HESI CASE STUDY
1. The client asks the nurse what makes everyone think that they are an alcoholic. The client
states when they drink, they don't have to think aboutproblems and that others must feel the
same way. How should the nurse respond to the client?
Explain that their lab values are consistent with alcohol abuse.
Ask the client if they are worried about becoming an alcoholic.
Providing the client with a screening tool for alcoholism.
Refer to the client's blood alcohol level at admission.: Explain that their lab values are
consistent with alcohol abuse.
Liver enzymes are not elevated until serious damage has occurred after years (10+)of drinking
alcohol. Additionally, alcoholism includes at least two social complications
due to excessive use of alcohol. The nurse is aware of the client's accident and bloodalcohol level
that precipitated hospitalization.
2. Ethical-Legal Considerations: Discharge Against Medical Advice (AMA)The client
becomes increasingly angry and leaves the hospital withoutdischarge orders from the HCP.
Who should the nurse notify of the client's action? (Select all that apply. One,some, or all
options may be correct.)
Select all that apply
The client's next of kin.
The charge nurse.
The police.
The client's HCP.
The local Alcoholics Anonymous group.: The charge nurse.
The charge nurse should be notified of all unexpected actions on the unit, includinga client
leaving AMA.
The client's HCP.
The client's HCP should be notified of the following: that the client has left, the relevant
circumstances, and the client's condition at the time of departure.
3. The nurse discusses the situation with another nurse who states that the client should have
been sedated and restrained to keep them from leaving. In which situations is the use of
physical restraints appropriate? (Select all that apply. One, some, or all options may be
correct.)
Select all that apply
A combative and agitated client who is pulling at the indwelling catheters andIV lines.
A client who verbally abuses the staff.
A client who is at high risk for injury to self for whom no other safety measures have been
, successful.
A client who is at high risk for injury because of insufficient nursing personnel.
A disoriented client who is trying to dislodge a tracheotomy tube.: A combative and agitated
client who is pulling at the indwelling catheters and IV lines.
This would be appropriate to prevent harm to the client.
A client who is at high risk for injury to self for whom no other safety measures have been
successful.
The nurse must be able to document not only the clear need for the use of restraints,but also the
other avenues of protection that have been attempted prior to the use of restraints.
A disoriented client who is trying to dislodge a tracheotomy tube.
This information is an indication that the client is a danger to self, which indicatesthe need for
restraints.
4. Hepatic EncephalopathyTwo days later, the client is transported back to the emergency
department by ambulance. The nurse assesses the client's responses using the Glasgow Coma
Scale (GCS).The nurse's focused assess-ment findings include:
Eyes open in response to pain.
Only mumbles when asked a question.Arm flexes in response to pain.
What is client's Glasgow Coma Scale rating obtained in this assessment? (Enter numerical
value only. If rounding is necessary, round to the nearestwhole number.): 8
5. The client is minimally responsive and has a Glasgow Coma Scale ratingof 8. The client
is admitted with a diagnosis of hepatic encephalopathy. Whichof the client's serum laboratory
values requires intervention by the nurse?
Serum ammonia 157 mcg/dL (112.1 mcmol/L)
pH 7.50
PaCO2 50 mmHg
Serum albumin 0.60 g/dL (6 g/L): Serum ammonia 157 mcg/dL (112.1 mcmol/L)
Increased ammonia levels are toxic to CNS tissue, resulting in encephalopathy. Serum
ammonia levels increase in cirrhosis as the liver becomes less efficient in converting ammonia
to urea. The client is disoriented to time, loss of meaningful conversation, marked confusion,
incomprehensible speech. Serum ammonia nor-mal range 10.0-80.0 mcg/dL (7.14-57.12
mcmol/L).
6. The HCP orders the following:
Lactulose 300 mL retention enema every 6 hours
Rifaximin 550 mg BID via nasogastric tube
5% Dextrose Injection IV
1. The client asks the nurse what makes everyone think that they are an alcoholic. The client
states when they drink, they don't have to think aboutproblems and that others must feel the
same way. How should the nurse respond to the client?
Explain that their lab values are consistent with alcohol abuse.
Ask the client if they are worried about becoming an alcoholic.
Providing the client with a screening tool for alcoholism.
Refer to the client's blood alcohol level at admission.: Explain that their lab values are
consistent with alcohol abuse.
Liver enzymes are not elevated until serious damage has occurred after years (10+)of drinking
alcohol. Additionally, alcoholism includes at least two social complications
due to excessive use of alcohol. The nurse is aware of the client's accident and bloodalcohol level
that precipitated hospitalization.
2. Ethical-Legal Considerations: Discharge Against Medical Advice (AMA)The client
becomes increasingly angry and leaves the hospital withoutdischarge orders from the HCP.
Who should the nurse notify of the client's action? (Select all that apply. One,some, or all
options may be correct.)
Select all that apply
The client's next of kin.
The charge nurse.
The police.
The client's HCP.
The local Alcoholics Anonymous group.: The charge nurse.
The charge nurse should be notified of all unexpected actions on the unit, includinga client
leaving AMA.
The client's HCP.
The client's HCP should be notified of the following: that the client has left, the relevant
circumstances, and the client's condition at the time of departure.
3. The nurse discusses the situation with another nurse who states that the client should have
been sedated and restrained to keep them from leaving. In which situations is the use of
physical restraints appropriate? (Select all that apply. One, some, or all options may be
correct.)
Select all that apply
A combative and agitated client who is pulling at the indwelling catheters andIV lines.
A client who verbally abuses the staff.
A client who is at high risk for injury to self for whom no other safety measures have been
, successful.
A client who is at high risk for injury because of insufficient nursing personnel.
A disoriented client who is trying to dislodge a tracheotomy tube.: A combative and agitated
client who is pulling at the indwelling catheters and IV lines.
This would be appropriate to prevent harm to the client.
A client who is at high risk for injury to self for whom no other safety measures have been
successful.
The nurse must be able to document not only the clear need for the use of restraints,but also the
other avenues of protection that have been attempted prior to the use of restraints.
A disoriented client who is trying to dislodge a tracheotomy tube.
This information is an indication that the client is a danger to self, which indicatesthe need for
restraints.
4. Hepatic EncephalopathyTwo days later, the client is transported back to the emergency
department by ambulance. The nurse assesses the client's responses using the Glasgow Coma
Scale (GCS).The nurse's focused assess-ment findings include:
Eyes open in response to pain.
Only mumbles when asked a question.Arm flexes in response to pain.
What is client's Glasgow Coma Scale rating obtained in this assessment? (Enter numerical
value only. If rounding is necessary, round to the nearestwhole number.): 8
5. The client is minimally responsive and has a Glasgow Coma Scale ratingof 8. The client
is admitted with a diagnosis of hepatic encephalopathy. Whichof the client's serum laboratory
values requires intervention by the nurse?
Serum ammonia 157 mcg/dL (112.1 mcmol/L)
pH 7.50
PaCO2 50 mmHg
Serum albumin 0.60 g/dL (6 g/L): Serum ammonia 157 mcg/dL (112.1 mcmol/L)
Increased ammonia levels are toxic to CNS tissue, resulting in encephalopathy. Serum
ammonia levels increase in cirrhosis as the liver becomes less efficient in converting ammonia
to urea. The client is disoriented to time, loss of meaningful conversation, marked confusion,
incomprehensible speech. Serum ammonia nor-mal range 10.0-80.0 mcg/dL (7.14-57.12
mcmol/L).
6. The HCP orders the following:
Lactulose 300 mL retention enema every 6 hours
Rifaximin 550 mg BID via nasogastric tube
5% Dextrose Injection IV
