HESI EXIT EXAM V5

appropriate statement for the nurse is A) "Eat a balanced diet for your age." B) "Increase your intake of protein and Vitamin A." C) "Decrease fatty foods from your diet." D) "Do not use caffeine in any form, including chocolate." The correct answer is A: "Eat a balanced diet for your age." 11. The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds A) "The complaints of at least 3 common findings." B) "The absence of any opportunistic infection." C) "CD4 lymphocyte count is less than 200." D) "Developmental delays in children." The correct answer is C: "CD4 lymphocyte count is less than 200." 12. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate? A) Offer ice cream every 2 hours B) Place the child in a supine position C) Allow the child to drink through a straw D) Observe swallowing patterns The correct answer is D: Observe swallowing patterns 13. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? A) Acceptance of the pregnancy B) Focus on fetal development C) Anticipation of the birth D) Ambivalence about pregnancy The correct answer is C: Anticipation of the birth 14. The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions? A) Administration of cough suppressants B) Increasing oral fluid intake to 3000 cc per day C) Maintaining bed rest with bathroom privileges D) Performing chest physiotherapy twice a day The correct answer is B: Increasing oral fluid intake to 3000 cc per day 15. The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up? A) A 13 month-old unable to walk B) A 20 month-old only using 2 and 3 word sentences C) A 24 month-old who cries during examination D) A 30 month-old only drinking from a sip cup The correct answer is D: A 30 month-old only drinking from a sip cup 16. Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes? A) Give written pre and post tests B) Ask questions during practice C) Allow another diabetic to assist D) Observe a return demonstration The correct answer is D: Observe a return demonstration 17. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority? A) Elevate leg on 2 pillows B) Apply support stockings C) Apply warm compresses D) Maintain complete bed rest The correct answer is A: Elevate leg on 2 pillows 18. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child? A) Congenital cardiac defects B) An acute febrile illness C) Prolonged hypoxemia D) Severe multiple trauma The correct answer is C: Prolonged hypoxemia 19. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to A) A social worker from the local hospital B) An occupational therapist from the community center C) A physical therapist from the rehabilitation agency D) Another client with diabetes mellitus and takes insulin The correct answer is B: An occupational therapist from the community center 20. A priority goal of involuntary hospitalization of the severely mentally ill client is A) Re-orientation to reality B) Elimination of symptoms C) Protection from harm to self or others The correct answer is C: Protection from self harm and harm to others 21. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend A) Isometric B) Range of motion C) Aerobic D) Isotonic The correct answer is A: Isometric 22. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report A) Loss of consciousness B) Feeding problems C) Poor weight gain D) Fatigue with crying The correct answer is A: Loss of consciousness 23. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would A) Instruct the client to maintain a regular diet the day prior to the examination B) Restrict the client's fluid intake 4 hours prior to the examination C) Administer a laxative to the client the evening before the examination D) Inform the client that only 1 x-ray of his abdomen is necessary The correct answer is C: Administer a laxative to the client the evening before the examination 24. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? A) Altered tissue perfusion B) Risk for fluid volume deficit C) High risk for hemorrhage D) Risk for infection The correct answer is D: Risk for infection 25. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that A) Circumcision is delayed so the foreskin can be used for the surgical repair B) This procedure is contraindicated because of the permanent defect C) There is no medical indication for performing a circumcision on any child D) The procedure should be performed as soon as the infant is stable The correct answer is A: Circumcision is delayed so the foreskin can be used for the surgical repair 26. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? A) Confusion B) Loss of half of visual field C) Shallow respirations D) Tonic-clonic seizures The correct answer is C: Shallow respirations 27. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse9s best explanation of these findings? A) These side effects are common and should subside in a few days B) The client is probably having an allergic reaction and should discontinue the drug C) Taking the lithium on an empty stomach should decrease these symptoms D) Decreasing dietary intake of sodium and fluids should minimize the side effects The correct answer is A: These side effects are common and should subside in a few days 28. A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse? Recommended for you Document continues below 8 Hesi comprehensive maternity Test Bank 2020 Hesi comprehensive maternity Test Bank 2020 Care of adults and older adults 100% (1) A) Ask the client if he has noticed any bleeding or dark stools B) Tell the client to call 911 and go to the emergency department immediately C) Schedule a repeat Hemoglobin and Hematocrit in 1 month D) Tell the client to schedule an appointment with a hematologist The correct answer is A: Ask the client if he has noticed any bleeding or dark stools 29. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the A) Surgical repair of a diseased coronary artery B) Placement of an automatic internal cardiac defibrillator C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow D) Non-invasive radiographic examination of the heart The correct answer is C: Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow 30. