NURSING 246 HESI PRACTICE / REVIEW OF KEY
QUIZZES, AND PRACTICE QUESTIONS FOR
GUARANTEED SUCCESS / CONTAINS ANSWERS &
RATIONALES
Terms in this set (51)
The nurse palpates a weak Diminished hair on legs
pedal pulse in the client's
right foot. Which Skin cool to touch
assessment findings should
the RN document that are Capillary refill less than 3 seconds
consistent with diminished
peripheral circulation? Rationale
(Select all that apply.) Diminished hair on the legs and skin that is cool to
Diminished hair on legs touch are symptoms of decreased arterial blood flow.
The other options are not indicators for impaired
peripheral circulation.
Bruising on extremities
Skin cool to touch
Capillary refill less than 3
seconds
Darkened skin on
extremities
,The registered nurse (RN) Skin cool to touch.
palpates a weak pedal pulse
in the client's right foot. Capillary refill less than 3 seconds.
Which assessment findings Rationale
should the RN document that Diminished hair on the legs and skin that is cool to touch are
are consistent with expectant signs of decreased arterial blood flow.
diminished peripheral
circulation? (Select all that
apply.)
Diminished hair on legs.
Bruising on extremities.
Skin cool to touch.
Capillary refill less than 3
seconds.
Darkened skin on extremities.
Polydipsia.
The registered nurse (RN) is
Rationale
caring for a client who has a
A characteristic finding of DI is excretion of large quantities
closed head injury from a of urine (5 to 20L/day), and most clients compensate for
motor vehicle collision. Which fluid loss by drinking large amounts of water (polydipsia). DI
finding should the RN assess can occur when there has been damage or injury to the
pituitary gland or hypothalamus as a result of head trauma,
the client for the risk of
tumor or an illness such as meningitis. This damage
diabetes insipidus (DI)? interrupts the ADH production, storage and release causing
High fever. the excessive urination and thirst.
Low blood pressure.
Muscle rigidity.
Polydipsia.
,The registered nurse (RN) is Native language.
teaching a client who is being
discharged after treatment of Education level.
tuberculosis (TB). Which
cultural issues should the RN Type of lifestyle.
assess when preparing the
client for discharge? (Select Rationale
all that apply.) Native To ensure compliance the client's native language, education
language. level, lifestyle, and financial resources should be considered
when preparing the client's discharge instructions about the
continuation of treatment for TB.
Education level.
Type of lifestyle.
Financial resources.
Previous medical history.
, The registered nurse (RN) is Stiffness in right ankle joint.
caring for an older client who Rationale
has been bedridden for two Stiffness in joints is an early sign of contractures and muscle atrophy
weeks. Which assessment related to inactivity and immobility.
findings indicate to the RN
that the client is developing a
complication related to
immobility?
Decreased pedal pulses.
Edema in upper extremities.
Loss of appetite for food.
Stiffness in right ankle joint.
QUIZZES, AND PRACTICE QUESTIONS FOR
GUARANTEED SUCCESS / CONTAINS ANSWERS &
RATIONALES
Terms in this set (51)
The nurse palpates a weak Diminished hair on legs
pedal pulse in the client's
right foot. Which Skin cool to touch
assessment findings should
the RN document that are Capillary refill less than 3 seconds
consistent with diminished
peripheral circulation? Rationale
(Select all that apply.) Diminished hair on the legs and skin that is cool to
Diminished hair on legs touch are symptoms of decreased arterial blood flow.
The other options are not indicators for impaired
peripheral circulation.
Bruising on extremities
Skin cool to touch
Capillary refill less than 3
seconds
Darkened skin on
extremities
,The registered nurse (RN) Skin cool to touch.
palpates a weak pedal pulse
in the client's right foot. Capillary refill less than 3 seconds.
Which assessment findings Rationale
should the RN document that Diminished hair on the legs and skin that is cool to touch are
are consistent with expectant signs of decreased arterial blood flow.
diminished peripheral
circulation? (Select all that
apply.)
Diminished hair on legs.
Bruising on extremities.
Skin cool to touch.
Capillary refill less than 3
seconds.
Darkened skin on extremities.
Polydipsia.
The registered nurse (RN) is
Rationale
caring for a client who has a
A characteristic finding of DI is excretion of large quantities
closed head injury from a of urine (5 to 20L/day), and most clients compensate for
motor vehicle collision. Which fluid loss by drinking large amounts of water (polydipsia). DI
finding should the RN assess can occur when there has been damage or injury to the
pituitary gland or hypothalamus as a result of head trauma,
the client for the risk of
tumor or an illness such as meningitis. This damage
diabetes insipidus (DI)? interrupts the ADH production, storage and release causing
High fever. the excessive urination and thirst.
Low blood pressure.
Muscle rigidity.
Polydipsia.
,The registered nurse (RN) is Native language.
teaching a client who is being
discharged after treatment of Education level.
tuberculosis (TB). Which
cultural issues should the RN Type of lifestyle.
assess when preparing the
client for discharge? (Select Rationale
all that apply.) Native To ensure compliance the client's native language, education
language. level, lifestyle, and financial resources should be considered
when preparing the client's discharge instructions about the
continuation of treatment for TB.
Education level.
Type of lifestyle.
Financial resources.
Previous medical history.
, The registered nurse (RN) is Stiffness in right ankle joint.
caring for an older client who Rationale
has been bedridden for two Stiffness in joints is an early sign of contractures and muscle atrophy
weeks. Which assessment related to inactivity and immobility.
findings indicate to the RN
that the client is developing a
complication related to
immobility?
Decreased pedal pulses.
Edema in upper extremities.
Loss of appetite for food.
Stiffness in right ankle joint.
