Wk 7 hesi 2 - Medical surgical Concepts of Nursing II (BSN 266) Nightingale College A+
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Wk 7 hesi 2 - Medical surgical Concepts of Nursing II (BSN 266) Nightingale College A+ The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first?
Potassium 6.0 mEq.
Daily urine output of 400 ml. Peripheral neur...
Wk 7 hesi 2 - Medical surgical
Concepts of Nursing II (BSN 266)
Nightingale College A+
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The nurse is assessing a client with chronic kidney disease (CKD). Which finding
is most important for the nurse to respond to first?
Potassium 6.0 mEq.
Daily urine output of 400 ml.
Peripheral neuropathy.
Uremic fetor.
Rationale
Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte
disorder that can cause fatal arrhythmias, so the elevation of the potassium level
is a nursing priority.
In assessing cancer risk, the nurse identifies which woman as being at greatest
risk of developing breast cancer?
A 35-year-old multipara who never breastfed.
A 50-year-old whose mother had unilateral breast cancer.
A 55-year-old whose mother-in-law had bilateral breast cancer.
A 20-year-old whose menarche occurred at age 9.
Rationale
The most predictive risk factors for development of breast cancer are over 40
years of age and a positive family history (occurrence in the immediate family,
i.e., mother or sister). Other risk factors include nulliparity, no history of
breastfeeding, early menarche and late menopause, but are not considered as
predictive as a positive history of an immediate family member and over 40 years
old.
Which client should the nurse recognize as most likely to experience sleep
apnea?
Middle-aged female who takes a diuretic nightly.
Obese older male client with a short, thick neck.
Adolescent female with a history of tonsillectomy.
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School-aged male with a history of hyperactivity disorder.
Rationale
Sleep apnea is characterized by lack of respirations for 10 seconds or more
during sleep and is due to the loss of pharyngeal tone which allows the pharynx
to collapse during inspiration and obstructs air flow through the nose and mouth.
Risk factors which increase the condition of sleep apnea include: excessive
weight, increases the risk 4Xs more than normal weighing individuals; neck
circumference, thicker necks have narrower airways; individuals with inherited
narrower airways; males in general are more prone to sleep apnea; females risk
increase with being overweight and post-menopausal; increased age (geriatrics);
family history; use of alcohol, sedatives or tranquilizers; smokers and those who
suffer from nasal allergies.
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A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg.
Which action should the nurse implement?
Position the head of the bed (HOB) flat.
Withhold intravenous fluids.
Administer a bolus of IV fluids.
Give an antihypertensive medication.
Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines
or blood viscosity increases due to minimal fluid intake. Completed strokes
usually produce neurologic deficits within an hour, and the client's current
elevated blood pressure requires antihypertensive medication.
A postmenopausal client asks the nurse why she is experiencing discomfort
during intercourse. What response is best for the nurse to provide?
Estrogen deficiency causes the vaginal tissues to become dry and thinner.
Infrequent intercourse results in the vaginal tissues losing their elasticity.
Dehydration from inadequate fluid intake causes vulva tissue dryness.
Lack of adequate stimulation is the most common reason for dyspareunia.
Rationale
Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells,
so vaginal tissues tend to become thinner, drier, and the rugae become smoother
which reduces vaginal stretching that contributes to dyspareunia. The discomfort
during intercourse, primary cause can be contributed to the decrease in estrogen
hormone levels.
A middle-aged male client with diabetes continues to eat an abundance of foods
that are high in sugar and fat. According to the Health Belief Model, which event
is most likely to increase the client's willingness to become compliant with the
prescribed diet?
He visits his diabetic brother who just had surgery to amputate an infected foot.
He is provided with the most current information about the dangers of untreated
diabetes.
He comments on the community service announcements about preventing
complications associated with diabetes.
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