Hesi Pharmacology 2024 Practice
"I will ask one of the female nurses to bathe you."
Rationale
Many female Muslim clients are very modest and prefer to receive personal care from another
female because of their religious and cultural beliefs. The most culturally sensitive response is
for the male nurse to ask a female colleague to perform this task. - ANS-A male nurse is
assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client
requests that a female nurse perform this task. How should the male nurse respond?
"May I ask your daughter to help you with your personal hygiene?"
"I will ask one of the female nurses to bathe you."
"A staff member on the next shift will help you."
"I will keep you draped and hand you the supplies as you need them."
"It's highly likely that she will recover and return to her pre-illness state."
Rationale
Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested
development of normal interpersonal skills. Erikson describes the successful resolution of a
developmental crisis in the later years (older than 65-years) to include the achievement of a
sense of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and
accept the death of others (B). Depression is a component of normal grieving, and (A) does not
represent susceptible adaptation to the developmental crisis of an older adult, "Integrity vs
despair." (C and D) are judgmental and not therapeutic. - ANS-The daughter of an older woman
who became depressed following the death of her husband asks, "My mother was always
well-adjusted until my father died. Will she tend to be sick from now on?" Which response is
best for the nurse to provide?
"She is almost sure to be less able to adapt than before."
"It's highly likely that she will recover and return to her pre-illness state."
"If you can interest her in something besides religion, it will help her stay well."
"Cultural strains contribute to each woman's tendencies for recurrences of depression."
"What is concerning you this morning?"
Rationale
(C) is an open-ended question that encourages the client to discuss personal feelings. (A)
devalues the client and hinders further communication. Acting defensively and asking "why"
questions such as (B) are likely to elicit more anger and block communication. By deferring to
the client advocate (D), the nurse fails to even address the client's feelings of anger and
exasperation. - ANS-When the nurse enters a client's room to do an initial assessment, the
client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond?
,"There is no reason to be so angry."
"Why do I need to leave your room?"
"What is concerning you this morning?"
"Let me call the client advocate for you."
A 55-year-old woman who has had moderate low back pain for three months.
Rationale
Experiences with the same type of pain that has successfully been relieved makes it easier for a
client to interpret the pain sensation, and as a result, the client is better prepared to take steps
to relieve the pain (D). (A, B, and C) are having new experiences with pain. - ANS-The nurse
working in the emergency department is assessing four clients' ability to tolerate pain. Which
client is likely to tolerate a higher level of pain?
A 10-year-old who was burned by a camp fire earlier today.
A 70-year-old who has a postoperative infection from a surgery one week ago.
A 23-year-old woman who sprained her knee while bicycling.
A 55-year-old woman who has had moderate low back pain for three months.
A consistent, systematic approach.
Rationale
The most important factor in performing a physical assessment is following a consistent and
systematic technique (C) each time an assessment is performed to minimize variation in
sequence which may increase the likelihood of omitting a step or exam of an isolated area. The
method of completing a physical assessment (A, B, and D) may be at the discretion of the
examiner, but a consistent sequence by the examiner provides a reliable method to ensure
thorough review of the clients' history, complaints, or body systems. - ANS-Which technique is
most important for the nurse to implement when performing a physical assessment?
A head-to-toe approach.
The medical systems model.
A consistent, systematic approach.
An approach related to a nursing model.
A-Pre-medicate the client with an analgesic.
B-Inform the client of the plan for moving to the chair.
D-Ask the client to push the IV pole to the chair.
F-Assess the client's blood pressure.
Rationale
The nurse should plan to implement (A, B, D, and F). Pre-medicating the client with an
analgesic (A) reduces the client's pain during mobilization and maximizes compliance. To
ensure the client's cooperation and promote independence, the nurse should inform the client
, about the plan for moving to the chair (B) and encourage the client to participate by pushing the
IV pole when walking to the chair (D). The nurse should assess the client's blood pressure (F)
prior to mobilization, which can cause orthostatic hypotension. (C and E) are not indicated. -
ANS-The nurse is preparing a male client who has an indwelling catheter and an IV infusion to
ambulate from the bed to a chair for the first time following abdominal surgery. What action(s)
should the nurse implement prior to assisting the client to the chair? (Select all that apply.)
A-Pre-medicate the client with an analgesic.
B-Inform the client of the plan for moving to the chair.
C-Obtain and place a portable commode by the bed.
D-Ask the client to push the IV pole to the chair.
E-Clamp the indwelling catheter.
F-Assess the client's blood pressure.
A-Snack of potato chips, and diet soda.
B-Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
C-Breakfast of eggs, bacon, toast, and coffee.
E-Bedtime snack of crackers and milk.
Rationale
Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are
high in sodium. Only (D) is a meal that is in compliance with a low sodium, low protein diet. -
ANS-A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency
and hypertension, who gained 3 pounds in the last month. The nurse determines that the client
has been noncompliant with the diet, based on which report from the 24-hour dietary recall?
(Select all that apply.)
A-Snack of potato chips, and diet soda.
B-Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
C-Breakfast of eggs, bacon, toast, and coffee.
D-Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
E-Bedtime snack of crackers and milk.
Accused of diversion.
Rationale
Even if this is only one incident, the nurse may be suspected of taking medications on a regular
basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own
use, which should be reported to the peer review committee and to the State Board of Nursing.
(B, C, and D) are also of concern, but (A) is the most serious possible outcome. - ANS-A female
nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver
to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet in her
pocket. Which possible outcome of this situation should be the nurse's greatest concern?
Accused of diversion.
