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HESI RN Pathophisiology
Total Questions : 49
Showing 10 questions, Sign in for moreAn older adult client is admitted from a long-term care facility with purulent exudate draining from a sacral pressure ulcer is suspected to have methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? Select all that apply.
An older adult client presents to the emergency department (ED) with poorly controlled diabetes mellitus. He had been experiencing polyuria, nausea and vomiting, confusion, and unstable blood sugars. The client was stabilized in the ED and transferred to the medical unit for continued stabilization and management. The client has a history of cigarette smoking and has smoked one pack per day for the past 40 years. There is a history of moderate obesity, type 1 diabetes mellitus, and mobility issues. He requires the use of a walker for mobility.
1715
The client is moved from the gurney to the medical bed and requires two people to assist. The nurse performs a functional assessment. The client reports neuropathy in bilateral hands and lower legs. His skin is moist. He reports the need to wear an incontinence brief due to occasional accidents of both urine and stool. He explains that it is difficult for him to be able to move quickly enough when he feels the urge to use the bathroom. At home where he lives alone, he reports spending most of his time in his recliner, though he can ambulate within the home and does so if needed. He does feel like he slides in bed to move because repositioning is difficult. He is currently using a front wheeled walker. He reports difficulty eating a full meal and has less than optimal PO intake. Coarse lung sounds are noted.
The nurse reviews the client's data.
Choose the most likely options for the information missing from the sentence by selecting from the lists of options provided.
The client's assessment findings of
Explanation
The client's assessment findings of neuropathy and incontinence place him at a high risk for multiple other health issues and require immediate follow-up by the nurse.
Rationale:
Neuropathy. The client reports neuropathy in both hands and lower legs. Neuropathy leads to decreased sensation, increasing the risk of falls, pressure injuries, and unnoticed wounds, which can become severe due to diabetes-related poor healing. It also contributes to mobility limitations, further affecting the client’s safety and independence.
Incontinence. The client experiences urinary and fecal incontinence due to difficulty moving quickly enough to reach the bathroom. Incontinence increases the risk of skin breakdown, infections, and pressure ulcers, especially since the client has mobility issues and spends prolonged time sitting.
Moist skin. While moist skin may suggest sweating or autonomic dysfunction, it is not as significant a risk factor as neuropathy and incontinence, which directly impact skin integrity and mobility.
Coarse lung sounds. Coarse lung sounds may indicate fluid retention or respiratory congestion, but they are not as immediately concerning as neuropathy and incontinence, which increase the risk for skin damage, infection, and functional decline.
An older adult client presents to the emergency department (ED) with poorly controlled diabetes mellitus. He had been experiencing polyuria, nausea and vomiting, confusion, and unstable blood sugars. The client was stabilized in the ED and transferred to the medical unit for continued stabilization and management. The client has a history of cigarette smoking and has smoked one pack per day for the past 40 years. There is a history of moderate obesity, type 1 diabetes mellitus and mobility issues. He requires the use of a walker for mobility.
The nurse reviews the client's data.
Which factor(s) place the client at greatest risk for skin injuries? Select all that apply.
An older adult client presents to the emergency department (ED) with poorly controlled diabetes mellitus. He had been experiencing polyuria, nausea and vomiting, confusion, and unstable blood sugars. The client was stabilized in the ED and transferred to the medical unit for continued stabilization and management. The client has a history of cigarette smoking and has smoked one pack per day for the past 40 years. There is a history of moderate obesity, type 1 diabetes mellitus and mobility issues. He requires the use of a walker for mobility.
The nurse reviews the client's data.
After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.
Which test for HIV is used primarily as a confirmatory test rather than a generalized screening test?
A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. Which is the greatest clinical risk related to this situation?
The public health nurse is evaluating resources in a rural community. Which healthcare resource is most important to the community?
The nurse is caring for a one-month-old infant admitted for suspected congenital hypothyroidism. Which diagnostic test results should the nurse report to the healthcare provider?
The client is a 19-year-old female college student. She has had type 1 diabetes mellitus for 14 years. She is currently in the endocrinology clinic for a follow-up visit.
|
Laboratory Test |
Result |
Reference Range |
|
Hemoglobin A1C (today)
|
8.2%
|
4 to 5.9%
|
|
Hemoglobin A1C (3 months ago) |
7.5%
|
4 to 5.9%
|
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and to parameters the nurse should monitor to assess the client's progress.
Explanation
Potential Condition:
Diabetic neuropathy – The client has a history of type 1 diabetes, and her elevated Hemoglobin A1C (8.2%) suggests poor blood glucose control, which increases the risk of diabetic neuropathy.
Actions to Take:
Perform a sensory test on both feet – Diabetic neuropathy can cause loss of sensation in the feet. A sensory test helps assess nerve function and detect early signs of neuropathy.
Instruct the client to change to clean, dry socks – Proper foot care is crucial for preventing infections and complications in clients with diabetes. Keeping feet dry reduces the risk of skin breakdown and infections.
Parameters to Monitor:
Pedal pulses – Poor circulation is a common complication of diabetes and neuropathy. Monitoring pedal pulses helps assess blood flow to the feet.
Blood glucose – Tight glucose control is essential for preventing the progression of diabetic neuropathy. Monitoring blood glucose levels helps guide management and treatment adjustments.
Which information is most important for the nurse to consider in determining a client's need for an obesity counseling referral?
Reference Range:
Body mass index (BMI) [18.0 kg/m2 to 24.9 kg/m
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