NR226 HESI Study – Nursing Leadership & Management Comprehensive Review Guide and
Practice Questions
4
Protecting the client from injury is the immediate priority during a seizure. Elevating the head of
the bed would have no effect on the client's condition or safety. Restraining the client's arms
and legs could cause injury. Placing a tongue blade or other object in the client's mouth could
damage the teeth. - correct answer ✔✔A client is having a tonic-clonic seizure. Which is a
priority nursing action?
1
Elevating the head of the bed
2
Restraining the client's arms and legs
3
Placing a tongue blade in the client's mouth
4
Taking measures to prevent injury
3
Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium,
potassium, and chloride. These changes will manifest as a change in mental status and
confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and
decreased bowel sounds because these can be prominent as general normal findings in the
elderly client. - correct answer ✔✔The nurse assesses an elderly client with a diagnosis of
dehydration and recognizes which finding as an early sign of dehydration?
1
Sunken eyes
2
Dry, flaky skin
,3
Change in mental status
4
Decreased bowel sounds
2,3,4,5
Anorexia causes nutritional problems; nutrition is a category on the Braden Scale. Hemiplegia
causes mobility problems; this affects the categories of mobility, activity, and friction on the
Braden Scale. Clients with a history of diabetes can also have peripheral neuropathy, causing
numbness or loss of sensation in the hands in feet; sensory perception is a category on the
Braden Scale. Urinary incontinence causes moisture, a category on the Braden Scale. Age is not
used in the Braden Scale. - correct answer ✔✔A nurse uses the Braden Scale to predict a client's
risk for developing pressure ulcers. Which data should the nurse use to determine a client's
score on this scale? Select all that apply.
1
Age
2
Anorexia
3
Hemiplegia
4
History of diabetes
5
Urinary incontinence
4
The more dependent the client was on the deceased for support, the more difficult the grieving
process will be. Emotional and financial considerations are major factors. The duration of the
couple's relationship and the age of the wife at the time of the man's death are not major
, influences on the mourning outcome. The health of the surviving spouse at the time of the
death may or may not be a major factor in the mourning outcome; the spouse may be healthy
and still be dependent on the partner. - correct answer ✔✔A hospice nurse is caring for a dying
client and his wife. What factor will be a major determinant in the mourning outcome for the
wife?
1
Duration of the relationship shared by the couple
2
Age of the wife at the time of the husband's death
3
Health of the surviving spouse at the time of the death
4
Importance of the deceased person as a source of support
1
Saline mouthwashes are soothing to the oral mucosa and help clean the mouth, minimizing
infection. Stomatitis refers to the oral cavity; karaya is used to protect the skin around a stoma
created on the abdomen. Stomatitis does not cause diarrhea or fluid loss. The abdomen is not
involved; stomatitis is an inflammation of the oral mucosa. - correct answer ✔✔A client is
experiencing stomatitis as a result of chemotherapy. Which action should the nurse take when
caring for this client?
1
Provide frequent saline mouthwashes
2
Use karaya powder to decrease irritation
3
Increase fluid intake to compensate for accompanying diarrhea
4
Offer meticulous skin care of the abdomen with a gentle antiseptic
Practice Questions
4
Protecting the client from injury is the immediate priority during a seizure. Elevating the head of
the bed would have no effect on the client's condition or safety. Restraining the client's arms
and legs could cause injury. Placing a tongue blade or other object in the client's mouth could
damage the teeth. - correct answer ✔✔A client is having a tonic-clonic seizure. Which is a
priority nursing action?
1
Elevating the head of the bed
2
Restraining the client's arms and legs
3
Placing a tongue blade in the client's mouth
4
Taking measures to prevent injury
3
Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium,
potassium, and chloride. These changes will manifest as a change in mental status and
confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and
decreased bowel sounds because these can be prominent as general normal findings in the
elderly client. - correct answer ✔✔The nurse assesses an elderly client with a diagnosis of
dehydration and recognizes which finding as an early sign of dehydration?
1
Sunken eyes
2
Dry, flaky skin
,3
Change in mental status
4
Decreased bowel sounds
2,3,4,5
Anorexia causes nutritional problems; nutrition is a category on the Braden Scale. Hemiplegia
causes mobility problems; this affects the categories of mobility, activity, and friction on the
Braden Scale. Clients with a history of diabetes can also have peripheral neuropathy, causing
numbness or loss of sensation in the hands in feet; sensory perception is a category on the
Braden Scale. Urinary incontinence causes moisture, a category on the Braden Scale. Age is not
used in the Braden Scale. - correct answer ✔✔A nurse uses the Braden Scale to predict a client's
risk for developing pressure ulcers. Which data should the nurse use to determine a client's
score on this scale? Select all that apply.
1
Age
2
Anorexia
3
Hemiplegia
4
History of diabetes
5
Urinary incontinence
4
The more dependent the client was on the deceased for support, the more difficult the grieving
process will be. Emotional and financial considerations are major factors. The duration of the
couple's relationship and the age of the wife at the time of the man's death are not major
, influences on the mourning outcome. The health of the surviving spouse at the time of the
death may or may not be a major factor in the mourning outcome; the spouse may be healthy
and still be dependent on the partner. - correct answer ✔✔A hospice nurse is caring for a dying
client and his wife. What factor will be a major determinant in the mourning outcome for the
wife?
1
Duration of the relationship shared by the couple
2
Age of the wife at the time of the husband's death
3
Health of the surviving spouse at the time of the death
4
Importance of the deceased person as a source of support
1
Saline mouthwashes are soothing to the oral mucosa and help clean the mouth, minimizing
infection. Stomatitis refers to the oral cavity; karaya is used to protect the skin around a stoma
created on the abdomen. Stomatitis does not cause diarrhea or fluid loss. The abdomen is not
involved; stomatitis is an inflammation of the oral mucosa. - correct answer ✔✔A client is
experiencing stomatitis as a result of chemotherapy. Which action should the nurse take when
caring for this client?
1
Provide frequent saline mouthwashes
2
Use karaya powder to decrease irritation
3
Increase fluid intake to compensate for accompanying diarrhea
4
Offer meticulous skin care of the abdomen with a gentle antiseptic
