LATEST Med Surg Hesi EXAM VERIFIED SOLUTION 100% CORRECT ANSWERS

The nurse is planning care for a client who has a right hemispheric stroke. Which nursing diagnosis should the nurse include in the plan of care? A Impaired physical mobility related to right-sided hemiplegia. B Risk for injury related to denial of deficits and impulsiveness. C Impaired verbal communication related to speech-language deficits. D Ineffective coping related to depression and distress about disability. - ANSWER B) Risk for injury related to denial of deficits and impulsiveness. With right-brain damage, a client experience difficulty in judgment and spatial perception and is more likely to be impulsive and move quickly, which placing the client at risk for falls (B). Although clients with right and left hemisphere damage may experience impaired physical mobility, the client with right brain damage will manifest physical impairments on the contralateral side of the body, not the same side (A). The client with a left-brain injury may manifest right-sided hemiplegia with speech or language deficits (C). A client with left-brain damage is more likely to be aware of the deficits and experience grief related to physical impairment and depression (D). After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented? A Report the findings to the surgeon. B Irrigate the indwelling urinary catheter. C Apply manual pressure to the bladder. D Increase the IV flow rate for 15 minutes. - ANSWER A) Report the findings to the surgeon. An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon. Although other actions (B, C, and D) may be indicated, the assessment findings should be reported to the healthcare provider. The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms should this client most likely exhibit? Loss of short-term memory, facial tics and grimaces, and constant writhing movements. Shuffling gait, masklike facial expression, and tremors of the head. Extreme muscular weakness, easy fatigability, and ptosis. Numbness of the extremities, loss of balance, and visual disturbances. - ANSWER B) Shuffling gait, masklike facial expression, and tremors of the head. (B) are common clinical features of Parkinsonism. (A) are symptoms of chorea, (C) of myasthenia gravis, and (D) of multiple sclerosis. A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? Prevention of deformities. Avoidance of joint trauma. Relief of joint inflammation. Improvement in joint strength. - ANSWER A) Prevention of deformities. Splints may be used at night by clients with rheumatoid arthritis to prevent deformities (A) caused by muscle spasms and contractures. Splints are not used for (B). (C) is usually treated with medications, particularly those classified as non-steroidal antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated. The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? She sustained an insect bite to her left arm yesterday. She has lost twenty pounds since the surgery. Her healthcare provider now prescribes a calcium channel blocker for hypertension. Her hobby is playing classical music on the piano. - ANSWER A) She sustained an insect bite to her left arm yesterday. A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema (A). (B) is not a factor. Lymphedema is not significantly related to vascular circulation (C). Only overuse of the arm, such as weight-lifting, would cause lymphedema--(D) would not. A client is placed on a respirator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12h IV is prescribed. Which nursing diagnosis is the priority for this client? Impaired communication related to paralysis of skeletal muscles. High risk for infection related to increased intracranial pressure. Potential for injury related to impaired lung expansion. Social isolation related to inability to communicate. - ANSWER A) Impaired communication related to paralysis of skeletal muscles. To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant such as vecuronium is usually prescribed. Impaired communication (A) is a serious outcome because the client cannot communicate his/her needs. Although this client might also experience (D), it is not a priority when compared to (A). Infection is not related to increased intracranial pressure (B). The respirator will ensure that the lungs are expanded (C). Dysrhythmias are a concern for any client. However, the presence of a dysrhythmia is more serious in an elderly person because elderly persons usually live alone and cannot summon help when symptoms appear. elderly persons are more likely to eat high-fat diets which make them susceptible to heart disease. cardiac symptoms, such as confusion, are more difficult to recognize in the elderly. elderly persons are intolerant of decreased cardiac output which may result in dizziness and falls. - ANSWER D) elderly persons are intolerant of decreased cardiac output which may result in dizziness and falls. Cardiac output is decreased with aging (D). Because of loss of contractility and elasticity, blood flow is decreased and tachycardia is poorly tolerated. Therefore, if an elderly person experiences dysrhythmia (tachycardia or bradycardia), further compromising their cardiac output, they are more likely to experience syncope, falls, transient ischemic attacks, and possibly dementia. Most elderly persons do not eat high- fat diets (B) and most are not confused (C). Although many elderly persons do live alone, inability to summon help (A) cannot be assumed. Small bowel obstruction is a condition characterized by which finding? Severe fluid and electrolyte imbalances. Metabolic acidosis. Ribbon-like stools. Intermittent lower abdominal cramping. - ANSWER A) Severe fluid and electrolyte imbalances. Among the findings characteristic of a small bowel obstruction is the presence of severe fluid and electrolyte imbalances (A). (B, C, and D) are findings associated with large bowel obstruction. Which assessment finding by the nurse during a client's clinical breast examination requires follow-up? Newly retracted nipple. A thickened area where the skin folds under the breast. Whitish nipple discharge. Tender lumpiness noted bilaterally throughout the breasts. - ANSWER A) Newly retracted nipple.