HESI Final - MedSurg (Red Book &Misc Evolve Resources)
A 25-year-old female patient with D
systemic lupus erythematosus (SLE) Rationale: The patient's statement about not going anywhere because o
who has a facial rash and alopecia tells hating the way he/she looks supports the diagnosis of social isolation
the nurse, "I never leave my house because of embarrassment about the effects of the SLE. Activity intolera
because I hate the way I look." An is a possible problem for patients with SLE, but the information about th
appropriate nursing diagnosis for the patient does not support this as a diagnosis. The rash with SLE is nonpru
patient is: There is not evidence of lack of social skills for this patient.
A.Activity intolerance related to
fatigue and inactivity.
B.Impaired social interaction related to
lack of social skills.
C.Impaired skin integrity related to
itching and skin sloughing.
D.Social isolation related to
embarrassment about the effects of
SLE.
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
A 46-year-old female client is A
admitted for acute renal failure Rationale:Creatinine is a product of muscle metabolism that is filtered by
secondary to diabetes and glomerulus, and blood levels of this substance are not affected by dieta
hypertension. Which test is the best fluid intake. An elevated creatinine strongly indicates nephron loss, redu
indicator of adequate glomerular filtration.
filtration?
A.Serum creatinine.
B.Blood Urea Nitrogen (BUN).
C.Sedimentation rate.
D.Urine specific gravity.
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
A 55-year-old male client has been C
admitted to the hospital with a medical Rationale:Smoking, considered to be a modifiable risk factor, is the mos
diagnosis of chronic obstructive significant risk factor for the development of COPD. The exact mechanis
pulmonary disease (COPD). Which risk genetic and hereditary implications for the development of COPD is stil
factor is the most significant in the under investigation, although exposure to similar predisposing factors (e
development of this client's COPD? smoking or inhaling secondhand smoke) may increase the likelihood of
A.The client's father was diagnosed COPD incidence among family members. Options B and D do not excee
with COPD in his 50s. the risks associated with cigarette smoking in the development of COPD
B.A close family member contracted
tuberculosis last year.
C.The client smokes one to two packs
of cigarettes per day.
D.The client has been 40 pounds
overweight for 15 years.
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
A 63-year-old client with type 2 A
diabetes mellitus is admitted for Rationale:Symptoms associated with decreased blood supply are weak
treatment of an ulcer on the heel of absent pedal and tibial pulses. The client with diabetes experiences vas
the left foot that has not healed with scarring as a result of atherosclerotic changes in the peripheral vessels.
wound care. The nurse observes that results in compromised perfusion to the dependent extremities, which
the entire left foot is darker in color further delays wound healing in the affected foot. Although flexion and
than the right foot. Which additional extension may be limited, depending on the degree of damage, this is n
symptom should the nurse expect to always the case. Options B and D are signs of adequate perfusion of the
find? foot, which would not be expected in this client.
A.Pedal pulses will be weak or absent
in the left foot.
B.The client will state that the left foot
is usually warm.
C.Flexion and extension of the left foot
will be limited.
D.Capillary refill of the client's left toes
will be brisk.
A 25-year-old female patient with D
systemic lupus erythematosus (SLE) Rationale: The patient's statement about not going anywhere because o
who has a facial rash and alopecia tells hating the way he/she looks supports the diagnosis of social isolation
the nurse, "I never leave my house because of embarrassment about the effects of the SLE. Activity intolera
because I hate the way I look." An is a possible problem for patients with SLE, but the information about th
appropriate nursing diagnosis for the patient does not support this as a diagnosis. The rash with SLE is nonpru
patient is: There is not evidence of lack of social skills for this patient.
A.Activity intolerance related to
fatigue and inactivity.
B.Impaired social interaction related to
lack of social skills.
C.Impaired skin integrity related to
itching and skin sloughing.
D.Social isolation related to
embarrassment about the effects of
SLE.
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
A 46-year-old female client is A
admitted for acute renal failure Rationale:Creatinine is a product of muscle metabolism that is filtered by
secondary to diabetes and glomerulus, and blood levels of this substance are not affected by dieta
hypertension. Which test is the best fluid intake. An elevated creatinine strongly indicates nephron loss, redu
indicator of adequate glomerular filtration.
filtration?
A.Serum creatinine.
B.Blood Urea Nitrogen (BUN).
C.Sedimentation rate.
D.Urine specific gravity.
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
A 55-year-old male client has been C
admitted to the hospital with a medical Rationale:Smoking, considered to be a modifiable risk factor, is the mos
diagnosis of chronic obstructive significant risk factor for the development of COPD. The exact mechanis
pulmonary disease (COPD). Which risk genetic and hereditary implications for the development of COPD is stil
factor is the most significant in the under investigation, although exposure to similar predisposing factors (e
development of this client's COPD? smoking or inhaling secondhand smoke) may increase the likelihood of
A.The client's father was diagnosed COPD incidence among family members. Options B and D do not excee
with COPD in his 50s. the risks associated with cigarette smoking in the development of COPD
B.A close family member contracted
tuberculosis last year.
C.The client smokes one to two packs
of cigarettes per day.
D.The client has been 40 pounds
overweight for 15 years.
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
A 63-year-old client with type 2 A
diabetes mellitus is admitted for Rationale:Symptoms associated with decreased blood supply are weak
treatment of an ulcer on the heel of absent pedal and tibial pulses. The client with diabetes experiences vas
the left foot that has not healed with scarring as a result of atherosclerotic changes in the peripheral vessels.
wound care. The nurse observes that results in compromised perfusion to the dependent extremities, which
the entire left foot is darker in color further delays wound healing in the affected foot. Although flexion and
than the right foot. Which additional extension may be limited, depending on the degree of damage, this is n
symptom should the nurse expect to always the case. Options B and D are signs of adequate perfusion of the
find? foot, which would not be expected in this client.
A.Pedal pulses will be weak or absent
in the left foot.
B.The client will state that the left foot
is usually warm.
C.Flexion and extension of the left foot
will be limited.
D.Capillary refill of the client's left toes
will be brisk.
