HESI MED SURG Form A & B | Questions With Answers | LATEST 2023/2024 | Graded A+

A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help? Assess staf f members' hand hygiene practices  This is the best possible answer- Power Point (PP) Slide 7 Igi-Pg 418. The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection? Intact skin and mucous membrane  Power Point Slide 5 Igi-p 415 Which type of transmission-based precautions must the nurse use to prevent the transmission of tuberculosis? Airborne Precautions pg 419 A nurse is assessing patients on a medical-surgical unit. Which adult patient does the nurse identify as being at greatest risk for insensible water loss? A patient who is febrile with diaphoresis A nurse is assessing a patient with hypokalemia and notes that the patient’s hand-grip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take FIRST? Assess the patient's respiratory rate, rhythm, and depth  Fluid and Electrolyte table page 2 Which patient is at risk for hypokalemia? Patient with pancreatitis who has continuous nasogastric suction  Fluid and Electrolyte Table pg 2 1. What is the minimum amount of urine per day needed to excrete toxic products? 400 to 600 mL  Slide 6 pg 165 A patient with heart failure asks, ―Why do I need to weigh myself every day?‖ How would the nurse respond? ―Weight is the best indication that you are gaining or losing fluid." pg. 168 The patient who has undergone which surgical procedure is most at risk for hypocalcemia? Parathyroidectomy A nurse is caring for a patient who is experiencing excessive diarrhea. The patient’s arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg and HCO3 16 mEq/L. Which provider order does the nurse expect to receive? Sodium Bicarbonate 100 mEq diluted in 1 Liter of D5W Power Point Slide 11 in notes Igi page 195 The nurse is caring for a patient who is hyperventilating. The patient’s arterial blood gas values are pH 7.52, PaO2 94mmHg, PaCO2 31 mmHg and HCO3 26mEq. Which question would the nurse ask when developing this patient’s plan of care? You appear anxious. What is causing your distress?  Open end question Asking for clarication A patient who has Clostridioides difficile with severe diarrhea will likely have related alteration in which acid base balance? Metabolic Acidosis  Slide 11 p 192 Which nursing assessment nding indicates a worsening of respiratory acidosis? Respiratory Depression pg. 192 A patient has taken antacids for the past 3 weeks to relieve heart burn. What alteration in the acid base balance with the nurse likely nd? Metabolic Alkalosis pg. 196 The person is with respiratory acidosis is considered full compensated with which ABG? pH 7.35 PaCO2 is 75 and the HCO3 is 30  Slide 16 pg 190 An emergency department nurse obtains the health history of a patient. Which statement by the patient would alert the nurse to the occurrence of heart failure? I get short of breath when I climb stairs The nurse evaluates prescriptions for a patient with chronic heart failure. Which class of medications would the nurse expect to nd on the patient’s medication administration record to decrease cardiac workload? Ace Inhibitors Slides 17 and 23. JCHAO Core Measure A nurse prepares to discharge a patient with chronic heart failure home who is prescribed home healthcare services. Which priority information would be communicated to the home health nurse upon discharge? Medication reconciliation  Slides 23 24 and Igi table 35-4 A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left- sided heart failure? I wake up at night short of breath.  Slide 12 and 14 Igi p. 695 A nurse assesses a patient admitted to the cardiac unit. Which statement by the patient alerts the nurse to the possibility of right-sided heart failure? My shoes t tight lately  Slide 15 and Igi p696 A nurse admits a patient who is experiencing an exacerbation of heart failure. What action would the nurse take rst? Assess the patient’s respiratory status  Slides 13 and 14 Igi pg 695 The nurse performing a physical assessment on a patient with known cardiovascular disease observes ascites and +3 pitting edema to lower extremities. The patient reports loss of appetite and nausea. How does the nurse interpret these ndings? Right Side Heart Failure A patient has been diagnosed with hypertension but does not take the prescribed antihypertensive medication because of the patient’s lack of symptoms. What is the best response by the nurse? Most people with hypertension do not have symptoms  Slides 13 and 14 pg 722 A student nurse asks what essential hypertension is. What response by the registered nurse is best? It is hypertension with no specific cause  Slide 6 and Igi p. 721 Upon assessment the nurse identies the following: stasis dermatitis along ankles extending onto calves with +1 edema bilaterally. What condition is does the patient likely have? Venous Insufficiency  Slide 34 pg 747 What statement by a middle age male patient shows an understanding of self-care with essential hypertension? ― I better limit my sweets and salts.