurse, "For the past month I've been
having a lot of trouble sleeping. I can't seem to fall asleep, and when I finally do
get to sleep, I find that I wake up a number of times during the night." Which
information should the nurse obtain first?
, Does the client snore or experience sleep apnea?
How intense does the client rate his pain on a scale of 1 to 10?
What type of medications does the client take before bedtime?
Are there any white noise or lights on during the night? Answer - How intense
does the client rate his pain on a scale of 1 to 10?
A client with degenerative arthritis may have sleep disturbances related to
chronic pain, so the client's pain intensity should be determined. Other factors
that may affect the client's sleep patterns and should be considered after
assessing the client's arthritic pain and how it is managed.
Which evidence supports the application of healthcare informatics and client
care technology?
The elimination of chaos in solving informatics problems.
The emergence of new and appropriate knowledge structures.
A solution for informatics problems with data flow records and work flow
documentation.
A new sense of order to a problem that facilitates cost-effective analysis and
evaluation of care. Answer - A new sense of order to a problem that facilitates
cost-effective analysis and evaluation of care.
Chaordic theory is the mix of chaos and order that is often a harmonious
coexistence of both. This theory is seen in living organisms and its principles
have been used as guidelines for creating human organizations or businesses,
such as informatics. Electronic medical records and client care technology
produce a vast amount of data, such as client assessments, planning,
documentation of treatment, and evaluation of client care, that must be cost-
effectively organized.
