HESI 1 BSN 266 Medical surgical
The nurse is providing dietary instructions to a 68-year-old client who is at high
risk for development of coronary heart disease (CHD). Which information should
the nurse include?
Limit dietary selection of cholesterol to 300 mg per day.
Increase intake of soluble fiber to 10 to 25 grams per day.
Decrease plant stanols and sterols to less than 2 grams/day. Ensure
saturated fat is less than 30% of total caloric intake.
Rationale
To reduce risk factors associated with coronary heart disease, the daily intake of
soluble fiber should be increased to between 10 and 25 gm. According to the
American Heart Association, soluble fibers helps reduce the LDL cholesterol
levels.
Despite several eye surgeries, a 78-year-old client who lives alone has persistent
vision problems. The visiting nurse is discussing home safety hazards with the
client. The nurse suggests that the edges of the steps be painted which color?
White.
Light green.
Medium yellow.
Black.
Rationale
The color yellow is the easiest for a person with failing vision to see.
A client receiving cholestyramine (Questran) for hyperlipidemia should be
evaluated for what vitamin deficiency?
K.
B12.
B6.
C.
,Rationale
This drug is administered to help lower the triglycerides levels. One of the side
effects clients should be monitored for an increased prothrombin time and
prolonged bleeding times which would alert the nurse to a vitamin K deficiency.
These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K.
The nurse is caring for a client with a stroke resulting in right-sided paresis and
aphasia. The client attempts to use the left hand for feeding and other self-care
activities. The spouse becomes frustrated and insists on doing everything for the
client. Based on this data, which nursing diagnosis should the nurse document
for this client?
Situational low self-esteem related to functional impairment and change in role
function.
Disabled family coping related to dissonant coping style of significant person.
Interrupted family processes related to shift in health status of family member.
Risk for ineffective therapeutic regimen management related to complexity of care.
Rationale
A stroke affects the whole family and in this case the spouse probably thinks that
she is helping and needs to feel that she is contributing to the client's care. Her
help is noted as being incongruent with attempts of self-care by the client thereby
disabling family coping.
The nurse is interviewing a male client with hypertension. Which additional
medical diagnosis in the client's history presents the greatest risk for developing
a cerebral vascular accident (CVA)?
Diabetes mellitus.
Hypothyroidism.
Parkinson's disease.
Recurring pneumonia.
Rationale
According to the National Stroke Association (2013), history of diabetes mellitus
poses the greatest risk for developing a CVA, 2-4Xs more than those who do not
have diabetes mellitus. The reason for this occurrence is related to the excess
glucose circulating throughout the body not being utilizing by the cells of the
body, leading to the increased fatty deposits or clots inside the blood vessels in
the brain or neck, eventually causing a stroke.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse
expects the laboratory test results to indicate a decreased serum level of which
substance?
, Sodium.
Antidiuretic hormone.
Potassium.
Glucose.
Rationale
Clients with primary hyperaldosteronism exhibit a profound decline in the serum
levels of potassium (hypokalemia). Hypertension, along with the hypokalemia are
the most prominent and universal signs for this condition. If both of these
findings are present, there is 50% likelihood the client to be diagnosed with
hyperaldosteronism.
Which intervention should the nurse implement for a female client diagnosed with
pelvic relaxation disorder?
Describe proper administration of vaginal suppositories and cream.
Encourage the client to perform Kegel exercises 10 times daily.
Explain the importance of using condoms when having sexual intercourse.
Discuss the importance of keeping a diary of daily temperature and menstrual cycle
events. Rationale
Pelvic relaxation disorders are structural disorders resulting from weakening
support tissues of the pelvis. Kegel exercises helps strengthen the surrounding
muscles.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis.
Which statement by the nurse provides the most accurate explanation for use of
the splints?
Prevention of deformities.
Avoidance of joint trauma.
Relief of joint inflammation.
Improvement in joint strength.
Rationale
Splints may be used at night by clients with rheumatoid arthritis to prevent
deformities caused by muscle spasms and contractures.