‖ A patient with peripheral arterial disease comes into the oce for a follow up appointment. What tells you additional teaching is needed? Patient is seated with legs crossed and reading a book on healthy eating What is the normal measurement of the PR interval in an ECG? .12 to. 20 second  Jones pg. 22 What is the fourth step in analyzing an ECG rhythm strip ? Measure the PR interval  slide 23 Jones 26 What ECG rhythm is characterized by a saw-tooth waves instead of P-waves? Atrial Flutter  Slide 43 Jones 42 When looking at ECG monitor paper. What does the horizontal axis represent? Time  Slide 12 Jones pg 21 The nurse has just given a patient with a history of chronic angina his third dose of sublingual nitroglycerin. What statement warrants the nurse to notify the provider? My pain is a bit better, but it feels different than usual  Chart 38-2 pg 773 #1. The home health nurse has been caring for a patient with a chronic respiratory disorder. Today the patient seems confused when she is normally alert and oriented to time, place and person. What is the FIRST nursing action? . Check oxygen saturation with a pulse oximeter #2. The nurse has just taken report on a patient with COPD, who is experiencing severe dyspnea. The following have just resulted: ABG's =pH 7.32 PaCO2=62 PaO2=46 HCO3= 28. The patient has the following vital signs: T 99.8F, P 110, R 28 BP 150/80. What should the nurse do FIRST? Do a focused pulmonary assessment and titrate oxygen therapy #3. The nurse is instructing a patient regarding complications of COPD. Which statement by the patient indicates the need for additional teaching? "My COPD is a serious illness, but it will be cured if I quit smoking." #4. A patient has been diagnosed with tuberculosis. What action by the discharge nurse takes HIGHEST priority? . Educating the patient on the adherence to the treatment regimen. #5. A nurse is teaching a patient how to perform pursed lip breathing. Which instructions would the nurse include in this teaching? Close your mouth and breathe in through your nose #6. Which statement is true about the relationship between smoking cessation and the pathophysiology of COPD? . c. Smoking cessation slows the rate of disease progression of COPD #7. A patient with chronic asthma ask the nurse, "I am really enjoying going for walks, but I always have an asthma attack with exercise. Do you have any ideas?" Encourage the patient to use his short acting bronchodilator 30 minutes before he goes for walks #8 A family member of a patient with COPD asks the nurse, "What is the purpose of making him cough on a routine basis?" What' is the nurse's best response? "It improves air exchange by increasing airow in the large airways. #9 . A patient is 12 hour post op from a left lower lobectomy. The patient asks; " Why do I have 2 chest tubes?" What is the BEST answer by the nurse? The upper chest tube is removing air from the pleural cavity and the lower chest tube is removing the bloody drainage." #10. The nurse is caring for a patient who is 12 hours post tracheostomy. While assessing the patient, which observation made by the nurse warrants immediate notication of the provider? Skin is puffy around the neck with a crackling sensation upon palpation #11. The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient? d. The patient is encouraged to cough and do deep-breathing exercises often and use incentive spirometry . #12. A patient has COPD with chronic diculty breathing. In planning this patient's care, what dietary requirements are needed for this patient? Patients with COPD have increased metabolic needs so encourage high calorie and high protein foods. #13. The nurse has just received an elderly patient from the recovery room who is drowsy but is capable of following instructions. Pulse oximetry has dropped from 95% to 90% on room air. What is the PRIORITY nursing intervention? . Have the patient use the incentive spirometer to help with pulmonary hygiene #14. The nurse is developing a teaching plan for a patient with COPD using the priority patient problem of insucient knowledge related to energy conservation. What does the nurse recommend the patient AVOID? . Eating three large meals per day #15. The nurse has completed a community presentation about Lung