NEW 2023 HESI EXIT EXAM GRADED A+
A client is admitted to the intensive care unit with diabetes insipidus due to a
pituitary gland tumor. Which potential complication should the nurse monitor
closely?
A. Hypokalemia
B.Ketonuria.
C. Peripheral edema
D. Elevated blood pressure - answerA. Hypokalemia
Pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes
insipidus, which causes massive polyuria and serum electrolyte imbalances,
including hypokalemia, which can lead to lethal arrhythmias.
A 3-year-old boy was successfully toilet trained prior to his admission to the
hospital for injuries sustained from a fall. His parents are very concerned about
this regression in toileting. Which information should the nurse provide the
parents?
A. A retraining program will need to be initiated when the child returns home.
B. Diapering will be provided since hospitalization is stressful to preschoolers.
C. Children usually resume their toileting behaviors when they leave the hospital.
D. A potty chair will be brought from home so he can maintain his toileting skills. -
answerC.
Children usually resume their toileting behaviors when they leave the hospital.
The parents should be reassured that once the child is back in his familiar
environment, he is likely to resume using the toileting behaviors (C). Retraining (A)
is unlikely to be needed and such information might be distressing to the parents.
(B) does not address the parents' concern. Bringing a potty chair from home (B) is
likely to increase the child's stress because he is being encouraged to perform
toileting skills while he remains in unfamiliar surroundings.
The family of an older woman reports that they are no longer capable of caring for
her at home. While performing the admission assessment at a long-term care
facility, the nurse determines that the client is in continent of urine, has dry
mucous membranes, and has a large bruise on the coccyx. What interventions
should the nurse include in the plan of care? (Select all that apply.)
,A. Thicken liquids and provide pureed foods.
, B. Apply a barrier cream to perianal areas.
C. Report suspicion of elder abuse.
D. Implement toilet training program.
E. Offer beverages at frequent intervals. - answerB. Apply a barrier cream to
perianal areas.
D. Implement toilet training program.
E. Offer beverages at frequent intervals.
The plan of care should include measures to prevent skin breakdown due to
the incontinence using a barrier cream (B) and a toileting program (D) to help
reduce the incidence of incontinence. Dry mucous membranes indicate the
need for increased fluids (E). Further assessment is needed before the other
interventions are indicated.
Sleep apnea - obesity - answerObesity is a risk factor for OSAS, and calculation
of BMI provides data related to obesity. A BMI of 30.00 and above is considered
obese.
pyloric stenosis- preop - answerHydrating an infant prior to surgery with prescribed
IV fluids is the highest priority bc vomiting associated with pyloric stenosis often
contributes to dehydration.
diabetes insipidus - answerPituitary tumors that suppress ADH result in DI,
which can cause massive polyuria and serum electrolytes imbalances, including
hypokalemia which can lead to lethal arrythmias.
acute pancreatitis - care - answerThe pathophysiologic processes in AP result form
oral fluid and food ingestion that causes secretion of pancreatic enzymes, which
destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis
of the pancreas. The main focus of nursing care is reducing pain caused by
pancreatic destruction through interventions that decrease GI activity such as
keeping the pt NPO.
A client is admitted to the intensive care unit with diabetes insipidus due to a
pituitary gland tumor. Which potential complication should the nurse monitor
closely?
A. Hypokalemia
B.Ketonuria.
C. Peripheral edema
D. Elevated blood pressure - answerA. Hypokalemia
Pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes
insipidus, which causes massive polyuria and serum electrolyte imbalances,
including hypokalemia, which can lead to lethal arrhythmias.
A 3-year-old boy was successfully toilet trained prior to his admission to the
hospital for injuries sustained from a fall. His parents are very concerned about
this regression in toileting. Which information should the nurse provide the
parents?
A. A retraining program will need to be initiated when the child returns home.
B. Diapering will be provided since hospitalization is stressful to preschoolers.
C. Children usually resume their toileting behaviors when they leave the hospital.
D. A potty chair will be brought from home so he can maintain his toileting skills. -
answerC.
Children usually resume their toileting behaviors when they leave the hospital.
The parents should be reassured that once the child is back in his familiar
environment, he is likely to resume using the toileting behaviors (C). Retraining (A)
is unlikely to be needed and such information might be distressing to the parents.
(B) does not address the parents' concern. Bringing a potty chair from home (B) is
likely to increase the child's stress because he is being encouraged to perform
toileting skills while he remains in unfamiliar surroundings.
The family of an older woman reports that they are no longer capable of caring for
her at home. While performing the admission assessment at a long-term care
facility, the nurse determines that the client is in continent of urine, has dry
mucous membranes, and has a large bruise on the coccyx. What interventions
should the nurse include in the plan of care? (Select all that apply.)
,A. Thicken liquids and provide pureed foods.
, B. Apply a barrier cream to perianal areas.
C. Report suspicion of elder abuse.
D. Implement toilet training program.
E. Offer beverages at frequent intervals. - answerB. Apply a barrier cream to
perianal areas.
D. Implement toilet training program.
E. Offer beverages at frequent intervals.
The plan of care should include measures to prevent skin breakdown due to
the incontinence using a barrier cream (B) and a toileting program (D) to help
reduce the incidence of incontinence. Dry mucous membranes indicate the
need for increased fluids (E). Further assessment is needed before the other
interventions are indicated.
Sleep apnea - obesity - answerObesity is a risk factor for OSAS, and calculation
of BMI provides data related to obesity. A BMI of 30.00 and above is considered
obese.
pyloric stenosis- preop - answerHydrating an infant prior to surgery with prescribed
IV fluids is the highest priority bc vomiting associated with pyloric stenosis often
contributes to dehydration.
diabetes insipidus - answerPituitary tumors that suppress ADH result in DI,
which can cause massive polyuria and serum electrolytes imbalances, including
hypokalemia which can lead to lethal arrythmias.
acute pancreatitis - care - answerThe pathophysiologic processes in AP result form
oral fluid and food ingestion that causes secretion of pancreatic enzymes, which
destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis
of the pancreas. The main focus of nursing care is reducing pain caused by
pancreatic destruction through interventions that decrease GI activity such as
keeping the pt NPO.
