ASSESSED HESI REMEDATIONS
FOR GERONTOLOGY
An older client is near the completion of a series of blood transfusions. The practical nurse (PN)
identifies and reports to the nurse that the client has developed a rapid bounding pulse, elevated blood
pressure, and swollen superficial veins. Which should the PN suspect is causing these findings? -
CORRECT ANSWER -Volume overload.
Rationale
The addition of extra fluid volume during a transfusion may present certain risks for older clients with
compromised cardiac function or renal status. Signs such as a rapid bounding pulse, hypertension, and
swollen superficial veins should alert the nurse to the possibility of fluid volume overload.
An older client has developed sepsis and SIRS (systemic inflammatory response syndrome) as a result of
an infected wound. Which scenario should the practical nurse (PN) recognize as correct to reinforce
teaching to a family member on how SIRS affects the body initially? - CORRECT ANSWER -The
endothelial lining of blood vessels becomes damaged causing leakage into tissues.
Rationale
SIRS (systemic inflammatory response syndrome) is the result of an injury causing an overwhelming
inflammatory response that threatens vital organ changes. This response manifests in the blood vessels
that result in damaged endothelium lining that causes leakage of fluid into the body's tissues. As blood
flow to the bodies vital organs become compromised resulting in damage and multiple organ
dysfunction syndrome (MODS).
The practical nurse (PN) is assisting the nurse who is performing an admission assessment of an older
client who has been admitted for severe partial-thickness and full-thickness burns of the legs and
buttocks. Which condition is the client at greatest risk developing initially? - CORRECT ANSWER -
Hypovolemic shock.
Rationale
,Hypovolemic shock produced by burns occurs most often in people with large partial-thickness or full-
thickness burns. It is caused primarily by a shift of plasma from the vascular space into the interstitial
space.
An older client is admitted with partial-thickness burn injuries, covering 50% of the client's body. Which
adverse response to thermal burns is a nursing priority? - CORRECT ANSWER -Hypovolemia.
Rationale
The client with extensive burn injuries is at risk for hypovolemia, especially during the first 36 hours after
the injuries have occurred. Insufficient fluid volume is directly related to increased capillary leakage and
fluid shift from the intravascular space to the interstitial space after the burn insult.
Which factors are most important for the practical nurse (PN) to identify and report when performing a
focused assessment on an older client with possible alcohol abuse? - CORRECT ANSWER -Depression.
Social isolation.
Loss of interest in hobbies.
Rationale
Alcoholism in the older client is often underreported and undertreated. The changes of aging and
developmental may contribute to alcohol use. Older clients are often socially isolated, have sensory
deficits, and depression which all contribute to substance use.
An older client reports to the practical nurse (PN) about having constipation. Which response should the
PN use to clarify the client's report of constipation? - CORRECT ANSWER -"Describe the characteristics of
your stools."
Rationale
Bowel elimination patterns can differ widely from person to person. To clarify symptoms of
constipation, the nurse should determine if stools are hard, dry, and difficult to pass or if the client has
to strain to defecate
,An older client is scheduled for a hemorrhoidectomy. Which postoperative prescription should the
practical nurse (PN) anticipate? - CORRECT ANSWER -Stool softener.
Rationale
Bowel movements after a hemorrhoidectomy will cause some pain. A stool softener is usually
prescribed to lessen the discomfort of the passage of stool.
The practical nurse (PN) should monitor for which clinical indicator when providing care to an older
client with cholelithiasis and obstructive jaundice? - CORRECT ANSWER -Dark urine.
Rationale
An older client with cholelithiasis and obstructive jaundice may have increased bile levels in the
bloodstream. When bile levels in the bloodstream are high, as in obstructive jaundice, urine appears
dark due to bile in the urine.
The health care provider prescribed intermittent nasogastric tube (NGT) feedings to supplement an
older client's oral nutritional intake. The practical nurse (PN) should administer the NGT feeding slowly
in order to reduce the risk of which hazard? - CORRECT ANSWER -Aspiration.
Rationale
The cardiac sphincter of the stomach is slightly opened to admit the nasogastric tube, so contents may
be forced back up through the esophagus, resulting in regurgitation which can cause an increased risk
for aspiration. The practical nurse (PN) should administer the feeding slowly to prevent these
complications.