Cancer. Which statement from a participant demonstrates an understanding of the information presented? The primary prevention for reducing the risk of lung cancer is to stop smoking and avoid secondhand smoke #16. A patient with a tracheostomy is unable to speak. He is not in acute distress but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach in this situation? Ask questions that can be answered with a "yes" or "no" response #17. The discharge nurse is planning treatment for a patient with a relapse of tuberculosis. Which action will be most effective in ensuring that the patient completes treatment? . Enroll the patient in direct observation therapy #18. A patient who smokes is being discharged home on oxygen therapy. The patient tells the nurse, "I can't wait to get to the car and get a cigarette." What is the nurse's best response? "Let's discuss why smoking around oxygen is dangerous #19. A patient with chronic bronchitis ask the nurse, "What can I do to get these secretions up?" Drink at least 2 liters a day #20. A patient with chronic bronchitis is showing signs of hypoxia. Which clinical manifestation is the priority to look out for in this patient? Large amounts of thick mucus #21. The clinic nurse has taught a patient with COPD about seasonal inuenza prevention. Which statement indicates the need for further teaching? " I need to start antibiotics as soon as I have the first symptoms of the flu. #22. A hospitalized patient with active tuberculosis needs to go for a chest x-ray. The transport has arrived and states, "This patient is on isolation. I cannot take this patient to radiology?" What is the nurse's best response? "I will get the patient a surgical mask before you take him #23. When treating a patient with hypoxia, the amount of oxygen administered is based on which factors? SELECT ALL THAT APPLY Pulse oximetry reading, arterial blood gas results #24. During an assessment of an elderly patient who is in the initial postoperative period, The nurse hears ne crackles and diminished lung sounds bilaterally in the bases. Which nursing intervention helps relieve this respiratory problem? d. Encourage coughing and deep breathing During an assessment of an elderly patient who is in the initial postoperative period, The nurse hears ne crackles and diminished lung sounds bilaterally in the bases. Which nursing intervention helps relieve this respiratory problem? d. Encourage coughing and deep breathing A patient with a history of COPD was admitted 24 hours ago with hypoxia related to exacerbation of left sided heart failure. The patient has had 4000mL of urine output in the past 24 hours and lungs are clear with oxygen at 50% per Venturi Mask. The patient is currently sitting up and watching TV. Vital signs are T 98F, P 88, R 20 and BP 120/70 with an oxygen saturation of 95%. Based on the nurse's knowledge of Oxygen Therapy, what nursing intervention should be a PRIORITY . Obtain an order to titrate oxygen therapy to an oxygen saturation between 88% and 92% A patient demonstrates labored, shallow, respirations and a respiratory rate of 32 per min with a pulse oximetry reading of 85%. What is the FIRST PRIORITY nursing action? c. Start oxygen via nasal cannula at 2L/min The nurse is caring for a patient with a history of COPD who is currently on a Venturi Mask at 40%. Lungs are diminished in the bases, but otherwise clear. The patient's current ABG's are pH 7.35 pCO2 55 pHCO3 of 30 and a pO2 95. Vital signs are T 98F, P 68, R 18 and O2 Sat of 97%. The patient is lethargic and states " I am so sleepy this morning." What nursing action should the nurse due FIRST? Obtain an order to titrate down the venturi mask to maintain an oxygen saturation greater than 92% A patient with active tuberculosis states, "I do not want to go home and give this disease to my wife and children? "I understand your concern, your family has already been exposed to tuberculosis and should be tested." The nurse is taking a patient history on a new patient to a clinic. The patient reports waking up feeling tired, even after 8 good hours of sleep. What action would the nurse take rst? Ask the patient if she has ever been evaluated for sleep apnea The nurse has determined that a patient with COPD has a priority problem of impaired oxygenation related to reduced airway size, muscle fatigue and excessive mucus production. Which action is best to delegate to the unlicensed assistive personnel (CNA)? . Report a respiratory rate greater than 26 / min A 22 year old patient with blunt force trauma to the chest was admitted from the emergency department with oxygen at 5 L/min per nasal cannula. The patient is resting