HESI 101HESI Comprehensive B Practice

1. An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take? A.Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. B.Hold the next dose of digoxin until the health care provider can be notified because the serum digoxin level is elevated. C.Administer the next dose of digoxin and notify the health care provider that the child is showing signs of toxicity. D.Notify the health care provider that the child's pulse rate is below normal for her age group. A Rationale: Nausea and vomiting are early signs of digoxin toxicity. However, the normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min and the therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, (A) is the best of the choices provided because the serum digoxin level is within normal levels. (B) is not warranted by the data presented. The digoxin level is within the therapeutic range and the child is not showing signs of toxicity (C). The child's pulse rate is within normal range for her age group (D). 2. A 12-year-old boy complains to the nurse that he is "short" (4'5" [53 inches]). His twin sister is 5 inches taller than he is (4'10" [58 inches]). Based on these findings, what conclusion should the nurse reach? A.The boy is not growing as normally expected. B.The girl is experiencing a period of unexpected growth. C.A normal growth spurt occurs in girls 1 to 2 years earlier than boys. D.Male-female twins are not identical; therefore, their growth cannot be C Rationale: Girls experience a growth spurt at 9.5 to 14.5 years of age and boys at 10.5 to 16 years of age (C). There are insufficient data to support (A); growth trends must be assessed to reach such a conclusion. (B) is not unexpected. The fact that the children are twins has less to do with their growth than the fact that they are male and female (D).compared. 3. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, has been terminated from her job, and has not left the house since that time. This client is displaying symptoms of which disorder? A.Claustrophobia B.Acrophobia C.Agoraphobia D.Necrophobia C Rationale: Agoraphobia (C) is the fear of crowds or of being in an open place. (A) is the fear of being in closed places. (B) is the fear of high places. (D) is an abnormal fear of death or bodies after death. A phobia is an unrealistic fear associated with severe anxiety. 4. An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen? A.Long-acting medication is more effective than daily medication. B.A client with substance abuse must not take any oral medications. C.There will continue to be a risk of alcohol and drug interaction. D.Support groups are only helpful for substance abuse treatment. C Rationale: Alcohol enhances the side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. Therefore, the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM (C). (A, B, and D) provide incorrect information. 5. An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which D Rationale: The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and selective is convinced are going to cause her to have a heart attack. What action should the nurse take? A.Take the client's blood pressure and reassure her that questioning will not cause a heart attack. B.Explain that treatment is based on information obtained in the assessment. C.Encourage the client to relax so that she can provide the information requested. D.Empower the client to share her story of why she is here at the mental health clinic.