HERZING UNIVERSITY HESI MILESTONE 2 SPOT –
ON EXAM SOLUTIONS
A client with GERD is being treated with dietary management. The client states, "I like to have a glass of juice everyday." Which juice will the nurse recommend? - correct answer ✔✔ Answer: Apple Juice
A primary healthcare provider prescribes a low-sodium, high-potassium diet for client with Cushing Syndrome. Which explanation should the nurse provide to the client about the need to follow this diet? - correct answer✔✔ Answer: "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."
Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis? - correct answer ✔✔ Answer: Urine Osmolarity
A client has a history of GERD. Why should the nurse monitor the client for clinical manifestation of heart disease? - correct answer ✔✔ Esophageal pain may imitate the symptoms of a heart attack
A nurse is teaching a 15-year-old adolescent with newly diagnosed type 1 diabetes about self-care. What
is the primary long-term goal this nurse and client should agree on? - correct answer ✔✔ Maintaining normoglycemia
The nurse is caring for a client before, during and immediately after surgery. Which type of care is provided to the client? - correct answer ✔✔ Care that supports homeostatic regulation
A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. What is the priority nursing intervention? - correct answer ✔✔ Performing postural drainage
A nurse is planning to teach a school-aged child with newly diagnosed type 1 diabetes about self-care. After an assessment of what the child knows about diabetes, what is the next nursing intervention? - correct answer✔✔ Developing a sequence of goals with the child and parents. The nurse concludes that a client with glaucoma needs education when the client makes which statement? - correct answer ✔✔ "It is dangerous for me to use sedatives."
Sedatives have no effect on intraocular pressure
A mother reports feeding her infant immediately before arriving in the emergency department. After completing the assessment, the nurse reports which finding immediately to the primary healthcare provider because it likely indicated pyloric stenosis? - correct answer ✔✔ Peristaltic waves that transverse the epigastrium.
The registered nurse is teaching a student nurse the points to be included while educating a client on cortisol replacement therapy about self-management. Which statement provided by the student nurse indicates the need for further teaching? - correct answer ✔✔ "I will advise the client to take the medication before meals."
Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis? - correct answer ✔✔ Urine osmolarity
A client with a completed ischemic stroke has a blood pressure of 180/90 mmHg. Which action should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medication. - correct answer ✔✔ D
Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, and the client's current elevated blood pressure requires antihypertensive medication.
A client has been hospitalized with a femur fracture and is being treated with traction. Which action by the nurse is the priority when caring for this client?
A. Assess neurovascular status.
B. Change the client's position.
C. Inspect the traction equipment. D. Review pain medication orders. - correct answer ✔✔ A
The use of traction for long bone fractures reduces the potential for damage to the surrounding tissues. Reports of increased pain may indicate circulatory compromise or tissue damage (compartment syndrome). Assessing the client's neurovascular status is the nurse's highest priority.
A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet?
A. He visits his diabetic brother who just had surgery to amputate an infected foot.
B. He is provided with the most current information about the dangers of untreated diabetes.
C. He comments on the community service announcements about preventing complications associated with diabetes.
D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet. - correct answer✔✔ A
The loss of a limb due to diabetes by a family member should be the strongest event or "cue to action" and is most likely to increase the client's perceived seriousness of the disease.
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
A. Give 20 mEq of potassium chloride.
B. Initiate continuous cardiac monitoring.
C. Arrange a consultation with the dietician.
D. Teach about the side effects of diuretics. - correct answer ✔✔ B
Hypokalemia (normal 3.5 to 5 mEq/L [3.5 to 5 mmol/L]) causes changes in myocardial irritability and ECG
waveform, so it is most important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or other life-threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride should be given so that the effects of potassium replacement on the cardiac rhythm can be monitored.
Which description of pain is consistent with a diagnosis of rheumatoid arthritis?
A. Joint pain is worse in the morning and involves symmetric joints.
B. Joint pain is better in the morning and worsens throughout the day.
C. Joint pain is consistent throughout the day and is relieved by pain medication. D. Joint pain is worse during the day and involves unilateral joints. - correct answer ✔✔ A
Rheumatoid arthritis (RA) is an autoimmune disease that causes joint pain and swelling. RA is characterized by pain that is worse when arising and involves symmetric joints.
A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history?
A. Jewish European ancestry.
B. H. pylori bowel infection.
C. Family history of irritable bowel syndrome.
D. Age between 25 and 55 years. - correct answer ✔✔ A
Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry.
The client is taking digoxin for congestive heart failure. The nurse would be correct in withholding a dose
of digoxin based on which assessment?
A. serum digoxin level is 1.5.
B. blood pressure is 104/68.
C. serum potassium level is 3.
D. apical pulse is 68/min. - correct answer ✔✔ C
Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L).
The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. When taking the client's medical history, which information is most for the nurse to obtain?
A. Irritable bowel syndrome.
B. Diverticulitis.
C. Crohn's disease.
D. Ulcerative colitis. - correct answer ✔✔ D
The RN should ask the client if he has a history of ulcerative colitis, which is characterized by severe abdominal cramping, pain, tenesmus, and dehydration.