comfortably in bed. Vital Signs are stable. Oxygen Saturation is 94%. Lung sounds are clear. Based on the nurse's knowledge of oxygen therapy. What nursing action should be a priority? Humidify oxygen to prevent drying of mucous membranes A patient is receiving oxygen therapy through a nonrebreather mask. What is the correct nursing intervention? Ensure that valves and rubber flaps are patent, functional and not stuck. After walking back from the bathroom, a patient with COPD has a pulse oximetry reading of 89%. What is the nurse's FIRST priority actio Assess the patient for respiratory distress and recheck the pulse oximeter reading in 15 minutes A nurse is caring for a patient who is day 2 post-op from a left total knee replacement. The patient's admission history documents the patient is a 2 pack a day cigarette smoker x 20 years. Which statement by the patient requires further investigation? c. "I am coughing up some nasty rust colored, thick, milky stuff." A nurse is caring for a patient with pulmonary emphysema. The patient states, " I really don't go out with my friends and family anymore." How should the nurse respond? . "What is causing you to limit your social activities? The nurse is caring for a patient with chronic bronchitis and notes the following clinical ndings: Dependent Edema, Distended Neck Veins, Increasing Dyspnea and Increased Fatigue. What condition is the patient exhibiting? . Cor Pulmonale What principle guides the nurse when providing oxygen therapy for a patient with COPD? The patient with COPD should receive oxygen therapy at rates to reduce hypoxia and bring the SpO2 level to between 88% and 92%. The nurse is caring for an adult patient with a chronic respiratory disorder. What is BEST information about vaccine? . It is important to get a pneumonia vaccine; and get a yearly seasonal inuenza vaccine A nurse is caring for a patient who has been using oxygen therapy for the past 5 days in the hospital. What assessment nding indicates that outcomes for patient safety with oxygen therapy are being met? Intact skin behind the ears The nurse is caring for an older adult who uses a wheelchair and spends over half of the day in bed. Which interventions is important in promoting pulmonary hygiene related to age and decreased mobility? Assist the patient with turning, coughing and deep breathing every 2 hours. A patient is being readmitted for worsening pulmonary emphysema. The patient is noncompliant with medication regimen and continues to smoke. What action does the nurse perform FIRST? . Assess the patient's respiratory status When caring for a patient with chronic bronchitis, which of these nursing interventions will NOT help the patient mobilize secretions? b. Limit fluid intake to less than 2 liters a day A home health nurse is visiting a new patient who uses oxygen in the home. For which factors does the nurse assess when determining if the patient if using oxygen safely? (SELECT ALL THAT APPLY) a. A "NO SMOKING" sign is posted on the door , c. Electrical appliances have a three-prong cord. Flammable liquids are stored outside in the garage. Which parameter does the nurse monitor to ensure that a patient's response to oxygen therapy gas exchange is adequate? SELECT ALL THAT APPLY Pulse oximetry level of consciousness respiratory rate arterial blood gases The nurse is taking a history on a patient who reports sleeping in a recliner chair at night because lying in the bed causes shortness of breath and air hunger. How is this documented? a. Orthopnea A patient has been complaint with drug therapy for tuberculosis and has returned as instructed for follow up. Which indicates that the patient is no longer contagious? . Three negative sputum cultures Exam 3 The nurse is assessing a patient with Parkinson Disease. Which assessment ndings does the nurse expect to observe? (Select all that apply). The correct answers are: tremors upper extremities, rigidity, postural instability, slowness of movement. A nurse assesses a client who has a history of migraine. Which clinical manifestation would the nurse identify as an early sign of a migraine with aura? Visual disturbances  The typical migraine is described as unilateral, throbbing, accompanied by a sensitive scalp and photophobia. pg 875 The nurse is assessing a patient after thyroid surgery and discovers harsh, high pitched respiratory sounds. The patient is drooling and is a having diculty swallowing. What is the nurse's FIRST action? Call the rapid response team Laryngeal Stridor is an acute respiratory obstruction, respond by immediatedly call a rapid response team to aid in intubation. pg . 