FUNDAMENTAL PN HESI SPECIALTY V1
1. A nurse is preparing to assess a patient for orthostatic hypotension.
Which piece of equipment will the nurse obtain to assess for this condition?
a. Thermometer
b. Elastic stockings
c. Blood pressure cuff
d. Sequential compression devices
ANS: C
A blood pressure cuff is needed. Orthostatic hypotension is a drop of blood
pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic
pressure and symptoms of dizziness, light-headedness, nausea, tachycardia,
pallor, or fainting when the patient changes from the supine to standing
position. A thermometer is used to assess for fever. Elastic stockings and
sequential compression devices are used to prevent thrombus.
2. The patient has been in bed for several days and needs to be
ambulated. Which action will the nurse take first?
a. Maintain a narrow base of support.
b. Dangle the patient at the bedside.
c. Encourage isometric exercises.
d. Suggest a high-calcium diet.
ANS: B
To prevent injury, nurses implement interventions that reduce or eliminate the
effects of orthostatic hypotension. Mobilize the patient as soon as the physical
condition allows, even if this only involves dangling at the bedside or moving to
a chair. A wide base of support increases balance. Isometric exercises (i.e.,
activities that involve muscle tension without muscle shortening) have no
beneficial effect on preventing orthostatic hypotension, but they improve
activity tolerance. A high-calcium diet can help with osteoporosis but can be
detrimental in an immobile patient.
3. A nurse reviews an immobilized patient’s laboratory results and
discovers hypercalcemia. Which condition will the nurse monitor for most 1
closely in this patient?
a. Hypostatic pneumonia
, b. Renal calculi
c. Pressure ulcers
d. Thrombus formation
ANS: B
Renal calculi are calcium stones that lodge in the renal pelvis or pass through the
ureters. Immobilized patients are at risk for calculi because they frequently have
hypercalcemia. Hypercalcemia does not lead to hypostatic pneumonia, pressure
ulcers, or thrombus formation. Immobility is one cause of hypostatic pneumonia,
which is inflammation of the lung from stasis or pooling of secretions. A pressure
ulcer is an impairment of the skin that results from prolonged ischemia
(decreased blood supply) within tissues. A thrombus is an accumulation of
platelets, fibrin, clotting factors, and cellular elements of the blood attached to
the interior wall of a vein or artery, which sometimes occludes the lumen of the
vessel.
4. A nurse is caring for an immobile patient. Which metabolic
alteration will the nurse monitor for in this patient?
a. Increased appetite
b. Increased diarrhea
c. Increased metabolic rate
d. Altered nutrient metabolism
ANS: D
Immobility disrupts normal metabolic functioning: decreasing the metabolic
rate, altering the metabolism of carbohydrates, fats, and proteins; causing fluid,
electrolyte, and calcium imbalances; and causing gastrointestinal disturbances
such as decreased appetite and slowing of peristalsis, leading to constipation.
5. A nurse is preparing a care plan for a patient who is immobile. Which
psychosocial aspect will the nurse consider?
a. Loss of bone mass
b. Loss of strength
c. Loss of weight
d. Loss of hope
ANS: D 2
Loss of hope is a psychosocial aspect. Patients with restricted mobility may have
some depression. Depression is an affective disorder characterized by
1. A nurse is preparing to assess a patient for orthostatic hypotension.
Which piece of equipment will the nurse obtain to assess for this condition?
a. Thermometer
b. Elastic stockings
c. Blood pressure cuff
d. Sequential compression devices
ANS: C
A blood pressure cuff is needed. Orthostatic hypotension is a drop of blood
pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic
pressure and symptoms of dizziness, light-headedness, nausea, tachycardia,
pallor, or fainting when the patient changes from the supine to standing
position. A thermometer is used to assess for fever. Elastic stockings and
sequential compression devices are used to prevent thrombus.
2. The patient has been in bed for several days and needs to be
ambulated. Which action will the nurse take first?
a. Maintain a narrow base of support.
b. Dangle the patient at the bedside.
c. Encourage isometric exercises.
d. Suggest a high-calcium diet.
ANS: B
To prevent injury, nurses implement interventions that reduce or eliminate the
effects of orthostatic hypotension. Mobilize the patient as soon as the physical
condition allows, even if this only involves dangling at the bedside or moving to
a chair. A wide base of support increases balance. Isometric exercises (i.e.,
activities that involve muscle tension without muscle shortening) have no
beneficial effect on preventing orthostatic hypotension, but they improve
activity tolerance. A high-calcium diet can help with osteoporosis but can be
detrimental in an immobile patient.
3. A nurse reviews an immobilized patient’s laboratory results and
discovers hypercalcemia. Which condition will the nurse monitor for most 1
closely in this patient?
a. Hypostatic pneumonia
, b. Renal calculi
c. Pressure ulcers
d. Thrombus formation
ANS: B
Renal calculi are calcium stones that lodge in the renal pelvis or pass through the
ureters. Immobilized patients are at risk for calculi because they frequently have
hypercalcemia. Hypercalcemia does not lead to hypostatic pneumonia, pressure
ulcers, or thrombus formation. Immobility is one cause of hypostatic pneumonia,
which is inflammation of the lung from stasis or pooling of secretions. A pressure
ulcer is an impairment of the skin that results from prolonged ischemia
(decreased blood supply) within tissues. A thrombus is an accumulation of
platelets, fibrin, clotting factors, and cellular elements of the blood attached to
the interior wall of a vein or artery, which sometimes occludes the lumen of the
vessel.
4. A nurse is caring for an immobile patient. Which metabolic
alteration will the nurse monitor for in this patient?
a. Increased appetite
b. Increased diarrhea
c. Increased metabolic rate
d. Altered nutrient metabolism
ANS: D
Immobility disrupts normal metabolic functioning: decreasing the metabolic
rate, altering the metabolism of carbohydrates, fats, and proteins; causing fluid,
electrolyte, and calcium imbalances; and causing gastrointestinal disturbances
such as decreased appetite and slowing of peristalsis, leading to constipation.
5. A nurse is preparing a care plan for a patient who is immobile. Which
psychosocial aspect will the nurse consider?
a. Loss of bone mass
b. Loss of strength
c. Loss of weight
d. Loss of hope
ANS: D 2
Loss of hope is a psychosocial aspect. Patients with restricted mobility may have
some depression. Depression is an affective disorder characterized by