An 81-year-old resident in a long-term care facility begins to refuse food, particularly solids, and
repeatedly yells, "Leave me alone!" The client has lost a total of 6 pounds over the past month. What is
the best initial nursing intervention? - CORRECT ANSWER -Assess to identify changes in emotional or
physical status.
Rationale
, Emotional and physical changes may cause anorexia, a loss in appetite. The first step is to assess for any
changes in physical status that may have prompted the loss in appetite and refusal of solids food. Due to
the refusal of solids should prompt the practical nurse (PN) to examine the client's oral cavity for any
signs of ulcerations, possible yeast infection and check the fitting of the client's dentures if applicable. If
no physical signs or symptoms are present, then the PN needs to report the findings of the nurse, so the
client's emotional and psychological status can be further evaluated.
The practical nurse (PN) is providing care to a postoperative older client who has type 1 diabetes. Which
scenario should the PN recognize as a risk factor for the development of diabetic ketoacidosis? -
CORRECT ANSWER -Presence of infection.
Rationale
In an older client with type 1 diabetes, there is not enough insulin available to meet increased demands.
The practical nurse (PN) should monitor this client for signs and symptoms of postoperative infection,
which increases the body's metabolic rate and places the client at greater risk for diabetic ketoacidosis.
An 81-year-old resident in a long-term care facility begins to refuse food, particularly solids, and
repeatedly yells, "Leave me alone!" The client has lost a total of 6 pounds over the past month. What is
the best initial nursing intervention? - CORRECT ANSWER -Assess to identify changes in emotional or
physical status.
Rationale
Emotional and physical changes may cause anorexia, a loss in appetite. The first step is to assess for any
changes in physical status that may have prompted the loss in appetite and refusal of solids food. Due to
the refusal of solids should prompt the practical nurse (PN) to examine the client's oral cavity for any
signs of ulcerations, possible yeast infection and check the fitting of the client's dentures if applicable. If
no physical signs or symptoms are present, then the PN needs to report the findings of the nurse, so the
client's emotional and psychological status can be further evaluated.
The heathcare provider prescribed enteral feedings for an older client with severe sepsis and multi-
organ failure. What is the main purpose of this prescription? - CORRECT ANSWER -To reduce bacterial
systemic movement through intestinal wall and improve gastrointestinal perfusion.
FOR GERONTOLOGY
An older client is near the completion of a series of blood transfusions. The practical nurse (PN)
identifies and reports to the nurse that the client has developed a rapid bounding pulse, elevated blood
pressure, and swollen superficial veins. Which should the PN suspect is causing these findings? -
CORRECT ANSWER -Volume overload.
Rationale
The addition of extra fluid volume during a transfusion may present certain risks for older clients with
compromised cardiac function or renal status. Signs such as a rapid bounding pulse, hypertension, and
swollen superficial veins should alert the nurse to the possibility of fluid volume overload.
An older client has developed sepsis and SIRS (systemic inflammatory response syndrome) as a result of
an infected wound. Which scenario should the practical nurse (PN) recognize as correct to reinforce
teaching to a family member on how SIRS affects the body initially? - CORRECT ANSWER -The
endothelial lining of blood vessels becomes damaged causing leakage into tissues.
Rationale
SIRS (systemic inflammatory response syndrome) is the result of an injury causing an overwhelming
inflammatory response that threatens vital organ changes. This response manifests in the blood vessels
that result in damaged endothelium lining that causes leakage of fluid into the body's tissues. As blood
flow to the bodies vital organs become compromised resulting in damage and multiple organ
dysfunction syndrome (MODS).
The practical nurse (PN) is assisting the nurse who is performing an admission assessment of an older
client who has been admitted for severe partial-thickness and full-thickness burns of the legs and
buttocks. Which condition is the client at greatest risk developing initially? - CORRECT ANSWER -
Hypovolemic shock.
Rationale
,Hypovolemic shock produced by burns occurs most often in people with large partial-thickness or full-
thickness burns. It is caused primarily by a shift of plasma from the vascular space into the interstitial
space.
An older client is admitted with partial-thickness burn injuries, covering 50% of the client's body. Which
adverse response to thermal burns is a nursing priority? - CORRECT ANSWER -Hypovolemia.
Rationale
The client with extensive burn injuries is at risk for hypovolemia, especially during the first 36 hours after
the injuries have occurred. Insufficient fluid volume is directly related to increased capillary leakage and
fluid shift from the intravascular space to the interstitial space after the burn insult.
