HESI RN Medical Surgical

Question 1: View While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

A. Increasing anxiety. B. Inappropriate laughter. C. Asymmetrical weakness. D. Weakened cough effort.

Explanation

A. Increasing anxiety may require intervention, but it does not pose an immediate threat to the client's health compared to other options.

B. Inappropriate laughter could indicate emotional lability, a common symptom in ALS, but it does not typically require immediate intervention unless it's accompanied by other concerning symptoms.

C. Asymmetrical weakness is common in ALS but may not necessarily warrant immediate intervention unless it is significantly affecting the client's ability to perform essential functions.

D. Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.

Question 2: View

Patient Data

Exhibits

Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.

A. Obesity B. Hypertension C. Drinks beer nightly D. Daily aspirin E. Type 2 diabetes mellitus F. Sleep apnea G. Ibuprofen for pain H. Nonsmoker I. Osteoarthritis

Explanation

A. Obesity is a significant risk factor for gout as it can increase uric acid production and decrease its excretion.

B. Hypertension is commonly associated with gout, potentially due to shared risk factors including kidney health and certain medications that can raise uric acid levels.

C. Alcohol, especially beer, is a well-known trigger for gout attacks because it increases uric acid production and reduces its excretion.

D. Low doses of aspirin can increase uric acid levels by reducing its excretion through the kidneys.

E. While not a direct risk factor, type 2 diabetes is often associated with metabolic syndrome, which includes several risk factors for gout.

F. Research suggests a link between sleep apnea and increased risk of gout, possibly through the effects of intermittent hypoxia on uric acid levels.

G. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are typically used to treat gout attacks and do not generally increase the risk of developing gout. They can, however, affect kidney function with prolonged use.

H. Smoking is not directly linked to gout risk; smoking cessation is generally beneficial for overall health but does not increase gout risk.

I. Osteoarthritis is a different type of joint disease and does not increase the risk of developing gout.

Question 3: View

Exhibits

Select the 3 dietary choices that are not part of the recommended diet for a client with gout.

A. Garlic B. Liver C. Spinach D. Oatmeal E. Chicken F. Shrimp G. Lentil H. Quinoa I. Oranges J. Sardines

Explanation

A. Garlic is generally considered safe for individuals with gout.

B. Organ meats like liver are very high in purines and should be avoided in a diet for managing gout.

C. Spinach contains moderate amounts of purines, but newer research suggests that they may not increase the risk of gout attacks as much as once thought, and they provide other health benefits that can be weighed in dietary decisions.

D. Oatmeal is generally considered safe for individuals with gout.

E. Chicken is generally considered safe for individuals with gout.

F. Seafood, particularly shellfish like shrimp, is also high in purines and generally recommended to be limited or avoided in a gout diet.

G. Lentils contain moderate amounts of purines, but newer research suggests that they may not increase the risk of gout attacks as much as once thought, and they provide other health benefits that can be weighed in dietary decisions.

H. Quinoa is generally considered safe for individuals with gout.

I. Oranges is generally considered safe for individuals with gout.

J. Small oily fish such as sardines are another source of high purines and are often advised against in the diet of someone managing gout.

Question 4: View The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

A. Eating patterns of dietary intake. B. Activity level of bowel sounds. C. Level and amount of physical activity. D. Color and consistency of feces.

Explanation

A. Eating patterns and dietary intake are crucial in managing chronic pancreatitis as certain foods can exacerbate symptoms. Identifying dietary triggers and making appropriate dietary modifications can help alleviate abdominal pain.

B. The activity level of bowel sounds may provide information about gastrointestinal motility but is not directly related to pain management in chronic pancreatitis.

C. Physical activity can impact overall health but may not directly alleviate abdominal pain associated with chronic pancreatitis.

D. The color and consistency of feces may indicate malabsorption or other gastrointestinal issues but may not directly address the client's pain management needs.

Question 5: View

A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?

A. Fentanyl. B. Hydromorphone. C. Morphine. D. Oxycodone.

Explanation

A. Fentanyl and hydromorphone are potent opioids often used for pain management, but they are not typically first-line medications for acute chest pain associated with suspected myocardial infarction.

B. Hydromorphone, like fentanyl, is an opioid analgesic primarily used for moderate to severe pain but is not the first choice for managing acute chest pain.

C. Morphine is the medication of choice for managing acute chest pain associated with myocardial infarction. It helps alleviate pain, reduce myocardial oxygen demand, and relieve anxiety.

