Concepts of Nursing II: Week 7 HESI 2 -
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The nurse is assessing a client with chronic kidney disease (CKD). Which finding
is most important for the nurse to respond to first?
Potassium 6.0 mEq.
Daily urine output of 400
ml. Peripheral
neuropathy.
Uremic fetor.
Rationale
Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte
disorder that can cause fatal arrhythmias, so the elevation of the potassium level
is a nursing priority.
In assessing cancer risk, the nurse identifies which woman as being at greatest
risk of developing breast cancer?
A 35-year-old multipara who never breastfed.
A 50-year-old whose mother had unilateral breast cancer.
A 55-year-old whose mother-in-law had bilateral breast
cancer. A 20-year-old whose menarche occurred at age
9.
Rationale
The most predictive risk factors for development of breast cancer are over 40
years of age and a positive family history (occurrence in the immediate family,
i.e., mother or sister). Other risk factors include nulliparity, no history of
breastfeeding, early menarche and late menopause, but are not considered as
predictive as a positive history of an immediate family member and over 40 years
old.
Which client should the nurse recognize as most likely to experience sleep
apnea?
Middle-aged female who takes a diuretic
nightly. Obese older male client with a
short, thick neck. Adolescent female with a
history of tonsillectomy.
School-aged male with a history of hyperactivity disorder.
Rationale
Sleep apnea is characterized by lack of respirations for 10 seconds or more
during sleep and is due to the loss of pharyngeal tone which allows the pharynx
to collapse during inspiration and obstructs air flow through the nose and
mouth. Risk factors which increase the condition of sleep apnea include:
excessive weight, increases the risk 4Xs more than normal weighing individuals;
neck circumference, thicker necks have narrower airways; individuals with
,inherited narrower airways; males in general are more prone to sleep apnea;
females risk increase with being overweight and post-menopausal; increased
age (geriatrics); family history; use of alcohol, sedatives or tranquilizers;
smokers and those who suffer from nasal allergies.
, A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg.
Which action should the nurse implement?
Position the head of the bed (HOB)
flat. Withhold intravenous fluids.
Administer a bolus of IV fluids.
Give an antihypertensive
medication. Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines
or blood viscosity increases due to minimal fluid intake. Completed strokes
usually produce neurologic deficits within an hour, and the client's current
elevated blood pressure requires antihypertensive medication.
A postmenopausal client asks the nurse why she is experiencing discomfort
during intercourse. What response is best for the nurse to provide?
Estrogen deficiency causes the vaginal tissues to become dry and
thinner. Infrequent intercourse results in the vaginal tissues losing
their elasticity.
Dehydration from inadequate fluid intake causes vulva tissue dryness.
Lack of adequate stimulation is the most common reason for
dyspareunia. Rationale
Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells,
so vaginal tissues tend to become thinner, drier, and the rugae become smoother
which reduces vaginal stretching that contributes to dyspareunia. The discomfort
during intercourse, primary cause can be contributed to the decrease in estrogen
hormone levels.
A middle-aged male client with diabetes continues to eat an abundance of foods
that are high in sugar and fat. According to the Health Belief Model, which event
is most likely to increase the client's willingness to become compliant with the
prescribed diet?
He visits his diabetic brother who just had surgery to amputate an
infected foot.
He is provided with the most current information about the dangers of
untreated diabetes.
He comments on the community service announcements about
preventing
complications associated with diabetes.
His wife expresses a sincere willingness to prepare meals that are within
his
prescribed
diet.
Rationale
The loss of a limb due to diabetes by a family member should be the strongest
event or "cue to action" and is most likely to increase the client's perceived
seriousness of the disease.
The nurse is planning to initiate a socialization group for older residents of a
Medical surgical Latest Update 100%
Guaranteed.
The nurse is assessing a client with chronic kidney disease (CKD). Which finding
is most important for the nurse to respond to first?
Potassium 6.0 mEq.
Daily urine output of 400
ml. Peripheral
neuropathy.
Uremic fetor.
Rationale
Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte
disorder that can cause fatal arrhythmias, so the elevation of the potassium level
is a nursing priority.
In assessing cancer risk, the nurse identifies which woman as being at greatest
risk of developing breast cancer?
A 35-year-old multipara who never breastfed.
A 50-year-old whose mother had unilateral breast cancer.
A 55-year-old whose mother-in-law had bilateral breast
cancer. A 20-year-old whose menarche occurred at age
9.
Rationale
The most predictive risk factors for development of breast cancer are over 40
years of age and a positive family history (occurrence in the immediate family,
i.e., mother or sister). Other risk factors include nulliparity, no history of
breastfeeding, early menarche and late menopause, but are not considered as
predictive as a positive history of an immediate family member and over 40 years
old.
Which client should the nurse recognize as most likely to experience sleep
apnea?
Middle-aged female who takes a diuretic
nightly. Obese older male client with a
short, thick neck. Adolescent female with a
history of tonsillectomy.
School-aged male with a history of hyperactivity disorder.
Rationale
Sleep apnea is characterized by lack of respirations for 10 seconds or more
during sleep and is due to the loss of pharyngeal tone which allows the pharynx
to collapse during inspiration and obstructs air flow through the nose and
mouth. Risk factors which increase the condition of sleep apnea include:
excessive weight, increases the risk 4Xs more than normal weighing individuals;
neck circumference, thicker necks have narrower airways; individuals with
,inherited narrower airways; males in general are more prone to sleep apnea;
females risk increase with being overweight and post-menopausal; increased
age (geriatrics); family history; use of alcohol, sedatives or tranquilizers;
smokers and those who suffer from nasal allergies.
, A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg.
Which action should the nurse implement?
Position the head of the bed (HOB)
flat. Withhold intravenous fluids.
Administer a bolus of IV fluids.
Give an antihypertensive
medication. Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines
or blood viscosity increases due to minimal fluid intake. Completed strokes
usually produce neurologic deficits within an hour, and the client's current
elevated blood pressure requires antihypertensive medication.
A postmenopausal client asks the nurse why she is experiencing discomfort
during intercourse. What response is best for the nurse to provide?
Estrogen deficiency causes the vaginal tissues to become dry and
thinner. Infrequent intercourse results in the vaginal tissues losing
their elasticity.
Dehydration from inadequate fluid intake causes vulva tissue dryness.
Lack of adequate stimulation is the most common reason for
dyspareunia. Rationale
Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells,
so vaginal tissues tend to become thinner, drier, and the rugae become smoother
which reduces vaginal stretching that contributes to dyspareunia. The discomfort
during intercourse, primary cause can be contributed to the decrease in estrogen
hormone levels.
A middle-aged male client with diabetes continues to eat an abundance of foods
that are high in sugar and fat. According to the Health Belief Model, which event
is most likely to increase the client's willingness to become compliant with the
prescribed diet?
He visits his diabetic brother who just had surgery to amputate an
infected foot.
He is provided with the most current information about the dangers of
untreated diabetes.
He comments on the community service announcements about
preventing
complications associated with diabetes.
His wife expresses a sincere willingness to prepare meals that are within
his
prescribed
diet.
Rationale
The loss of a limb due to diabetes by a family member should be the strongest
event or "cue to action" and is most likely to increase the client's perceived
seriousness of the disease.
The nurse is planning to initiate a socialization group for older residents of a