1269. The nurse is caring for an older alert and oriented adult patient who is at risk for falling related to altered balance and decreased coordination. Which initial intervention will the nurse employ for this patient? (Select all that apply) The correct answers are: Instruct the patient to move slowly when changing positions., Instruct the patient to call for assistance before getting out of bed., Place the call bell and personal items within the patient’s reach A nurse teaches a patient with diabetes mellitus about foot care. Which statements would the nurse include in this patient’s teaching? (Select all that apply.) Chart 64-6 Foot care instructions for the patient with DM. pg 1307. The correct answers are: ―Do not walk around barefoot.‖, ―Trim toenails straight across with a nail clipper.‖ An older adult in the family practice clinic reports a decrease in hearing over the past week. What action by the nurse should be rst? Ask, ―How do you clean your ears?‖  pg. 987 personal history related to hearing. A nurse is completing discharge teaching with a patient diagnosed with myasthenia gravis. What teaching is most important about drug therapy? Keep prescribed medications and a glass of water at your bedside if you are weak in the am. Chart 44-5 helpful hints for teaching about drug therapy and myasthenia gravis. A patient experiences dysphagia after a stroke and has been working with the speech pathologist on eating. What nursing assessment best indicates that a priority goal for this problem has been met? The patient has clear lungs sounds on auscultation The nurse at the rehabilitation hospital is discharging a patient who has had an ischemic stroke. What predicators put the patient at risk for post stroke depression? (Select all that apply.) The correct answers are: A history of depression., Has expressive aphasia, Inability to ambulate pg. 939 Self- Management Education- As part of the discharge process teach the family about the signs and symptoms of depression. The strongest predictors of post stroke depression are history of depression, severity of stroke and post stroke physical and cognitive impairment. You are the nurse in a pediatric clinic, the grandmother of a patient has sudden diculty speaking and trouble seeing. What is your FIRST PRIORITY? Call 911  Pg. 928 A stroke is a medical emergency and should be treated immediately to reduce or prevent permanent disability. What is the priority in caring for a patient with trigeminal neuralgia? Pain Management  The priority for care of the patient with TN is pain management pg. 924. The nurse has taught a client recently diagnosed with multiple sclerosis about the course of the illness and possible complications. Which statement by the client indicates the need for additional teaching? Once I begin the medications, I will not have periods of exacerbation  MS is characterized by periods of remission and exacerbation pg. 888 During the nurse’s assessment of a patient with Parkinson disease, the nurse notes that the patient has a masklike face with wide-open fixed staring eyes. What functional assessment is now a priority? Ability to chew and swallow  pg. 869 Change in facial expression or a masklike face can lead to difficulty chewing and swallowing because it is caused by rigidity in the facial muscles. A nurse is providing care for a patient with amyotrophic lateral sclerosis (ALS). The patient states, ―I do not want to be placed on a mechanical ventilator.‖ What is the nurse’s best response? ―What would you like to be done if you begin to have diculty breathing.‖  Open-end question allows patient to discuss feelings. A client is admitted to the hospital with the diagnosis of Cushing Syndrome. The nurse monitors the client for which problem that is likely to occur with the diagnosis? Mood Disturbances When this syndrome develops, the normal function of the glucocorticoids becomes exaggerated. This response can cause mood disturbances such as memory loss, poor concentration and cognition. Pg. 1257. The nurse admits a client who has right sided weakness, aphasia, and urinary incontinence. The client's son states, "if this is a stroke, it is the kiss of death." What initial response should the nurse make? " What information have you been given about your mother?"  Open ended and allows son a chance to express his feelings. A patient who has suffered from an ischemic stroke has aphasia. Which nursing interventions will promote effective communication. (Select all that apply). The correct answers are: Present one step commands., Speak slowly., Allow extra time for response. Present one idea or thought, speak slowly not loudly. Do not rush patient when trying to speak. A nurse is caring for five patients on a neurological step-down unit. After receiving the hand off report, which patient should the nurse see rst? Patient with a Glasgow coma scale score that was 10 and is now 8.  