Hesi level 2 (Nsg 170) Questions with 100% Correct Answers

A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? A. Sleeping six to eight hours. B. Achieve a sense of control. C. Utilize problem solving skills. D. Increased focus of attention. - B. Achieve a sense of control. The experience of psychological discomfort may be as real as physical pain for the client and should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of control is a key need (B) before (A, C and D) are addressed. A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client? A) I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight. B) I will let you have one cracker, but that is all you can have for the rest of tonight. C) What did the healthcare provider tell you about the test you are having tomorrow? D) The test you are having tomorrow requires that you have nothing by mouth tonight. - D. "The test you are having tomorrow requires that you have nothing by mouth tonight." Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic statement because the nurse is responding to the client's question and providing him the reason why. A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) A.Marijuana cigarettes do not affect sperm count. B.Alcohol consumption can cause erectile dysfunction. C.Low testosterone levels affect sperm production. D.Cessation of smoking improves general health and fertility. E.Obesity has no effect on sperm production. - B, C, D Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected by low testosterone levels and obesity. Which response by a client with a nursing diagnosis of Spiritual distress indicates to the nurse that a desired outcome measure has been met? A.Expresses concern about the meaning and importance of life. B.Remains angry at God for the continuation of the illness. C.Accepts that punishment from God is not related to illness. D.Refuses to participate in religious rituals that have no meaning. - C.Accepts that punishment from God is not related to illness Acceptance that her illness is not God punishing her, indicates a desired outcome for some degree of resolution of spiritual distress A mother brings her 4-month-old infant to the clinic for a well-child checkup. She asks if she should go back to work now or stay at home with the baby. How should the nurse respond to the mother? A.Mothers can promote healthy bonding by staying at home during the child's first years. B.Determine if other family relatives can stay at home with the baby. C.Ask the mother to talk about the options she has been considering. D.Returning to work when an infant is young helps the baby to adjust to other children. - C.Ask the mother to talk about the options she has been considering. It is common for mothers to feel ambivalent about returning to work and caring full time for children at home. The nurse should assist the mother to explore her feelings on the subject while focusing on the optimal, appropriate, safe, and available options for her child A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? A. "It may hurt a little because of the incision made in your throat." B. "It won't hurt because you're such a big boy." C. "It won't hurt because we put you to sleep." D. "It may hurt but we'll give you medicine to help you feel better." - D. "It may hurt but we'll give you medicine to help you feel better." Answering questions simply and directly provides comfort for the preschool-age child and builds confidence in the healthcare team. A postoperative client has been receiving a continuous IV infusion of meperidine (Demerol) 35 mg/hr for four days. The client has a PRN prescription for Demerol 100 mg PO q3h. The nurse notes that the client has become increasingly restless, irritable and confused, stating that there are bugs all over the walls. What action should the nurse take first? A..Administer a PRN dose of the PO meperidine (Demerol). B.Administer naloxone (Narcan) IV per PRN protocol. C.Decrease the IV infusion rate of the meperidine (Demerol) per protocol. D.Notify the healthcare provider of the client's confusion and hallucinations. - C.Decrease the IV infusion rate of the meperidine (Demerol) per protocol. The client is exhibiting symptoms of Demerol toxicity which is consistent with the large doses of Demerol received over four days. Decreasing the infusion rate of the Demerol as per protocol is the most effective action to immediately decrease the amount of serum Demerol. The next nursing action is for the nurse to notify the healthcare provider. A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. What is the best response for the nurse to provide? A. "Tell your friends and family so that they can help you." B. "Get involved with a support group. I will give you some names." C. "Talk only to other friends who are infertile since only they can help." D. "Start adoption proceedings immediately since obtaining an infant is very difficult." - B: "Get involved with a support group. I will give you some names." A support group provides a safe haven for the couple to share their feelings and experience, gain insight from others dealing with the same experience, and assure the couple that they are not alone in their situation. A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse document as health risk factors for the client? (Select all that apply.) A.Age. B.Drug addiction. C.History of abuse. D.Pregnancy. E.Homelessness. F.Unmarried. - A, B, C, D, E Health risk factors for this client include age, drug addiction, pregnancy, history of abuse and homelessness. Each factor should be considered individually. The client, as an adolescent mother, is at high risk for nutritional deficits, anemia, gestational diabetes and hypertension, which also impact the fetus' risk for small for gestational age, fetal anomalies, and fetal demise. Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby? A.Tell them there is nothing to fear. B. Insist that they hold infant so they can grieve. C.Respect their wishes and release the body to the morgue. D.Keep the body available for a few hours in case they change their minds. - D.Keep the body available for a few hours in case they change their minds. Grieving parents should be encouraged to hold their infant after death to facilitate closure. If parents are hesitant about seeing or holding their dead infant, the fetus should be available for a few hours in the event they change their mind after the initial shock. The other actions are not indicated. A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the birth? A.Ask the family if they would like to see and hold the infant after birth. B.Inquire if the parents want a picture taken after the infant is born. C.Discuss with the parents which funeral home should be notified. D.Find out if the client has a special outfit for the infant after the birth. - A.Ask the family if they would like to see and hold the infant after birth. Interventions and support from the nursing staff during a prenatal loss are extremely important in the grief process and healing of the parents. Research had shown it is most helpful for a mother and father to see and hold their deceased infant after delivery, so the parents should be given this opportunity initially after birth. The other actions should be done after determining the parents' wishes and providing the opportunity for bonding and closure with their infant. A client who had a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement? A.Ready the client for discharge. B.Notify pastoral care to offer the client a blessing. C.Ask the client what name she had picked out for the infant. D.Inquire if the client would like to see what was obtained from her D&C. - C.Ask the client what name she had picked out for the infant