ON EXAM SOLUTIONS
A client with GERD is being treated with dietary management. The client states, "I like to have a glass of juice everyday." Which juice will the nurse recommend? - correct answer ✔✔ Answer: Apple Juice
A primary healthcare provider prescribes a low-sodium, high-potassium diet for client with Cushing Syndrome. Which explanation should the nurse provide to the client about the need to follow this diet? - correct answer✔✔ Answer: "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."
Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis? - correct answer ✔✔ Answer: Urine Osmolarity
A client has a history of GERD. Why should the nurse monitor the client for clinical manifestation of heart disease? - correct answer ✔✔ Esophageal pain may imitate the symptoms of a heart attack
A nurse is teaching a 15-year-old adolescent with newly diagnosed type 1 diabetes about self-care. What
is the primary long-term goal this nurse and client should agree on? - correct answer ✔✔ Maintaining normoglycemia
The nurse is caring for a client before, during and immediately after surgery. Which type of care is provided to the client? - correct answer ✔✔ Care that supports homeostatic regulation
A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. What is the priority nursing intervention? - correct answer ✔✔ Performing postural drainage
A nurse is planning to teach a school-aged child with newly diagnosed type 1 diabetes about self-care. After an assessment of what the child knows about diabetes, what is the next nursing intervention? - correct answer✔✔ Developing a sequence of goals with the child and parents. The nurse concludes that a client with glaucoma needs education when the client makes which statement? - correct answer ✔✔ "It is dangerous for me to use sedatives."
Sedatives have no effect on intraocular pressure
A mother reports feeding her infant immediately before arriving in the emergency department. After completing the assessment, the nurse reports which finding immediately to the primary healthcare provider because it likely indicated pyloric stenosis? - correct answer ✔✔ Peristaltic waves that transverse the epigastrium.
The registered nurse is teaching a student nurse the points to be included while educating a client on cortisol replacement therapy about self-management. Which statement provided by the student nurse indicates the need for further teaching? - correct answer ✔✔ "I will advise the client to take the medication before meals."
Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis? - correct answer ✔✔ Urine osmolarity
A client with a completed ischemic stroke has a blood pressure of 180/90 mmHg. Which action should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medication. - correct answer ✔✔ D
Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, and the client's current elevated blood pressure requires antihypertensive medication.
A client has been hospitalized with a femur fracture and is being treated with traction. Which action by the nurse is the priority when caring for this client?
A. Assess neurovascular status.
B. Change the client's position.
C. Inspect the traction equipment. D. Review pain medication orders. - correct answer ✔✔ A
The use of traction for long bone fractures reduces the potential for damage to the surrounding tissues. Reports of increased pain may indicate circulatory compromise or tissue damage (compartment syndrome). Assessing the client's neurovascular status is the nurse's highest priority.
A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet?
A. He visits his diabetic brother who just had surgery to amputate an infected foot.
B. He is provided with the most current information about the dangers of untreated diabetes.
C. He comments on the community service announcements about preventing complications associated with diabetes.
D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet. - correct answer✔✔ A
The loss of a limb due to diabetes by a family member should be the strongest event or "cue to action" and is most likely to increase the client's perceived seriousness of the disease.
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
A. Give 20 mEq of potassium chloride.
B. Initiate continuous cardiac monitoring.
C. Arrange a consultation with the dietician.
D. Teach about the side effects of diuretics. - correct answer ✔✔ B
Hypokalemia (normal 3.5 to 5 mEq/L [3.5 to 5 mmol/L]) causes changes in myocardial irritability and ECG
waveform, so it is most important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or other life-threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride should be given so that the effects of potassium replacement on the cardiac rhythm can be monitored.
Which description of pain is consistent with a diagnosis of rheumatoid arthritis?
A. Joint pain is worse in the morning and involves symmetric joints.
B. Joint pain is better in the morning and worsens throughout the day.
C. Joint pain is consistent throughout the day and is relieved by pain medication. D. Joint pain is worse during the day and involves unilateral joints. - correct answer ✔✔ A
Rheumatoid arthritis (RA) is an autoimmune disease that causes joint pain and swelling. RA is characterized by pain that is worse when arising and involves symmetric joints.
A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history?
A. Jewish European ancestry.
B. H. pylori bowel infection.
C. Family history of irritable bowel syndrome.
D. Age between 25 and 55 years. - correct answer ✔✔ A
Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry.
The client is taking digoxin for congestive heart failure. The nurse would be correct in withholding a dose
of digoxin based on which assessment?
A. serum digoxin level is 1.5.
B. blood pressure is 104/68.
C. serum potassium level is 3.
D. apical pulse is 68/min. - correct answer ✔✔ C
Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L).
The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. When taking the client's medical history, which information is most for the nurse to obtain?
A. Irritable bowel syndrome.
B. Diverticulitis.
C. Crohn's disease.
D. Ulcerative colitis. - correct answer ✔✔ D
The RN should ask the client if he has a history of ulcerative colitis, which is characterized by severe abdominal cramping, pain, tenesmus, and dehydration.