The Glasgow coma scale is used to establish a patient’s neurological assessment the lower the number shows a decrease in neurological function. After teaching a client newly diagnosed with epilepsy, the nurse assesses the client’s understanding. Which statement indicates a need for additional teaching? ―As long as I take my seizure medications, I will not have another seizure.‖  pg. 880 health teaching for patient with epilepsy. A patient is diagnosed with trigeminal neuralgia. Which therapy is the rst-line choice for this patient? Antiepileptic such as carbamazepine.  Pg. 924 The rst choice for drug therapy is carbamazepine which is an antiepileptic. Which priority problem should the nurse address with a patient with hypothyroidism? Depression and withdrawal  Depression is the most common reason for seeking medical attention in patients with hypothyroidism pg. 1272. A patient with myasthenia gravis reports having difficulty climbing stairs, lifting heavy objects, and raising arms over the head. What is pathophysiology of this patient’s symptoms due to? Progressive muscle weakness. Chart 44-3 Key Features of myasthenia gravis Motor manifestations affecting mobility A nurse plans care for an 82-year-old patient who is experiencing age-related sensory perception changes. Which priority intervention would the nurse include in the patient’s plan of care? Ensure that the path to the bathroom is free from clutter.  Touch sensation decreases and may not feel items underfoot. Pg. 845. Which statements about hypothyroidism are accurate? The correct answers are: It occurs more often in women., It can be caused by a iodine deficiency., Myxedema coma is a rare but serious complication. Order: Levothyroxine 0.05 mg PO daily Available: Levothyroxine 50 mcg/tab How many tabs will you given? 1.0 tablets  The nurse is caring for a patient with Parkinson's disease; writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? Provide 6 small meals per day with a soft consistency.  Small frequent meals may aid a patient with difficulty swallowing. pg. 871. The nurse is preparing to discharge a patient with transient ischemic attack (TIA). What topics should the nurse include in discharge education? (Select all that apply) The correct answers are: reduction of high blood pressure, antiplatelet medication regimen, smoking cessation, Controlling diabetes Pg. 928 Preventing another TIA or possible stroke may include reduction of high blood pressure, use of antiplatelet medications and modifying rest factors. A patient has been diagnosed with Bell’s Palsy. What statement by the patient reinforces the need of additional discharge education? ―My face will look like this forever.‖  pg. 924 Facial Paralysis. Most patients go into remission within 3 months. A nurse is teaching older adults at a senior center about changes to the ears that occur with aging. What instruction should the nurse include? (Select all that apply.) Hair in the ear canal may become coarser and longer causing more ear wax build up., Hearing function may be reduced because ear wax becomes drier and impacts more easily., The pinna becomes elongated because of loss of subcutaneous tissue. A nurse assesses a patient with type 2 diabetes and notes decreased tactile sensation in both feet. What action would the nurse take FIRST? Assess the patient's feet for sign s of injury. Assessment of the diabetic foot is important in care of the diabetic patient. Chart 64-5 pg. 1306. The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client’s primary care giver? Encourage the primary caregiver to learn resuscitation procedures.  pg. 922 Because of risk for respiratory compromise encourage family to learn resuscitation procedures Which patient has the highest risk factors for restless leg syndrome? A 65-year-old smoker with type 2 diabetes.  Pg. 922 The incidence is higher in patients with DM type 2, chronic kidney disease and peripheral neuropathy. A client with diabetes mellitus has a blood glucose level of 644 mg/dl. The nurse interprets that this client is at risk for developing which type of acid base imbalance? Metabolic Acidosis  DM can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose rises. At the same time, the cells of the body use all available glucose. Then the body breaks down fat and glycogen for fuel. The byproduct of fat metabolism is acidotic. Pg. 1311 A 68 year old patient has arrived in the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a PRIORITY? Schedule a STAT computed tomography (CT) of the head.  