The nurse is teaching a female client who uses a contraceptive diaphragm about
reducing the risk for toxic shock syndrome (TSS). Which information should the
nurse include? (Select all that apply.)
Select all that apply
Remove the diaphragm immediately after intercourse.
Wash the diaphragm with an alcohol solution.
Use the diaphragm to prevent conception during the menstrual cycle.
, Do not leave the diaphragm in place longer than 8 hours after intercourse. Replace
the old diaphragm every 3 months.
Rationale
The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent
pregnancy but should not remain for longer than 8 hours to avoid the risk of TSS.
The diaphragm should be replaced every 3 months to maintain integrity. A client
has a staging procedure for cancer of the breast and ask the nurse which type of
breast cancer has the poorest prognosis. Which information should the nurse
offer the client?
Stage II.
Invasive infiltrating ductal carcinoma.
T1N0M0.
Inflammatory with peau d'orange.
Rationale
Inflammatory breast cancer onset is very rapid and a very rare form of breast
cancer and is considered the most aggressive form of breast malignancies. It is
often mistaken for a breast infection because it has a thickened appearance like
an orange peel (peau d'orange), causing the breast to become swollen and
tender.
A client with a 16-year history of diabetes mellitus is having renal function tests
because of recent fatigue, weakness, elevated blood urea nitrogen, and serum
creatinine levels. Which finding should the nurse conclude as an early symptom
of renal insufficiency?
Dyspnea.
Nocturia.
Confusion.
Stomatitis.
Rationale
As the glomerular filtration rate decreases in early renal insufficiency, metabolic
waste products, including urea, creatinine, and other substances, such phenols,
hormones, electrolytes, accumulate in the blood. In the early stage of renal
insufficiency, polyuria results from the inability of the kidneys to concentrate
urine and contribute to nocturia.
The nurse is planning care for a client with newly diagnosed diabetes mellitus
that requires insulin. Which assessment should the nurse identify before
beginning the teaching session?
Present knowledge related to the skill of injection.
Intelligence and developmental level of the client.
Willingness of the client to learn the injection sites.
Financial resources available for the equipment.
The nurse is providing dietary instructions to a 68-year-old client who is at high
risk for development of coronary heart disease (CHD). Which information should
the nurse include?
Limit dietary selection of cholesterol to 300 mg per day.
Increase intake of soluble fiber to 10 to 25 grams per day.
Decrease plant stanols and sterols to less than 2 grams/day. Ensure
saturated fat is less than 30% of total caloric intake.
Rationale
To reduce risk factors associated with coronary heart disease, the daily intake of
soluble fiber should be increased to between 10 and 25 gm. According to the
American Heart Association, soluble fibers helps reduce the LDL cholesterol
levels.
Despite several eye surgeries, a 78-year-old client who lives alone has persistent
vision problems. The visiting nurse is discussing home safety hazards with the
client. The nurse suggests that the edges of the steps be painted which color?
White.
Light green.
Medium yellow.
Black.
Rationale
The color yellow is the easiest for a person with failing vision to see.
A client receiving cholestyramine (Questran) for hyperlipidemia should be
evaluated for what vitamin deficiency?
K.
B12.
B6.
C.
,Rationale
This drug is administered to help lower the triglycerides levels. One of the side
effects clients should be monitored for an increased prothrombin time and
prolonged bleeding times which would alert the nurse to a vitamin K deficiency.
These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K.
The nurse is caring for a client with a stroke resulting in right-sided paresis and
aphasia. The client attempts to use the left hand for feeding and other self-care
activities. The spouse becomes frustrated and insists on doing everything for the
client. Based on this data, which nursing diagnosis should the nurse document
for this client?
Situational low self-esteem related to functional impairment and change in role
function.
Disabled family coping related to dissonant coping style of significant person.
Interrupted family processes related to shift in health status of family member.
Risk for ineffective therapeutic regimen management related to complexity of care.
Rationale
A stroke affects the whole family and in this case the spouse probably thinks that
she is helping and needs to feel that she is contributing to the client's care. Her
help is noted as being incongruent with attempts of self-care by the client thereby
disabling family coping.
