HESI TERM 2 EXIT EXAM STUDY GUIDE WITH COMPLETE SOLUTIONS

A 16-year old client who has admitted to the psychiatric unit. Which nursing intervention is MOST important for the practical nurse (PN) to implement? 1. Do not leave the client alone 2. Assess the family history for depression 3. Obtain information about previous suicide attempts 4. Limit visitation until the clients vital signs are stable - ? Do not leave the client alone The practical nurse is initiating a new prescription for nitroglycerin transdermal patch for a client with angina pectoris. What action has the highest priority in preventing tolerance to the nitrogylcerin? 1. Shave the chest hairs to ensure adequate skin contact 2. Label the patch with date, time, and nurse's initials 3. emove the patch at bedtime as prescribed - Remove the patch at bedtime as prescribed Constant observation is an intervention included in the plan of care for a female client with dementia because she is at risk for falls. When she walks to the door and asks to leave, the practice nurse (PN) is unable to convince her to return to her room. Which action should the PN take? 1. Allow the client 10 minutes to stand by the door 2. Request assistance to remove the client from the exit 3. Distract the client by offering to walk with her 4. Administer a PRN prescription for agitation - Distract the client by offering to walk with her A female client with obsessive compulsive disorder is admitted to the hospital for a cardiac catheterization. The afternoons before the procedure, the client begins to keep detailed notes if the nursing care she is receiving. At bedtime, she shows the list to the practical nurse (PN). Which action should the PN implement? 1. Ask the client to explain why she is writing down each nursing task 2. Encourage her to express her feelings about the upcoming procedure 3. Recommend strategies to control her obsessive compulsive behaviors 4. Explain the rationales for each nursing responsibilities - Encourage her to express her feelings about the upcoming procedure An 18-year-old female client who was released 3 weeks ago following two months of treatments for anorexia returns to the HCP office for a follow-up visit. Which statement indicates to the PN that the client is recovering and coping after treatment for anorexia nervous? 1. "If I don't go to college scholarship my parents will be very disappointed in me" 2. "My parents attempt to smother me, but I will not allow them to make my decisions." 3. "I know that I am fat and I plan to lose at least ten more pounds." 4. "I will not binge eat, vomit after I eat, or take laxatives or diuretics." - "I will not binge eat, vomit after I eat, or take laxatives or diuretics." A resident in a long term care facility is to receive fluconazole 150mg PO daily for seven days. The medication is available in 50mg tablets and the medication needs to be given for four more days. To ensure that there are sufficient tablets for the remaining four days, the practical nurse should confirm that there are how many remaining tablets? - 12 While changing the dressing of a clients abdominal incision, the practical nurse observes a large amount of purulent drainage on the dressing. Which data should the PN collect first? 1. Assess the degree of skin elasticity 2. determine the client's oxygen saturation 3. measure the client's body temperature 4. observe the appearance of the incision - ? observe the appearance of the incision A young male adult who suffered a concussion a week ago in a motor vehicle collision comes to the clinic because he is unable to sleep. When the practical nurse enters the examination room, the client is startled and is hyper-vigilant. After reassuring the client, which action should the PN implement? 1. Explain to the client that he is experiencing post-traumatic stress disorder 2. Ask the client if he would like to have a prescription for a night sedative. 3. Report the clients behavior to the HCP 4. Inquire about the clients daily intake of caffeinated drinks - Report the clients behavior to the HCP A client who is significantly overweight states to the practical nurse the desire to lose weight. Which action should the PN do first? assess the clients current dietary through recall 1. tell the client to eat 3 well balance meals daily 2. help the client plan high-protein, low carbohydrate meals 3. facilitate the client in developing an exercise schedule 4. Assess the client's dietary habits through recall - Assess the client's dietary habits through recall The practical nurse is evaluating the response of a client with psoriasis to a topical steroid medication. Which finding should the PN report to the charge nurse as an indication of possible local infection? 1. White lesions on psoriasis skin surface 2. broken veins where medication is used 3. itching on the skin areas with psoriasis 4. stretch mark where psoriasis is treated - White lesions on psoriasis skin surface