CT perfusion scan is used to assess ischemia of brain tissue. pg. 935. A patient is 12 hours post-operative from a thyroidectomy for uncontrolled hyperthyroidism. At 1200 the patient has a temperature of 98.9 F and at 1230 has a temperature of 99.8F. What is the nurse’s PRIORITY? Call the provider  Critical Rescue Box pg. 1270 Even a 1-degree difference in temperature may indicate an impending thyroid crisis. During a patient’s last visit, the nurse instructed the patient about migraine headaches and techniques to manage this condition. Which statement by the patient indicates teaching has been successful? ―I have been keeping track of when my headaches occur and what might be triggers.‖ pg. 875 trigger avoidance and management are important interventions for preventing migraine. Which discharge instruction should the nurse implement for the client newly diagnosed with myasthenia gravis? Identify specific measures to help avoid fatigue and undue stress. Pg. 922 Self-management education remind the patient to plan activities to allow for rest periods and to conserve energy. The nurse is preparing to discharge a patient with Meniere's Disease. Which statement about diet restrictions should be included in the discharge instructions? a low sodium diet to decrease endolymph fluid.  Dietary changes such as low salt can reduce the amount of endolymphatic fluid. pg. 996. The nurse is caring for a patient who is recovering from a stroke. The wife asks, ―Why are you working so hard to get my husband out of bed? He is just as happy in the bed.‖ What is the most appropriate response? ―We really need to get him started moving so he can gain strength.‖  Patient begin rehab as soon as possible to regain function and to prevent complications of immobility. Pg. 938. The nurse is assessing a patient with multiple scleroses. Which clinical manifestation warrants immediate intervention? Congested cough and dysphagia  Monitor the patient to determine if there are problems swallowing at mealtime that increases the risk of aspiration. pg. 892 A facility adheres to eight Core Measures for ischemic stroke care. The nurse should identify which statements as core measures? (Select all that apply) The correct answers are: Discharging the patient of a statin medication, Preventing Venous Thromboembolism, Providing and charting stroke education. Pg. 939 eight Core Measures for ischemic stroke care A client is admitted to the hospital with a suspected diagnosis of Graves' Disease. On the assessment, which manifestation related to the client's menstrual cycle should the nurse expect the client to most likely report? Amenorrhea Amenorrhea or decreased menstrual ow is common. Pg. 1266 A nurse is caring for a diabetic patient in the emergency department with a blood glucose of 500 g/dl. Which arterial blood gas value would the nurse identify as a potential ketoacidosis in this patient? pH 7.28, HCO3 18 mEq/L, PCO2 28 mmHg, PO2 98 mmHG.  DM can lead to metabolic acidosis. When the body does not have sucient circulating insulin, the blood glucose rises. At the same time, the cells of the body use all the available glucose. Then the body breaks down fat and glycogen for fuel. The byproduct of fat metabolism is acidotic. Pg. 1311 A client with myasthenia gravis is malnourished. What actions related to nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? Select All that Apply The correct answers are: Cutting foods up into small bites, Thickening liquids prior to drinking, Weighing the patient daily Chart 44-4 Best Practice for Patient safety. Improving nutrition in patients with myasthenia gravis. The UAP cannot assess the patient’s gag ree. x, nor can the UAP monitor lab values. A 72 year old patient with a history of stroke is coughing while eating a pureed meal. The patient states, "I have been getting choked on this baby food." Which nursing intervention should the nurse implement FIRST? Take the food away. The home health nurse is preparing a plan of care for a client with Meniere's Disease who is experiencing severe vertigo. What education should be included in the plan of care to assist the client with controlling vertigo? Avoid sudden head movements  Slower head movements can prevent vertigo. page 996. A patient with a history of Diabetes Mellitus Type 2 and emphysema has been admitted to the hospital with pneumonia. The patient is placed on an oral antidiabetic agent, antibiotics, and steroid therapy. The nurse needs to monitor for which clinical manifestation? Hyperglycemia Steroid therapy will increase the blood sugar.