(Complete 350 Q&A) HESI Med Surg 1 Test Bank 2022/2023

A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing pressure ulcers. Which physical characteristic of aging puts the client at risk? A.16% increase in overall body fat B.Reduced melanin production C.Thinning of the skin, with loss of elasticity D. Calcium loss in the bones - CORRECT ANSWER C.Thinning of the skin, with loss of elasticity Rationale: Thin none lastic skin is an important factor in pressure formation. The proportion of body fat to lean mass increases with age and might help decrease ulcer tendency. Option B causes gray hair. Option D can contribute to broken bones, but it is probably not a factor in pressure ulcer formation. In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take? A.Advise the client that the shunt is intact and ready for dialysis as scheduled. B.Encourage the client to keep the shunt site elevated above the level of the heart. C.Notify the health care provider of the findings immediately. D.Flush the site at least once with a heparinized saline solution. - CORRECT ANSWER C.Notify the health care provider of the findings immediately. Rationale: Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the health care provider so that intervention can be initiated to restore function of the shunt. Option A is incorrect. Option B will not resolve the obstruction. An AV shunt is internal and cannot be flushed without access using special needles. Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate (Mexate) therapy? A.Increase in rheumatoid factor B.Decrease in hemoglobin level C.Increase in blood glucose level D.Decrease in erythrocyte sedimentation rate (ESR; sed rate) - CORRECT ANSWER B. Decrease in hemoglobin level Rationale: Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in the hemoglobin level. Option A indicates disease progression but is not a side effect of the medication. Option C is not related to methotrexate. Option D indicates that inflammation associated with the disease has diminished. Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? A.Tinnitus, vertigo, and hearing difficulties B.Sudden, stabbing, severe pain over the lip and chin C.Unilateral facial weakness and paralysis D. Difficulty in chewing, talking, and swallowing - CORRECT ANSWER B. Sudden, stabbing, severe pain over the lip and chin Rationale: Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V). Option A would be characteristic of Ménière syndrome (cranial nerve VIII). Option C would be characteristic of Bell palsy (cranial nerve VII). Option D would be characteristic of disorders of the hypoglossal (cranial nerve XII). An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated? A.Help the client determine ways to increase his fluid intake. B.Obtain an appointment for the client to have an eye examination. C.Instruct the client to use oxygen at night and increase the humidification. D.Schedule the client for tests to determine his sensitivity to cat hair. - CORRECT ANSWER A.Help the client determine ways to increase his fluid intake. Rationale: Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness of breath. The nurse should suggest creative methods to increase the intake of fluids, such as having fruit juices in disposable containers readily available. Option B is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night. These symptoms are not indicative of option D and may unnecessarily upset the client, who depends on his pet for socialization. The home health nurse is assessing a male client being treated for Parkinson disease with carbidopa-levodopa. The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which intervention should the nurse implement? A.Perform a complete cranial nerve assessment. B.Instruct the client that he may be experiencing medication toxicity. C.Document the presence of these assessment findings. D.Advise the client to seek immediate medical evaluation. - CORRECT ANSWER C.Document the presence of these assessment findings Rationale: A masklike expression and infrequent blinking are common clinical features of parkinsonism. The nurse should document these expected findings. Options A and D are not necessary. Signs of toxicity of levodopa-carbidopa, include dyskinesia, hallucinations, and psychosis. A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client? A.Determine if all employees have had the hepatitis B vaccine series. B.Explain that this type of hepatitis can be transmitted when feeding the client. C.Assure the employees that they cannot contract hepatitis B when providing direct care. D.Tell the employees that wearing gloves and a gown are required when providing care. - CORRECT ANSWER A. Determine if all employees have had the hepatitis B vaccine series Rationale: Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination. There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, option C is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact. The nurse initiates neurologic checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neurologic function? A.Change in level of consciousness B.Increasing muscular weakness C.Changes in pupil size bilaterally D.Progressive nuchal rigidity - CORRECT ANSWER A.Change in level of consciousness Rationale: A decrease or change in the level of consciousness is usually the first indication of neurologic deterioration. Options B and C may also occur but are much less likely to be the first sign of neurologic compromise. Option D is often a sign of meningitis. Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns? A. Midnight census B.Oncoming shift census C.Average daily census D.Hourly census - CORRECT ANSWER C.Average daily census Rationale: An average daily census is determined by trend data and takes into account seasonal and daily fluctuations, so it is the best method for determining staffing needs. Options A and B provide data at a certain point in time, and that data could change quickly. It is unrealistic to expect to obtain an hourly census, and such data would only provide information about a certain point in time. A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first? A. Auscultate the client's breath sounds. B. Turn off the continuous feeding pump. C. Check placement of the nasogastric tube. D. Measure the amount of residual feeding. - CORRECT ANSWER B. Turn off the continuous feeding pump. Rationale: A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding to prevent further aspiration. Options A, C, and D should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.