NURS 420 Hesi Study Module 10
Physiological Health Problems
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
,NURS 420 Hesi Study Module 10
Physiological Health Problems
Client Needs: Physiological Integrity
Integrated Process: Nursing
Process/Assessment Content Area:
Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
1. 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
,NURS 420 Hesi Study Module 10
Physiological Health Problems
volume.
, NURS 420 Hesi Study Module 10
Physiological Health Problems
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.
2. 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
Physiological Health Problems
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
,NURS 420 Hesi Study Module 10
Physiological Health Problems
Client Needs: Physiological Integrity
Integrated Process: Nursing
Process/Assessment Content Area:
Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
1. 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
,NURS 420 Hesi Study Module 10
Physiological Health Problems
volume.
, NURS 420 Hesi Study Module 10
Physiological Health Problems
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.
2. 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
