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