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HESI RN Medical Surgical
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Showing 10 questions, Sign in for moreA 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months. The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not
Day 1, 0830
Temperature 100.5° F (38.1° C).
Heart rate 97 beats/minute
Respirations 18 breaths/minute
Blood pressure 151/87 mm Hg
Oxygen saturation 95% on room air
Height is 5 ft 11 in (180.34 cm)
Weight is 228 lb (103.4 kg)
Body mass index (BMI) is 31.8 kg/m2
Pain rating of 8 on 0 to 10 scale, in the right foot
Day 1, 0830:
Neurological Within normal limits (WNL)
Cardiovascular 1+ edema in bilateral lower extremities. Respiratory Diminished breath sounds in bilateral bases of the lungs. Gastrointestinal/Genitourinary WNL.
Integumentary Redness and warmth at the right great toe. On palpation, noted small hard firm deposits under the skin on the right great toe.
Musculoskeletal Pain and swelling in right great toe. Great toe is lightly deformed at the joint. Right sided limp present when
History and Physical Flow Sheet.
The nurse is reviewing the client's medical record to better understand the previous gout attacks.
Click to indicate if the findings are consistent with an acute gout attack, chronic gout, or both.
Each row must have at least one, but may have more than one, response option selected.
Explanation
Correct Answers:
Chronic gout: A, B, E Acute gout: C, D, E
Rationale:
The presence of tophi, small hard firm deposits under the skin, can be associated with chronic gout, as they are deposits of uric acid crystals that typically accumulate over time. A low-grade fever can accompany an acute gout attack, but it is not exclusive to it and can be seen in other conditions as well. Pain at the affected joint is a hallmark of an acute gout attack, and while gout can occur in more than one joint, it is more commonly monoarticular, especially in the early stages of the disease. Chronic gout is also characterized by repeated episodes of pain and inflammation of the affected joints. Renal dysfunction is not typically a feature of an acute gout attack but can be a complication of chronic gout due to the long-term deposition of uric acid crystals in the kidneys.
A 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months.
The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not
Day 1, 0830
Temperature 100.5° F (38.1° C) Heart rate 97 beats/minute Respirations 18 breaths/minute Blood pressure 151/87 mm Hg Oxygen saturation 95% on room air Height is 5 ft 11 in (180.34 cm)
Weight is 228 lb (103.4 kg)
Body mass index (BMI) is 31.8 kg/m2 Pain rating of 8 on 0 to 10 scale in the right
Client history has been collected, and the nurse performs a physical assessment and records vital signs
Patient Data
A 59-year-old male client presents to the clinic, reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months.
The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not improved and that he is unable to walk or work
Select the 3 dietary choices that are not part of the recommended diet for a client with gout.
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 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.
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.
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.
A client with a renal calculus reports severe right flank pain, nausea, and vomiting.
Which nursing problem has the highest priority?
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.
Initial Assessment
- Temperature 98.9° F (37.1° C)
- Heart rate 112 beats/minute
- Respirations 28 breaths/minute
- Blood pressure 130/86 mm Hg
- Oxygen saturation 88% on room air
- Lung sounds reveal expiratory wheezes
- Capillary refill time 2 seconds
Patient Data.
Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize
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.
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