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HESI STUDY PHYSIOLOGICAL HEALTH
PROBLEMS
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Hesi Study Module 10 Physiological Health Problems
Questions
1.ID: 383719769
A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see
first on the shift assessment?
A client admitted with pneumonia with a fever of 100° F and some diaphoresis Incorrect
A client with congestive heart failure with clear lung sounds on the previous shift
A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct
A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of
the arms
Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In
light of such a history, SOB could indicate that fluid-volume overload has once again developed. The
client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid
through the skin, but this client is not the priority.
Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, the client
who should be seen first. Recall the rule of assessment of the ABCs — airway, breathing, and circulation
— which means that the client experiencing SOB should take precedence over the other clients on the
unit. This client’s condition could progress to respiratory arrest if the client were not assessed
immediately on the basis of the signs and symptoms. Read each option and think about the client in
most critical condition and review the disorders to determine which clients have the most critical needs.
If you had difficulty with this question, review the various disease processes presented in this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered
collaborative care. (6th ed., p. 176). St. Louis: Saunders.
Level of Cognitive Ability: Analyzing
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Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
2.ID: 383719781
A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a
diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would
the nurse assess the client? Select all that apply.
Decreased pulse
Decreased urine output Correct
Increased blood pressure
Increased respiratory rate Correct
Decreased respiratory depth
Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid
volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an
attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are
decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes,
concentrated urine with increased specific gravity, increased hematocrit, and altered level of
consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-
volume overload.
Test-Taking Strategy: Use the process of elimination and focus on the subject, dehydration (deficient fluid
volume). Think about the pathophysiology of deficient fluid volume. Remember that the body will
increase the respiratory rate in an attempt to maintain the oxygen level. If you had difficulty with this
question, review the signs of insufficient fluid volume.
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Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered
collaborative care (6th ed., p. 179). St. Louis: Saunders.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Awarded 0.0 points out of 1.0 possible points.
3.ID: 383720547
A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am–7 pm shift.
Which client will the nurse monitor most closely for excessive fluid volume?
A 48-year-old client receiving diuretics to treat hypertension
A 35-year old client who is vomiting undigested food after eating
An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr Correct
A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy
Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive
fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other
causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of
hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion
of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is
at risk for deficient fluid volume.
Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk for excessive
fluid volume. Read each option and think about the fluid imbalance that could occur in each situation; in
the case of the incorrect options, it is fluid-volume deficiency; the only option reflecting conditions that
could result in an excess is the correct option. If you had difficulty with this question, review the causes
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HESI STUDY PHYSIOLOGICAL HEALTH
PROBLEMS
Downloaded by: Ariah |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
Send
Hesi Study Module 10 Physiological Health Problems
Questions
1.ID: 383719769
A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see
first on the shift assessment?
A client admitted with pneumonia with a fever of 100° F and some diaphoresis Incorrect
A client with congestive heart failure with clear lung sounds on the previous shift
A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct
A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of
the arms
Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In
light of such a history, SOB could indicate that fluid-volume overload has once again developed. The
client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid
through the skin, but this client is not the priority.
Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, the client
who should be seen first. Recall the rule of assessment of the ABCs — airway, breathing, and circulation
— which means that the client experiencing SOB should take precedence over the other clients on the
unit. This client’s condition could progress to respiratory arrest if the client were not assessed
immediately on the basis of the signs and symptoms. Read each option and think about the client in
most critical condition and review the disorders to determine which clients have the most critical needs.
If you had difficulty with this question, review the various disease processes presented in this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered
collaborative care. (6th ed., p. 176). St. Louis: Saunders.
Level of Cognitive Ability: Analyzing
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Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
2.ID: 383719781
A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a
diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would
the nurse assess the client? Select all that apply.
Decreased pulse
Decreased urine output Correct
Increased blood pressure
Increased respiratory rate Correct
Decreased respiratory depth
Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid
volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an
attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are
decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes,
concentrated urine with increased specific gravity, increased hematocrit, and altered level of
consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-
volume overload.
Test-Taking Strategy: Use the process of elimination and focus on the subject, dehydration (deficient fluid
volume). Think about the pathophysiology of deficient fluid volume. Remember that the body will
increase the respiratory rate in an attempt to maintain the oxygen level. If you had difficulty with this
question, review the signs of insufficient fluid volume.
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Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered
collaborative care (6th ed., p. 179). St. Louis: Saunders.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Awarded 0.0 points out of 1.0 possible points.
3.ID: 383720547
A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am–7 pm shift.
Which client will the nurse monitor most closely for excessive fluid volume?
A 48-year-old client receiving diuretics to treat hypertension
A 35-year old client who is vomiting undigested food after eating
An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr Correct
A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy
Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive
fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other
causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of
hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion
of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is
at risk for deficient fluid volume.
Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk for excessive
fluid volume. Read each option and think about the fluid imbalance that could occur in each situation; in
the case of the incorrect options, it is fluid-volume deficiency; the only option reflecting conditions that
could result in an excess is the correct option. If you had difficulty with this question, review the causes
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