HESI Adult Health 4801
C. Inflammation is reduced by inhibiting prostaglandin A client with rheumatoid arthritis is prescribed piroxicam (Feldene), a nonsteroidal
synthesis. anti-inflammatory drug (NSAID). Which effect is characteristic of (NSAIDs) used
for treating rheumatoid arthritis?
Rationale A. Production of replacement cartilage is stimulated.
Nonsteroidal anti-inflammatory drugs (NSAIDs), used for B. Further destruction of the articular cartilage is prevented.
treating rheumatoid arthritis, by inhibiting the synthesis of C. Inflammation is reduced by inhibiting prostaglandin synthesis.
prostaglandins and providing relief from the associated D. Bradykinin is inhibited, thereby reducing acute and chronic
pain. pain.
A. Acute pain related to movement of the stone. When planning care for a client with right renal calculi, which nursing diagnosis
has the highest priority?
Rationale A. Acute pain related to movement of the stone.
The nursing diagnosis of the highest priority is "Acute pain B. Impaired urinary elimination related to obstructed flow of
urine. related the renal calculi's movement". C. Risk for infection related to urinary stasis.
D. Deficient knowledge related to need for prevention of recurrence of calculi.
C. Teach measures to avoid the Valsalva maneuver The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which
nursing action should be included in the plan of care?
Rationale A. Perform active range of motion three times
daily The Valsalva maneuver, straining with bowel movements B. Monitor for Battle's sign every
four hours
while holding one's breath, increases intracerebral C. Teach measures to avoid the Valsalva
maneuver pressure (ICP) which may induce bleeding or rupture of D. Maintain the head of bed in a
flat position cerebral blood vessels.
,C. Metastatic cancer. Which preexisting diagnosis places a client at greatest risk of developing
superior vena cava syndrome?
Rationale A. Carotid stenosis.
Superior vena cava syndrome occurs when the superior B. Steatosis hepatitis.
vena cava (SVC) is compressed by outside structures, C. Metastatic
cancer. such as a growing tumor that impedes the return blood D.
Clavicular fracture. flow to the heart. Superior vena cava syndrome is likely to
occur with metastatic cancer from a primary tumor in the
upper lobe of the right lung that compresses the superior
vena cava.
A. Wheezing becomes louder. What assessment finding should the nurse identify that indicates a client with
an acute asthma exacerbation is beginning to improve after treatment?
Rationale A. Wheezing becomes louder.
In an acute asthma attack, air flow may be so significantly B. Cough remains
unproductive. restricted that breath sounds and wheezing is diminished. C.
Vesicular breath sounds decrease.
If the client is successfully responding to bronchodilators D. Bronchodilators stimulate
coughing. and respiratory treatments, wheezing should become
louder as the air flow increases in the airways. As the
airways open and mucous is mobilized in response to
treatment, the cough should become more productive.
Vesicular breath sounds are soft, low-pitched sounds
heard throughout th
B. Report inflammation of the incision site or the affected The nurse is providing postoperative instructions for a female client
after a arm. mastectomy. Which information should the nurse include in the teaching
plan?
D. Avoid lifting more than 4.5 kg (10 lb) or reaching above (Select all that
apply.) her head. Select all that
apply
A. Empty surgical drains once a week using procedure gloves.
Rationale B. Report inflammation of the incision site or the affected arm.
Part of a client's s/p (status post) mastectomy teaching C. Wear clothing with snug sleeves over the arm on the operative
side. plan should include reporting evidence of inflammation D. Avoid lifting more than 4.5 kg (10 lb) or reaching above her
head.
at the incision site or the affected arm, and to avoid lifting
or reaching above their head.
D. A 29-year-old woman whose uterus ruptured after Which client is at highest risk for compromised psychological adjustment after
a giving birth to her first child. hysterectomy?
A. A 46-year-old woman with three children and a recent promotion at work.
Rationale B. A 55-year-old woman with abnormal bleeding and pain for 3 years.
The client who is a primipara and is still in her childbearingC. A 62-year-old widow who has three friends who had uncomplicated
years and is at highest risk for unresolved conflicts about hysterectomies.
the end of her childbearing opportunities. D. A 29-year-old woman whose uterus ruptured after giving birth to her first child.
, B.Keeping the head of the bed elevated 30 degrees. When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube,
C. Changing the enteral-feeding bag every 24 hours. what protocols should the nurse implement for intermittent feedings? (Select all
D.Checking the placement of the tube by means of that apply.)
gastric aspiration. Select all that apply
E.Flushing the tube with 50 ml of normal saline solution A. Assessing residual amounts once a day.
after each feeding. B. Keeping the head of the bed elevated 30 degrees.
C. Changing the enteral-feeding bag every 24 hours.
Rationale D. Checking the placement of the tube by means of gastric aspiration.