D. Oxycodone is an opioid analgesic used for moderate to severe pain but is not typically indicated as first-line therapy for acute chest pain associated with myocardial infarction.

Question 6: View The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

A. Plan to assess the client's cognition after returning to the room. B. Confirm that this is an effective technique to help with ambulation. C. Assist the client to a carpeted area to walk more easily. D. Reorient the client to the present location and circumstances.

Explanation

A. Assessing the client's cognition may be appropriate if there are concerns about cognitive function, but in this scenario, the client's response indicates a coping mechanism for freezing episodes rather than cognitive impairment.

B. Confirming that the client's technique of pretending to step over a crack is an effective strategy acknowledges the client's self-initiated coping mechanism for freezing episodes, which can help promote independence in ambulation.

C. Assisting the client to a carpeted area may help reduce the risk of falls but does not directly address the freezing episode or the client's coping strategy.

D. Reorienting the client to the present location and circumstances is unnecessary as the client's response indicates a conscious coping strategy rather than confusion or disorientation.

Question 7: View

The nurse reviews the client history of the presenting illness in the electronic medical record.

Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.

A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.

The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.

A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath B. symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous C. inhaler was expired and was worried the medication was not working D. able to answer questions, pausing every few words to catch his breath E. The client reports that it has been a couple of months since he had an asthma attack

Explanation

In the provided scenario, the two key pieces of subjective data indicating the need for health interventions are the client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise. These details suggest that the client's asthma is not well-controlled, and the ineffectiveness of the rescue medication, especially with an expired inhaler, warrants immediate medical attention.

Question 8: View

A client with a renal calculus reports severe right flank pain, nausea, and vomiting.
Which nursing problem has the highest priority?

A. Acute pain related to renal calculus. B. Nutritional deficit related to nausea. C. Impaired renal function related to pain. D. Risk for aspiration related to vomiting.

Explanation

A. Acute pain related to renal calculus is important and needs to be addressed, but managing potential life-threatening conditions, like aspiration, takes precedence.

B. Nutritional deficit related to nausea is also a concern but is not as urgent as preventing aspiration.

C. Impaired renal function related to pain could be important in the long term, but it does not pose an immediate risk like aspiration does. Therefore, it is not the highest priority.

D. Risk for aspiration related to vomiting is the highest priority because it addresses the immediate potential for airway compromise, which can be life-threatening if the client aspirates vomitus. Ensuring the airway is protected and that aspiration does not occur is critical.

Question 9: View

Patient Data.

Exhibits

Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize

as the priority problem for this client, as evidenced by the client's statement,
dropdown
.

Explanation

The rationale for selecting impaired gas exchange is based on the clinical manifestations presented by the client. The client's difficulty in breathing, the need to pause to catch breath, the ineffectiveness of the rescue inhaler, and the expressed feeling of nervousness during episodes are indicative of a compromised gas exchange. This is further supported by the objective data: an oxygen saturation of 88% on room air is below normal levels, suggesting that the client is not receiving adequate oxygen. Expiratory wheezes indicate an obstruction of airflow, commonly seen in asthma attacks, which can impair gas exchange. Therefore, the nurse's assessment and the client's symptoms align with the diagnosis of impaired gas exchange, necessitating immediate intervention to improve the client's respiratory function.

Question 10: View

Patient Data

Exhibits

The nurse has implemented additional needed actions.

Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one, but may have more than one answer selected.

Assessment Data: Indicates the Interventions Were Successful/ No Indication that the Interventions Were Successful

A. Heart Rate 105 beats/minute B. Client can now speak in full sentences without pausing. C. Lung sounds clear D. Respirations 16 breaths/minute E. Client reports, “It’s a lot easier to breathe now.” F. Blood Pressure 122/84 mmHg

Explanation

Correct Answers:

Indicates the Interventions Were Successful: A, B, C, D, E, F

No Indication that the Interventions Were Successful: None

Rationale:

The assessment data provided indicates a positive response to the interventions for the asthma attack. The decrease in heart rate from 112 to 105 beats per minute, alongside the client's ability to speak in full sentences without pausing, suggests an improvement in respiratory function. Clear lung sounds and a reduction in respiratory rate to 16 breaths per minute further support this conclusion. The client's subjective report of eased breathing and the maintenance of blood pressure within normal limits post-intervention are also indicative of successful treatment. These observations collectively demonstrate the effectiveness of the administered medications and oxygen therapy in managing the acute asthma symptoms presented by the client.