NUR 314 MED-SURG HESI CLINICAL NURSING ASSESSMENT
AND INTERVENTION REVIEW: CASE-BASED Q&A FORMAT
WITH COMPLETE SOLUTION!!
1. Vitamin Deficiency Evaluation in Hyperlipidemia Treatment
Question:
A client receiving cholestyramine (Questran) for hyperlipidemia should be
evaluated for what vitamin deficiency?
Answer:
Vitamin K
Feedback:
Clients should be monitored for an increased prothrombin time and prolonged
bleeding times, which would alert the nurse to a vitamin K deficiency. These drugs
reduce absorption of the fat-soluble (lipid) vitamins A, D, E, and K.
2. Treatment Protocol for Atrial Fibrillation
Question:
Based on the analysis of the client's atrial fibrillation, the nurse should prepare the
client for which treatment protocol?
Answer:
Anticoagulation therapy
Feedback:
The client is experiencing atrial fibrillation. The nurse should prepare the client for
anticoagulation therapy, which should be prescribed before rhythm control
therapies to prevent cardioembolic events resulting from blood pooling in the
fibrillating atria.
,3. Early Symptoms of Renal Insufficiency in Diabetes
Question:
A client with a 16-year history of diabetes mellitus is having renal function tests
because of recent fatigue, weakness, elevated blood urea nitrogen, and serum
creatinine levels. Which finding should the nurse conclude as an early symptom of
renal insufficiency?
Answer:
Nocturia
Feedback:
As the glomerular filtration rate decreases in early renal insufficiency, metabolic
waste products accumulate in the blood. In the early stage, polyuria from the
kidneys' inability to concentrate urine leads to nocturia.
4. Chest Pressure in Client Receiving IV Vasopressin
Question:
A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture
reports substernal tightness and pressure across her chest. Which PRN protocol
should the nurse initiate?
Answer:
Start an IV nitroglycerin infusion
Feedback:
Vasoconstriction of the coronary arteries can lead to angina and myocardial
infarction. This should be counteracted by IV nitroglycerin as per prescribed
protocol.
,5. Parkinson’s Disease: Assessment for Care Planning
Question:
The nurse is completing an admission interview and assessment on a client with a
history of Parkinson's disease. Which question should provide information relevant
to the client's plan of care?
Answer:
Have you ever been 'frozen' in one spot, unable to move?
Feedback:
Clients with Parkinson's disease often experience difficulty initiating and
performing motor activities. They may report being rooted to the spot, unable to
move.
6. Common Symptoms in Long-Standing Parkinson’s Disease
Question:
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?
Answer:
Shuffling gait, masklike facial expression, and tremors of the head
, 7. Pain Assessment for Suspected Thrombophlebitis
Question:
An elderly male client comes to the geriatric screening clinic complaining of pain
in his left calf. The nurse notices a reddened area on the calf of his right leg which
is warm to the touch and suspects it might be thrombophlebitis. Which type of pain
should further confirm this suspicion?
Answer:
(Answer not provided in your original content. Please confirm the specific type of
pain expected, e.g., “pain on dorsiflexion of the foot – Homan’s sign.”)
answers: Pain in the calf upon exertion which is relieved by rest and elevating the
extremity.
The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox),
1 tablet PO PRN, for a client with chronic renal failure who is complaining of
indigestion. What intervention should the nurse implement?
answers: Question the healthcare provider's prescription
A 57-year-old male client is scheduled to have a stress-thallium test the following
morning and is NPO after midnight. At 0130, he is agitated because he cannot eat
and is demanding food. Which response is best for the nurse to provide to this
client?
answers: The test you are having tomorrow requires that you have nothing by
mouth tonight.
A middle-aged male client with diabetes continues to eat an abundance of foods
that are high in sugar and fat. According to the Health Belief Model, which event is
most likely to increase the client's willingness to become compliant with the
prescribed diet?
AND INTERVENTION REVIEW: CASE-BASED Q&A FORMAT
WITH COMPLETE SOLUTION!!
1. Vitamin Deficiency Evaluation in Hyperlipidemia Treatment
Question:
A client receiving cholestyramine (Questran) for hyperlipidemia should be
evaluated for what vitamin deficiency?
Answer:
Vitamin K
Feedback:
Clients should be monitored for an increased prothrombin time and prolonged
bleeding times, which would alert the nurse to a vitamin K deficiency. These drugs
reduce absorption of the fat-soluble (lipid) vitamins A, D, E, and K.
2. Treatment Protocol for Atrial Fibrillation
Question:
Based on the analysis of the client's atrial fibrillation, the nurse should prepare the
client for which treatment protocol?
Answer:
Anticoagulation therapy
Feedback:
The client is experiencing atrial fibrillation. The nurse should prepare the client for
anticoagulation therapy, which should be prescribed before rhythm control
therapies to prevent cardioembolic events resulting from blood pooling in the
fibrillating atria.
,3. Early Symptoms of Renal Insufficiency in Diabetes
Question:
A client with a 16-year history of diabetes mellitus is having renal function tests
because of recent fatigue, weakness, elevated blood urea nitrogen, and serum
creatinine levels. Which finding should the nurse conclude as an early symptom of
renal insufficiency?
Answer:
Nocturia
Feedback:
As the glomerular filtration rate decreases in early renal insufficiency, metabolic
waste products accumulate in the blood. In the early stage, polyuria from the
kidneys' inability to concentrate urine leads to nocturia.
4. Chest Pressure in Client Receiving IV Vasopressin
Question:
A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture
reports substernal tightness and pressure across her chest. Which PRN protocol
should the nurse initiate?
Answer:
Start an IV nitroglycerin infusion
Feedback:
Vasoconstriction of the coronary arteries can lead to angina and myocardial
infarction. This should be counteracted by IV nitroglycerin as per prescribed
protocol.
,5. Parkinson’s Disease: Assessment for Care Planning
Question:
The nurse is completing an admission interview and assessment on a client with a
history of Parkinson's disease. Which question should provide information relevant
to the client's plan of care?
Answer:
Have you ever been 'frozen' in one spot, unable to move?
Feedback:
Clients with Parkinson's disease often experience difficulty initiating and
performing motor activities. They may report being rooted to the spot, unable to
move.
6. Common Symptoms in Long-Standing Parkinson’s Disease
Question:
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?
Answer:
Shuffling gait, masklike facial expression, and tremors of the head
, 7. Pain Assessment for Suspected Thrombophlebitis
Question:
An elderly male client comes to the geriatric screening clinic complaining of pain
in his left calf. The nurse notices a reddened area on the calf of his right leg which
is warm to the touch and suspects it might be thrombophlebitis. Which type of pain
should further confirm this suspicion?
Answer:
(Answer not provided in your original content. Please confirm the specific type of
pain expected, e.g., “pain on dorsiflexion of the foot – Homan’s sign.”)
answers: Pain in the calf upon exertion which is relieved by rest and elevating the
extremity.
The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox),
1 tablet PO PRN, for a client with chronic renal failure who is complaining of
indigestion. What intervention should the nurse implement?
answers: Question the healthcare provider's prescription
A 57-year-old male client is scheduled to have a stress-thallium test the following
morning and is NPO after midnight. At 0130, he is agitated because he cannot eat
and is demanding food. Which response is best for the nurse to provide to this
client?
answers: The test you are having tomorrow requires that you have nothing by
mouth tonight.
A middle-aged male client with diabetes continues to eat an abundance of foods
that are high in sugar and fat. According to the Health Belief Model, which event is
most likely to increase the client's willingness to become compliant with the
prescribed diet?