Keeping the head of the bed elevated 30 degrees, E. Flushing the tube with 50 ml of normal saline solution after each
feeding. changing the enteral-feeding bag every 24 hours,
checking the placement of the tube by means of gastric
aspiration, and flushing the tube with 50 ml of normal
saline solution after each fe
D. Pathologic fracture of two ribs on the right chest. The nurse obtains a client's history that includes right mastectomy and radiation
therapy for cancer of the breast 10 years ago. Which current health problem
Rationale should the nurse consider is a consequence of the radiation
therapy? The ribs lie in the radiation pathway and lose density over A. Asthma.
time, becoming thin and brittle, so the occurrence of two B. Myocardial infarction.
right-sided ribs with pathological fractures resulting C. Chronic esophagitis with gastroesophageal
reflux. without evidence of trauma is related to radiationD. Pathologic fracture of two ribs on the right
chest. damage.
A. Use an end-tidal CO2 detector. Which intervention should the nurse implement that best confirms placement of
an endotracheal tube (ETT)?
Rationale A. Use an end-tidal CO2 detector.
The end-tidal carbon dioxide detector indicates the B. Auscultate for bilateral breath
sounds. presence of CO2 tidal by a color change or a number C. Obtain pulse oximeter
reading. indicated on the detector, which is supporting evidence D. Check symmetrical
chest movement. that the ETT is in the trachea, not the esophagus.
B. Serosanguineous nasal drainage. A client is admitted to the hospital with a traumatic brain injury after his head
violently struck a brick wall during a gang fight. Which finding is most important for
Rationale the nurse to assess further?
Any nasal discharge following a head injury should be A. A scalp laceration oozing blood.
evaluated to determine the presence of cerebral spinal B. Serosanguineous nasal drainage.
fluid which would indicate a tear in the dura making theC. Headache rated "10" on a 0-10 scale.
client susceptible to meningitis. D. Dizziness, nausea and transient confusion.
C. "I know I will miss having sexual intercourse with my A 48-year-old client with endometrial cancer is being discharged after a total
husband." hysterectomy and bilateral salpingo-oophorectomy. Which client
statement
indicates that further teaching is needed?
Rationale A. "Well, I don't have to worry about getting pregnant anymore."
Further teaching is needed in response to the client's B. "I can't wait to go on the cruise that I have planned for this summer."
misunderstanding of not being able to have sexual C. "I know I will miss having sexual intercourse with my husband."
intercourse after a hysterectomy, needs to be addressed. D. "I have asked my daughter to stay with me next week after I am discharged."
C. Inflammation is reduced by inhibiting prostaglandin A client with rheumatoid arthritis is prescribed piroxicam (Feldene), a nonsteroidal
synthesis. anti-inflammatory drug (NSAID). Which effect is characteristic of (NSAIDs) used
for treating rheumatoid arthritis?
Rationale A. Production of replacement cartilage is stimulated.
Nonsteroidal anti-inflammatory drugs (NSAIDs), used for B. Further destruction of the articular cartilage is prevented.
treating rheumatoid arthritis, by inhibiting the synthesis of C. Inflammation is reduced by inhibiting prostaglandin synthesis.
prostaglandins and providing relief from the associated D. Bradykinin is inhibited, thereby reducing acute and chronic
pain. pain.
A. Acute pain related to movement of the stone. When planning care for a client with right renal calculi, which nursing diagnosis
has the highest priority?
Rationale A. Acute pain related to movement of the stone.
The nursing diagnosis of the highest priority is "Acute pain B. Impaired urinary elimination related to obstructed flow of
urine. related the renal calculi's movement". C. Risk for infection related to urinary stasis.
D. Deficient knowledge related to need for prevention of recurrence of calculi.
C. Teach measures to avoid the Valsalva maneuver The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which
nursing action should be included in the plan of care?
Rationale A. Perform active range of motion three times
daily The Valsalva maneuver, straining with bowel movements B. Monitor for Battle's sign every
four hours
while holding one's breath, increases intracerebral C. Teach measures to avoid the Valsalva
maneuver pressure (ICP) which may induce bleeding or rupture of D. Maintain the head of bed in a
flat position cerebral blood vessels.
,C. Metastatic cancer. Which preexisting diagnosis places a client at greatest risk of developing
superior vena cava syndrome?
Rationale A. Carotid stenosis.
Superior vena cava syndrome occurs when the superior B. Steatosis hepatitis.
vena cava (SVC) is compressed by outside structures, C. Metastatic
cancer. such as a growing tumor that impedes the return blood D.
Clavicular fracture. flow to the heart. Superior vena cava syndrome is likely to
occur with metastatic cancer from a primary tumor in the
upper lobe of the right lung that compresses the superior
vena cava.
A. Wheezing becomes louder. What assessment finding should the nurse identify that indicates a client with
an acute asthma exacerbation is beginning to improve after treatment?
Rationale A. Wheezing becomes louder.