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? A) Institute seizure precautions B) Weigh the child twice per shift C) Encourage the child to eat protein-rich foods D) Relieve boredom through physical activity The correct answer is A: Institute seizure precautions 31. Following mitral valve replacement surgery a client develops PVC9s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc9s of D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute? A) 60 microdrops/minute B) 20 microdrops/minute C) 30 microdrops/minute D) 40 microdrops/minute The correct answer is A: 60 microdrops/minute 2 gm=2000 mgm 2000 mgm/500 cc = 4 mgm/x cc 2000x = 2000 x= 2000/2000 = 1 cc of IV solution/minute CC x 60 microdrops = 60 microdrops/minute 32. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first? A) Review the client's weight pattern over the year B) Ask the mother to record her diet for the last 24 hours C) Encourage her to talk about her view of herself D) Give her several pamphlets on postpartum nutrition The correct answer is C: Encourage her to talk about her view of herself 33. To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would A) Assist the client to use the bedside commode B) Administer stool softeners every day as ordered C) Administer anti dysrhythmics prn as ordered D) Maintain the client on strict bed rest The correct answer is B: Administer stool softeners every day as ordered 34. A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should A) Expose the cast to air and turn the child frequently B) Use a heat lamp to reduce the drying time C) Handle the cast with the abductor bar D) Turn the child as little as possible The correct answer is A: Expose the cast to air and turn the child frequently 35. The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate postoperative period? A) Raise the head of the bed at least 30 degrees B) Encourage ambulation within 24 hours C) Maintain in a flat position, logrolling as needed D) Encourage leg contraction and relaxation after 48 hours The correct answer is C: Maintain in a flat position, logrolling as needed 36. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to A) Convince the client that the hospital staff is trying to help B) Help the client to enter into group recreational activities C) Provide interactions to help the client learn to trust staff D) Arrange the environment to limit the client9s contact with other clients The correct answer is C: Provide interactions to help the client learn to trust staff 37. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate? A) Unequal leg length B) Limited adduction C) Diminished femoral pulses D) Symmetrical gluteal folds The correct answer is A: Unequal leg length 38. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to A) A cerebral vascular accident B) Postoperative meningitis C) Medication reaction D) Metabolic alkalosis The correct answer is A: A cerebral vascular accident 39. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: <We just don9t know how he caught the disease!= The nurse's response is based on an understanding that A) AGN is a streptococcal infection that involves the kidney tubules B) The disease is easily transmissible in schools and camps C) The illness is usually associated with chronic respiratory infections D) It is not "caught" but is a response to a previous B-hemolytic strep infection The correct answer is D: It is not "caught" but is a response to a previous B-hemolytic strep infection 40. A couple asks the nurse about risks of several birth control methods. What is he most appropriate response by the nurse? A) Norplant is safe and may be removed easily B) Oral contraceptives should not be used by smokers C) Depo-Provera is convenient with few side effects D) The IUD gives protection from pregnancy and infection The correct answer is B: Oral contraceptives should not be used by smokers 41. A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale? A) "Nursing will help contract the uterus and reduce your risk of bleeding." B) "Breastfeeding twins will take too much energy after the hemorrhage." C) "The blood transfusion may increase the risks to you and the babies." D) "Lactation should be delayed until the "real milk" is secreted." The correct answer is A: "Nursing will help contract the uterus and reduce your risk of bleeding." 42. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure? A) Place pillows under the knees B) Use elastic stockings continuously C) Encourage range of motion and ambulation D) Massage the legs twice daily The correct answer is C: Encourage range of motion and ambulation 43. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately? A) 3 episodes of vomiting in 1 hour B) Periodic crying and irritability C) Vigorous sucking on a pacifier D) No measurable voiding in 4 hours The correct answer is D: No measurable voiding in 4 hours 44. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt? A) "Addiction usually causes people to feel guilty. Don9t worry, it is a typical response due to your drinking behavior." B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?" C) "Don9t focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs." D) "You9ve caused a great deal of pain to your family and close friends, so it will take time to undo all the things you9ve done." The correct answer is B: "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?" 45. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client9s family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect? A) Oculogyric crisis B) Tardive dyskinesia C) Nystagmus D) Dysphagia The correct answer is A: Oculogyric crisis 46. Which of the following measures would be appropriate for the nurse to teach the parent of a nine month-old infant about diaper dermatitis? A) Use only cloth diapers that are rinsed in bleach B) Do not use occlusive ointments on the rash C) Use commercial baby wipes with each diaper change D) Discontinue a new food that was added to the infant's diet just prior to the rash The correct answer is D: Discontinue a new food that was added to the infant''s diet just prior to the rash 47. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need? A) Trust B) Initiative C) Independence D) Self-esteem The correct answer is C: Independence 48. Which behavioral characteristic describes the domestic abuser? A) Alcoholic B) Over confident C) High tolerance for frustrations D) Low self-esteem The correct answer is D: Low self-esteem 49. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing A) "This action of my lips helps to keep my airway open." B) "I can expel more when I pucker up my lips to breathe out." C) "My mouth doesn't get as dry when I breathe with pursed lips." D) "By prolonging breathing out with pursed lips the little areas in my lungs don't collapse." The correct answer is D: "By prolonging breathing out with pursed lips my little areas in my lungs don''t collapse." 50. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? A) "I have constant blurred vision." B) "I can't see on my left side." C) "I have to turn my head to see my room." D) "I have specks floating in my eyes." The correct answer is C: "I have to turn my head to see my room." 51. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"? A) "I don't remember anything about what happened to me." B) "I'd rather not talk about it right now." C) "It's all the other guy's fault! He was going too fast." D) "My mother is heartbroken about this." The correct answer is A: "I don''t remember anything about what happened to me." 52. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action? A) Check vital signs B) Massage the fundus C) Offer a bedpan D) Check for perineal lacerations The correct answer is B: Massage the fundus 53. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age? A) Double the birth weight B) Triple the birth weight C) Gain 6 ounces each week D) Add 2 pounds each month The correct answer is A: Double the birth weight 54. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse9s initial response should be to A) Give the client orientation materials and review the unit rules and regulations B) Introduce him/herself and accompany the client to the client9s room C) Take the client to the day room and introduce her to the other clients D) Ask the nursing assistant to get the client9s vital signs and complete the admission search The correct answer is B: Introduce him/herself and accompany the client to the client9s room 55. A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client A) Has increased airway obstruction B) Has improved airway obstruction C) Needs to be suctioned D) Exhibits hyperventilation The correct answer is A: Has increased airway obstruction 56. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse? A) "Focus on your sons' needs during the first days at home." B) "Tell each child what he can do to help with the baby." C) "Suggest that your husband spend more time with the boys." D) "Ask the children what they would like to do for the newborn." The correct answer is A: "Focus on your sons'' needs during the first days at home." 57. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is A) Progressive failure to adapt B) Feelings of anger or hostility C) Reunion wish or fantasy D) Feelings of alienation or isolation The correct answer is D: Feelings of alienation or isolation 58. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize A) They can expect the child will be mentally retarded B) Administration of thyroid hormone will prevent problems C) This rare problem is always hereditary D) Physical growth/development will be delayed The correct answer is B: Administration of thyroid hormone will prevent problems 59. A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness? A) Holistic healing B) Spiritual advising C) Herbal preparations D) Witchcraft potions The correct answer is A: Holistic healing 60. In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in A) Hearing, speech, and sight B) Endurance, strength, and mobility C) Learning, creativity, and judgment D) Balance, flexibility, and coordination The correct answer is C: Learning, creativity and judgment 61. In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next? A) Take the client's respirations, blood pressure (BP), temperature and then pupillary responses B) Place the client into the bed and administer the ordered PRN analgesic C) Check the client for bladder distention and the client's urinary catheter for kinks D) Turn the television off and then assist client to use relaxation techniques The correct answer is C: Check the client for bladder distention and the client''s urinary catheter for kinks 62. The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client complaint calls for immediate nursing action? A) Diaphoresis and shakiness B) Reduced lower leg sensation C) Intense thirst and hunger D) Painful hematoma on thigh The correct answer is A: Diaphoresis and shakiness 63. The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be A) Reduce fear and protect self-esteem B) Minimize anxiety and delay apprehension C) Avoid conflict and leave unpleasant situations D) Increase independence and communicate more often The correct answer is A: Reduce fear and protect self-esteem 64 In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test? A) Increased edema and weight gain B) Unchanged urine specific gravity C) Rapid protein excretion D) Decreased blood potassium The correct answer is B: Unchanged urine specific gravity 65. The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has A) Achieved developmental milestones at an erratic rate B) Delay in musculoskeletal development C) Displayed difficulty with speech development D) Delay in achievement of most developmental milestones The correct answer is D: Delayed in achieving all developmental milestones 66. A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect? A) Flushed skin B) Bradycardia C) Mental confusion D) Hypotension The correct answer is C: Mental confusion 67. Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure togetherwith pulmonary capillary wedge pressure with a pulmonary artery catheter. This action by the nurse will assess A) Right ventricular pressure B) Left ventricular end-diastolic pressure C) Acid-Base balance D) Coronary artery stability The correct answer is B: Left ventricular end diastolic pressure 68. The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching? A) Change the pillow covers every month B) Wash bed linens in warm water with a cold rinse C) Wash and rinse the bed linens in hot water D) Use air filters in the furnace system The correct answer is C: Wash and rinse the bed linens in hot water 69. A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate? A) Determine that adequate mist is supplied B) Inspect the nares and ears for skin breakdown C) Lubricate the tips of the cannula before insertion D) Maintain sterile technique when handling cannula The correct answer is B: Inspect the nares and ears for skin breakdown 70. The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation? A) Ask family members to dress the client B) Encourage the client to dress more quickly C) Allow the client the time needed to dress D) Demonstrate methods on how to dress more quickly The correct answer is C: Allow the client the time needed to dress 71. The nurse is assessing a 12 year-old who has Hemophilia A. Which finding would the nurse anticipate? A) An excess of red blood cells B) An excess of white blood cells C) A deficiency of clotting factor VIII D) A deficiency of clotting factors VIII and IX The correct answer is C: A deficiency of clotting factor VIII 72. The nurse is assessing a newborn infant and observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. A priority maternal assessment by the nurse should be to ask about A) Alcohol use during pregnancy B) Usual nutritional intake C) Family genetic disorders D) Maternal and paternal ages The correct answer is A: Alcohol use during pregnancy 73. A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which nursing approach should be the priority? A) Remove protective arm devices one at a time for short periods with supervision B) Initiate by mouth feedings when alert, with the return of the gag reflex C) Introduce to the parents how to cleanse the suture line with the prescribed protocol D) Position the infant on the back after feedings throughout the day The correct answer is A: Remove protective arm devices one at a time for short periods with supervision 74. The new graduate nurse interviews for a position in a nursing department of a large health care agency, described by the interviewer as having shared governance. Which of these statements best illustrates the shared governance model? A) An appointed board oversees any administrative decisions B) Nursing departments share responsibility for client outcomes C) Staff groups are appointed to discuss nursing practice and client education issues D) Non-nurse managers supervise nursing staff in groups of units The correct answer is B: Nursing departments share responsibility for client outcomes 75. The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best? A) "What is your reason for wanting such a plan?" B) "Have you talked with your health care provider about this?" C) "Let us discuss your rights as a couple." D) "Write your ideal plan for the next class." The correct answer is C: "Let us discuss your rights as a couple." 76. A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis A) Low serum albumin B) High serum cholesterol C) Abnormally low white blood cell count D) Elevated creatinine phosphokinase (CPK ) The correct answer is D: Elevated CPK (creatinine phosphokinase) 77. A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse? A) Call a chaplain B) Deny the feelings C) Cite recovery statistics D) Listen to the client The correct answer is D: Listen to the client 78. A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal? A) Hot dog, carrot sticks, gelatin, milk B) Soup, blenderized soft foods, ice cream, milk C) Peanut butter and jelly sandwich, chips, pudding, milk D) Baked chicken, applesauce, cookie, milk The correct answer is B: Soup, blenderized soft foods, ice cream, milk 79. The RN is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application? A) Infant will experience minimal pain B) Muscle spasms will be relieved C) Mobility will be managed as tolerated D) Tissue perfusion will be maintained The correct answer is D: Tissue perfusion will be maintained 80. The nurse would expect which eating disorder to have the greatest fluctuations in potassium? A) Binge eating disorder B) Anorexia nervosa C) Bulemia D) Purge syndrome The correct answer is C: Bulemia 81. When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility? A) Digestive problems B) Amenorrhea C) Electrolyte imbalance D) Blood disorders The correct answer is B: Amenorrhea 82. The nurse is planning care for a client with increased intracranial pressure. The best position for this client is A) Trendelenberg B) Prone C) Semi-Fowlers D) Side-lying with head flat The correct answer is C: Semi-Fowlers 83. While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality? A) Flexion of lower extremities B) Negative Ortlani response C) Lengthened leg of affected side D) Irregular hip symmetry The correct answer is D: Irregular hip symmetry 84. The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data? A) Impaired gas exchange related to acute infection and sputum production B) Ineffective airway clearance related to sputum production and ineffective cough C) Ineffective breathing pattern related to acute infection D) Anxiety related to hospitalization and role conflict The correct answer is B: Ineffective airway clearance related to sputum production and ineffective cough 85. A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is A) Central nervous system damage B) Moderate anemia C) Renal tubule damage D) Growth impairment The correct answer is A: Central nervous system damage 86. At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially A) Allow the staff to change assignments B) Clarify reasons for current assignments C) Help staff see the complexity of issues D) Facilitate creative thinking on staffing The correct answer is D: Facilitate creative thinking on staffing 87. A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to A) Insufficient oxygenation of the cardiac muscle B) Potential circulatory overload C) Left ventricular overload D) Electrolyte imbalance Company About Us StuDocu World University Ranking 2021 Doing Good Academic Integrity Jobs Dutch Website Contact & Help F.A.Q. 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