The nurse is interviewing a male client with hypertension. Which additional
medical diagnosis in the client's history presents the greatest risk for developing
a cerebral vascular accident (CVA)?
Diabetes mellitus.
Hypothyroidism.
Parkinson's disease.
Recurring pneumonia.
Rationale
According to the National Stroke Association (2013), history of diabetes mellitus
poses the greatest risk for developing a CVA, 2-4Xs more than those who do not
have diabetes mellitus. The reason for this occurrence is related to the excess
glucose circulating throughout the body not being utilizing by the cells of the
body, leading to the increased fatty deposits or clots inside the blood vessels in
the brain or neck, eventually causing a stroke.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse
expects the laboratory test results to indicate a decreased serum level of which
substance?
, Sodium.
Antidiuretic hormone.
Potassium.
Glucose.
Rationale
Clients with primary hyperaldosteronism exhibit a profound decline in the serum
levels of potassium (hypokalemia). Hypertension, along with the hypokalemia are
the most prominent and universal signs for this condition. If both of these
findings are present, there is 50% likelihood the client to be diagnosed with
hyperaldosteronism.
Which intervention should the nurse implement for a female client diagnosed with
pelvic relaxation disorder?
Describe proper administration of vaginal suppositories and cream.
Encourage the client to perform Kegel exercises 10 times daily.
Explain the importance of using condoms when having sexual intercourse.
Discuss the importance of keeping a diary of daily temperature and menstrual cycle
events. Rationale
Pelvic relaxation disorders are structural disorders resulting from weakening
support tissues of the pelvis. Kegel exercises helps strengthen the surrounding
muscles.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis.
Which statement by the nurse provides the most accurate explanation for use of
the splints?
Prevention of deformities.
Avoidance of joint trauma.
Relief of joint inflammation.
Improvement in joint strength.
Rationale
Splints may be used at night by clients with rheumatoid arthritis to prevent
deformities caused by muscle spasms and contractures.
The nurse is teaching a female client who uses a contraceptive diaphragm about
reducing the risk for toxic shock syndrome (TSS). Which information should the
nurse include? (Select all that apply.)
Select all that apply
Remove the diaphragm immediately after intercourse.
Wash the diaphragm with an alcohol solution.
Use the diaphragm to prevent conception during the menstrual cycle.
, Do not leave the diaphragm in place longer than 8 hours after intercourse. Replace
the old diaphragm every 3 months.
Rationale
The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent
pregnancy but should not remain for longer than 8 hours to avoid the risk of TSS.
The diaphragm should be replaced every 3 months to maintain integrity. A client
has a staging procedure for cancer of the breast and ask the nurse which type of
breast cancer has the poorest prognosis. Which information should the nurse
offer the client?
Stage II.
Invasive infiltrating ductal carcinoma.
T1N0M0.
Inflammatory with peau d'orange.
Rationale
Inflammatory breast cancer onset is very rapid and a very rare form of breast
cancer and is considered the most aggressive form of breast malignancies. It is
often mistaken for a breast infection because it has a thickened appearance like
an orange peel (peau d'orange), causing the breast to become swollen and
tender.
A client with a 16-year history of diabetes mellitus is having renal function tests
because of recent fatigue, weakness, elevated blood urea nitrogen, and serum
creatinine levels. Which finding should the nurse conclude as an early symptom
of renal insufficiency?
Dyspnea.
Nocturia.
Confusion.
Stomatitis.
Rationale
As the glomerular filtration rate decreases in early renal insufficiency, metabolic
waste products, including urea, creatinine, and other substances, such phenols,
hormones, electrolytes, accumulate in the blood. In the early stage of renal
insufficiency, polyuria results from the inability of the kidneys to concentrate
urine and contribute to nocturia.
The nurse is planning care for a client with newly diagnosed diabetes mellitus
that requires insulin. Which assessment should the nurse identify before
beginning the teaching session?
Present knowledge related to the skill of injection.
Intelligence and developmental level of the client.
Willingness of the client to learn the injection sites.
Financial resources available for the equipment.