In an acute asthma attack, air flow may be so significantly B. Cough remains
unproductive. restricted that breath sounds and wheezing is diminished. C.
Vesicular breath sounds decrease.
If the client is successfully responding to bronchodilators D. Bronchodilators stimulate
coughing. and respiratory treatments, wheezing should become
louder as the air flow increases in the airways. As the
airways open and mucous is mobilized in response to
treatment, the cough should become more productive.
Vesicular breath sounds are soft, low-pitched sounds
heard throughout th
B. Report inflammation of the incision site or the affected The nurse is providing postoperative instructions for a female client
after a arm. mastectomy. Which information should the nurse include in the teaching
plan?
D. Avoid lifting more than 4.5 kg (10 lb) or reaching above (Select all that
apply.) her head. Select all that
apply
A. Empty surgical drains once a week using procedure gloves.
Rationale B. Report inflammation of the incision site or the affected arm.
Part of a client's s/p (status post) mastectomy teaching C. Wear clothing with snug sleeves over the arm on the operative
side. plan should include reporting evidence of inflammation D. Avoid lifting more than 4.5 kg (10 lb) or reaching above her
head.
at the incision site or the affected arm, and to avoid lifting
or reaching above their head.
D. A 29-year-old woman whose uterus ruptured after Which client is at highest risk for compromised psychological adjustment after
a giving birth to her first child. hysterectomy?
A. A 46-year-old woman with three children and a recent promotion at work.
Rationale B. A 55-year-old woman with abnormal bleeding and pain for 3 years.
The client who is a primipara and is still in her childbearingC. A 62-year-old widow who has three friends who had uncomplicated
years and is at highest risk for unresolved conflicts about hysterectomies.
the end of her childbearing opportunities. D. A 29-year-old woman whose uterus ruptured after giving birth to her first child.
, B.Keeping the head of the bed elevated 30 degrees. When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube,
C. Changing the enteral-feeding bag every 24 hours. what protocols should the nurse implement for intermittent feedings? (Select all
D.Checking the placement of the tube by means of that apply.)
gastric aspiration. Select all that apply
E.Flushing the tube with 50 ml of normal saline solution A. Assessing residual amounts once a day.
after each feeding. B. Keeping the head of the bed elevated 30 degrees.
C. Changing the enteral-feeding bag every 24 hours.
Rationale D. Checking the placement of the tube by means of gastric aspiration.
Keeping the head of the bed elevated 30 degrees, E. Flushing the tube with 50 ml of normal saline solution after each
feeding. changing the enteral-feeding bag every 24 hours,
checking the placement of the tube by means of gastric
aspiration, and flushing the tube with 50 ml of normal
saline solution after each fe
D. Pathologic fracture of two ribs on the right chest. The nurse obtains a client's history that includes right mastectomy and radiation
therapy for cancer of the breast 10 years ago. Which current health problem
Rationale should the nurse consider is a consequence of the radiation
therapy? The ribs lie in the radiation pathway and lose density over A. Asthma.
time, becoming thin and brittle, so the occurrence of two B. Myocardial infarction.
right-sided ribs with pathological fractures resulting C. Chronic esophagitis with gastroesophageal
reflux. without evidence of trauma is related to radiationD. Pathologic fracture of two ribs on the right
chest. damage.
A. Use an end-tidal CO2 detector. Which intervention should the nurse implement that best confirms placement of
an endotracheal tube (ETT)?
Rationale A. Use an end-tidal CO2 detector.
The end-tidal carbon dioxide detector indicates the B. Auscultate for bilateral breath
sounds. presence of CO2 tidal by a color change or a number C. Obtain pulse oximeter
reading. indicated on the detector, which is supporting evidence D. Check symmetrical
chest movement. that the ETT is in the trachea, not the esophagus.
B. Serosanguineous nasal drainage. A client is admitted to the hospital with a traumatic brain injury after his head
violently struck a brick wall during a gang fight. Which finding is most important for
Rationale the nurse to assess further?
Any nasal discharge following a head injury should be A. A scalp laceration oozing blood.
evaluated to determine the presence of cerebral spinal B. Serosanguineous nasal drainage.
fluid which would indicate a tear in the dura making theC. Headache rated "10" on a 0-10 scale.
client susceptible to meningitis. D. Dizziness, nausea and transient confusion.
C. "I know I will miss having sexual intercourse with my A 48-year-old client with endometrial cancer is being discharged after a total
husband." hysterectomy and bilateral salpingo-oophorectomy. Which client
statement
indicates that further teaching is needed?
Rationale A. "Well, I don't have to worry about getting pregnant anymore."
Further teaching is needed in response to the client's B. "I can't wait to go on the cruise that I have planned for this summer."
misunderstanding of not being able to have sexual C. "I know I will miss having sexual intercourse with my husband."
intercourse after a hysterectomy, needs to be addressed. D. "I have asked my daughter to stay with me next week after I am discharged."
