HESI Comprehensive B Practice with rationale

1 An 8-year-old child is receiving . digoxin (Lanoxin) for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take? A. Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. B. Hold the next dose of digoxin until the health care provider can be notified because the serum digoxin level is elevated. C. Administer the next dose of digoxin and notify the health care provider that the child is showing signs of toxicity. D. Notify the health care provider that the child's pulse rate is below normal for her age group. 2 A 12-year-old boy complains to the . nurse that he is "short" (4'5" [53 inches]). His twin sister is 5 inches taller than he is (4'10" [58 inches]). Based on these findings, what conclusion should the nurse reach? A.The boy is not growing as normally expected. B. The girl is experiencing a period of unexpected growth. C.A normal growth spurt occurs in girls 1 to 2 years earlier than boys. D.Male-female twins are not identical; therefore, their growth cannot be A Rationale: Nausea and vomiting are early signs of digoxin toxicity. However, the normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min and the therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, (A) is the best of the choices provided because the serum digoxin level is within normal levels. (B) is not warranted by the data presented. The digoxin level is within the therapeutic range and the child is not showing signs of toxicity (C). The child's pulse rate is within normal range for her age group (D). C Rationale: Girls experience a growth spurt at 9.5 to 14.5 years of age and boys at 10.5 to 16 years of age (C). There are insufficient data to support (A); growth trends must be assessed to reach such a conclusion. (B) is not unexpected. The fact that the children are twins has less to do with their growth than the fact that they are male and female (D). compared. 3 A 45-year-old female client is admitted C . to the psychiatric unit for evaluation. Rationale: Her husband states that she has been Agoraphobia (C) is the fear of reluctant to leave home for the last 6 crowds or of being in an open months. The client has not gone to place. (A) is the fear of being in work for a month, has been terminated closed places. (B) is the fear of high from her job, and has not left the places. (D) is an abnormal fear of house since that time. This client is death or bodies after death. A displaying symptoms of which phobia is an unrealistic fear disorder? associated with severe anxiety. A.Claustrophobia B.Acrophobia C.Agoraphobia D.Necrophobia 4 An adult client with a medical C . diagnosis of substance abuse and Rationale: schizophrenia was recently switched Alcohol enhances the side effects of from oral fluphenazine HCl (Prolixin) Prolixin. The half-life of Prolixin to IM fluphenazine decanoate (Prolixin PO is 8 hours, whereas the half-life Decanoate) because of medication of the Prolixin Decanoate IM is 2 to noncompliance. What should the nurse 4 weeks. Therefore, the side effects teach the client and family about this of drinking alcohol are far more change in medication regimen? severe when the client drinks A.Long-acting medication is more alcohol after taking the long-acting effective than daily medication. Prolixin Decanoate IM (C). (A, B, B.A client with substance abuse must and D) provide incorrect not take any oral medications. information. C.There will continue to be a risk of alcohol and drug interaction. D.Support groups are only helpful for substance abuse treatment. 5 An adult female who presents at the D . mental clinic trembling and crying Rationale: becomes distressed when the nurse The client is exhibiting signs of attempts to conduct an assessment. moderate anxiety, which include She complains about the number of voice tremors, shakiness, somatic questions that are being asked, which complaints, and selective inattention.