HESI EXIT COMPREHENSIVE REVIEW B EXAM WITH RATIONALE

HESI EXIT COMPREHENSIVE REVIEW B EXAM WITH RATIONALE Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? A. States having difficulty with color perception B. Presents with opacity of the lens upon assessment C. Complains of seeing a cobweb-type structure in the visual field D. Reports the need to use a magnifying glass to see small print Rationale: Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment. Distorted color perception, opacity of the lens, and gradual vision loss are expected signs and symptom of cataracts but do not need immediate attention. 2. When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse to report to the primary health care provider? A. Ascending numbness from the feet to the knees B. Decrease in cognitive status of the client C. Blurred vision and sensation changes D. Persistent unilateral headache Rationale: A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist the client with mechanical ventilation. A primary health care provider will need to be contacted immediately. Options A, C, and D are findings associated with Guillain-Barré syndrome that should also be reported but are not as critical as the client's hypoxic status. 3. A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following? A. Fever, elevated white blood count, elevated platelets B. Fatigue, weight loss and anorexia, elevated red blood cells C. Hyperplasia of the gums, elevated white blood count, weakness D. Hypocellular bone marrow aspirate, fever, decreased hemoglobin level Rationale: Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia. Options A, B, and D state incorrect information for symptoms of leukemia. 4. The nurse enters the examination room of a client who has been told by her health care provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client? A. "I know many women who have survived ovarian cancer." B. "Let's talk about the treatments of ovarian cancer." C. "In my opinion I would suggest getting a second opinion." D. "Tell me about what you are feeling right now." Rationale: The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings. Giving false reassurance or personal suggestions are not therapeutic communication for the client