Pathophysiology HESI Remediation. Questions and answers. Graded A+

The nurse is caring for a post-operative client who has a saline lock in place and very little urine in the drainage bag. The client appears anxious and restless. The nurse notes that the client's hands are cool and moist, and that the capillary refill is prolonged. Which action should the nurse perform? Offer the client a warm blanket. Assess the client's breath sounds. Administer IV fluids per protocol. Review the client's medications. - Administer IV fluids per protocol. The client is showing signs of hypovolemic shock, a potential post-operative complication. The nurse correctly treats this problem by infusing IV fluids per protocol. When performing percussion of the lungs, the nurse notes a dull sound in the left lower chest. This finding may indicate the presence of which condition? Pneumothorax. Pleural effusion. Chronic bronchitis. Emphysema. - Pleural effusion. Percussion is used to assess pulmonary resonance. A dull sound indicates the presence of solid tissue, such as the liver in the right lower chest, or an abnormal accumulation of fluid, such as an effusion. Which characteristic is typical of hypertensive crisis? Clinical evidence of flatten jugular vein. Development of a headache or blurred vision. Diastolic blood pressure less than 110 mm Hg. Elevated cardiac enzymes. - Development of a headache or blurred vision. Hypertensive crisis involves elevated blood pressure that can cause organ damage if the blood pressure is not brought down immediately. This condition rarely occurs, often is a result of clients not taking their hypertensive medications as prescribed. The nurse is caring for a client with a fractured left hip. During the admission assessment, the nurse notes petechiae and an increased heart rate. Which action should the nurse perform next? Observe the fracture site for ecchymosis. Obtain the client's blood pressure. Document the assessment findings. Assess the client's breath sounds. - Assess the client's breath sounds. A client with a fractured hip is at an increased risk for fat embolism syndrome (FES). The fat emboli can travel throughout the circulatory system and block capillaries (resulting in petechiae) or small vessels supplying vital organs, including the lungs. The nurse should assess the client's breath sounds to determine if emboli have traveled to the client's lungs. While assessing a pediatric client with cerebral palsy, the nurse notes that the child feels rigid and has significant arching of the back. Which action should the nurse take? Reposition the child to a lying position. Review the child's medication history. Document the assessment findings. Report the findings to the child's parents. - Document the assessment findings. Cerebral palsy is a permanent disorder that leads to abnormalities in movement, posture, and in some cases, intellectual functioning. Stiffness and arching of the back are normal findings in a client with cerebral palsy. The nurse should document the expected findings. The nurse is assessing an adult client for lung cancer. Which question should the nurse include in the client interview? "Are you coughing up yellow-green mucus?" "Do you have a history of night sweats?" "Are you experiencing shortness of breath?" "Have you experienced sudden crushing chest pain?" - "Are you experiencing shortness of breath?" When assessing a client for lung cancer, the nurse should ask if the client is experiencing shortness of breath. Dyspnea is the most common symptom in clients with lung cancer. The emergency department nurse is caring for a client with a severe head injury. Which sign indicates a potentially fatal complication? Intractable neck pain. Loss of memory. Complaints of dizziness. Positive halo sign. - Positive halo sign. A client with a severe head injury may be at risk for a skull fracture. The presence of a halo sign (nasal or ear drainage that leaves a yellow halo on filter paper) indicates that cerebrospinal fluid is leaking from the client's cranial cavity as a result of a skull fracture. This finding must be reported to the health care provider immediately.