Which factors are most important for the practical nurse (PN) to identify and report when performing a
focused assessment on an older client with possible alcohol abuse? - CORRECT ANSWER -Depression.
Social isolation.
Loss of interest in hobbies.
Rationale
Alcoholism in the older client is often underreported and undertreated. The changes of aging and
developmental may contribute to alcohol use. Older clients are often socially isolated, have sensory
deficits, and depression which all contribute to substance use.
An older client reports to the practical nurse (PN) about having constipation. Which response should the
PN use to clarify the client's report of constipation? - CORRECT ANSWER -"Describe the characteristics of
your stools."
Rationale
Bowel elimination patterns can differ widely from person to person. To clarify symptoms of
constipation, the nurse should determine if stools are hard, dry, and difficult to pass or if the client has
to strain to defecate
,An older client is scheduled for a hemorrhoidectomy. Which postoperative prescription should the
practical nurse (PN) anticipate? - CORRECT ANSWER -Stool softener.
Rationale
Bowel movements after a hemorrhoidectomy will cause some pain. A stool softener is usually
prescribed to lessen the discomfort of the passage of stool.
The practical nurse (PN) should monitor for which clinical indicator when providing care to an older
client with cholelithiasis and obstructive jaundice? - CORRECT ANSWER -Dark urine.
Rationale
An older client with cholelithiasis and obstructive jaundice may have increased bile levels in the
bloodstream. When bile levels in the bloodstream are high, as in obstructive jaundice, urine appears
dark due to bile in the urine.
The health care provider prescribed intermittent nasogastric tube (NGT) feedings to supplement an
older client's oral nutritional intake. The practical nurse (PN) should administer the NGT feeding slowly
in order to reduce the risk of which hazard? - CORRECT ANSWER -Aspiration.
Rationale
The cardiac sphincter of the stomach is slightly opened to admit the nasogastric tube, so contents may
be forced back up through the esophagus, resulting in regurgitation which can cause an increased risk
for aspiration. The practical nurse (PN) should administer the feeding slowly to prevent these
complications.
An 81-year-old resident in a long-term care facility begins to refuse food, particularly solids, and
repeatedly yells, "Leave me alone!" The client has lost a total of 6 pounds over the past month. What is
the best initial nursing intervention? - CORRECT ANSWER -Assess to identify changes in emotional or
physical status.
Rationale
, Emotional and physical changes may cause anorexia, a loss in appetite. The first step is to assess for any
changes in physical status that may have prompted the loss in appetite and refusal of solids food. Due to
the refusal of solids should prompt the practical nurse (PN) to examine the client's oral cavity for any
signs of ulcerations, possible yeast infection and check the fitting of the client's dentures if applicable. If
no physical signs or symptoms are present, then the PN needs to report the findings of the nurse, so the
client's emotional and psychological status can be further evaluated.
The practical nurse (PN) is providing care to a postoperative older client who has type 1 diabetes. Which
scenario should the PN recognize as a risk factor for the development of diabetic ketoacidosis? -
CORRECT ANSWER -Presence of infection.
Rationale
In an older client with type 1 diabetes, there is not enough insulin available to meet increased demands.
The practical nurse (PN) should monitor this client for signs and symptoms of postoperative infection,
which increases the body's metabolic rate and places the client at greater risk for diabetic ketoacidosis.
An 81-year-old resident in a long-term care facility begins to refuse food, particularly solids, and
repeatedly yells, "Leave me alone!" The client has lost a total of 6 pounds over the past month. What is
the best initial nursing intervention? - CORRECT ANSWER -Assess to identify changes in emotional or
physical status.
Rationale
Emotional and physical changes may cause anorexia, a loss in appetite. The first step is to assess for any
changes in physical status that may have prompted the loss in appetite and refusal of solids food. Due to
the refusal of solids should prompt the practical nurse (PN) to examine the client's oral cavity for any
signs of ulcerations, possible yeast infection and check the fitting of the client's dentures if applicable. If
no physical signs or symptoms are present, then the PN needs to report the findings of the nurse, so the
client's emotional and psychological status can be further evaluated.
The heathcare provider prescribed enteral feedings for an older client with severe sepsis and multi-
organ failure. What is the main purpose of this prescription? - CORRECT ANSWER -To reduce bacterial
systemic movement through intestinal wall and improve gastrointestinal perfusion.
