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HESI/Saunders Online Review- Module 10-Physiological Health Problems Exam (A+Graded)
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HESI/Saunders Online Review- Module 10-Physiological HealthProblems Exam (A+Graded)
A client who has had a brain attack (stroke) exhibits right-sided unilateral neglect. The
nurse caring for the client is going to place the client's personal care items: - ANS B.
Within the client's reach on the right side
Rationale: Unilateral neglect is a failure to recognize one side of the body. The client
acts as if it is not there. The client does not look at the paralyzed limb when moving
about. Unilateral neglect results in increased risk for injury. It is possible for the client to
relearn to look for and to move the affected limb(s). Therefore in this condition the
client's personal care items are placed within the client's reach on the right side.
Hemiparesis is a weakness of the face, arm, and leg on one side. It is helpful to a client
with unilateral hemiparesis to have objects placed on the unaffected side and within
reach. This minimizes frustration of the client and promotes safety because the client is
not straining and stretching to reach items. The nurse adapts the client's environment to
the deficit by focusing on the client's unaffected side and by placing the client's
personal care items on the affected side within reach. Placing items out of the client's
reach presents a risk of injury.
The emergency department nurse evaluates a client who is diagnosed with left-sided
heart failure. Which of the following findings does the nurse expect to find? Answer E
Crackles upon auscultation of the lungs.
Rationale: Signs of left-sided heart failure result from decreased cardiac output and
increased pulmonary venous congestion, and the nurse would note signs related to the
respiratory system, such as cough, dyspnea, and crackles and wheezes on auscultation
of the lungs. Right-sided heart failure is associated with increased systemic venous
pressure and congestion, and the nurse would note signs such as neck vein distention,
dependent edema, abdominal distention, and weight gain.
A home care nurse has provided discharge instructions to a child's father regarding the
treatment of the child with croup. The father requires further instruction by the nurse if
he makes which statement? Response A "I should put a steam vaporizer in her room."
,Rationale: The steam from running water in a closed bathroom and cool mist from a
bedside humidizer or a freezer are helpful in reducing mucosal edema. A cool mist
humidifier is considered safer than a steam vaporizer that poses the risk of a scald burn.
Removing the child to the cool humid night air may also provide relief from mucosal
swelling.
A mother telephones the clinic and reports that her newborn's umbilicus site looks red
and edematous. The nurse should tell the mother to: Answer B Bring the newborn to the
clinic.
Rationale: Infection is manifested by dampness, drainage, discharge, swelling, and a
red base of the cord. If any of these infection manifestations occur, the infant must be
brought to the healthcare provider. The appropriate nursing actions include instructing
the mother to increase the frequency of cleansing the cord per day and to apply an ice
pack to the umbilical cord site, as well as informing her that this is normal.
Angina pectoris is the diagnosis for this client. The client's wife calls the physician's
office and reports to the nurse that her husband is having chest pain and has taken 2
sublingual nitroglycerin tablets 5 minutes apart and is getting no relief. The nurse
should instruct the client's wife to: -Answer D. Give her husband a third tablet and, if no
relief is obtained, call an ambulance to have him transported to the ED.
Rationale: Chest pain that does not subside with three doses of nitroglycerin taken 5
minutes apart and with rest is not typical anginal pain but instead an MI. The risk of
sudden cardiac death is highest during the 24-hour period following an MI; therefore,
the client should receive emergency care for the heart. If the client has to be taken to
the ED, the nurse should direct the client's wife to call an ambulance to take her
husband to the hospital. At no time should the client's wife drive the client to the hospital
because the client should avoid expelling energy and increasing workload on the heart;
furthermore, the client's wife would not be in a position to offer any care if an
emergency occurred on the way to the hospital. The advice given to the wife that she is
going to have to talk about the situation with a physician, who will call her when he gets
to his office, postpones appropriate interventions. Advising rest to the husband
postpones appropriate interventions; similarly, the usual practice is for a client to be
advised to take three nitroglycerin tablets in response to a typical angina attack prior to
requesting medical attention.
Mastitis is diagnosed in a client who recently gave birth. The nurse tells the woman that:
,- Answer D. Moist heat will increase circulation and may be used before the breasts are
emptied.
Rationale: Antibiotic therapy and continued decompression of the breasts, by means of
breastfeeding or with a breast pump, is prescribed for the client with mastitis. Usually,
the mother is able to continue feeding with both breasts. If the affected breast is too
sore, the mother may pump the breast gently. Regular emptying of the breast is
important in preventing abscess formation. Antibiotic therapy resolves mastitis in 24 to
48 hours. Additional supportive measures include moist heat or ice packs, breast
support, and analgesics. Moist heat promotes comfort and increases circulation. A
shower or hot packs should be done before emptying the breasts or before feeding.
A nurse is performing an assessment on a client diagnosed with mild preeclampsia.
Which of the following is indicative of an improvement in the client's condition? Answer
A. Trace protein in the urine.
Rationale: Preeclampsia is considered mild when the systolic blood pressure is 140 mm
Hg or greater but less than 160 mm Hg and the diastolic blood pressure is 90 mm Hg or
greater but less than 110 mm Hg, proteinuria is 1+ on a random dipstick and symptoms
such as headache, visual disturbances, and abdominal pain are absent. In addition,
signs of kidney or liver involvement are absent. An increased BUN level suggests kidney
impairment, a consequence of the preeclampsia.
A nurse is conducting an examination of a child who has been experiencing elevated
intracranial pressure and has been exhibiting decorticate posturing. The nurse notes
extension of the upper and lower extremities with internal rotation of the upper arms
and wrists and the knees and feet. The nurse interprets this finding as indicating that
the child's condition: - Answer C. Reflects deterioration in neurological status.
Rationale: The upper extremities flex and the lower extremities extend during
decorticate posturing. During decerebrate posturing both upper and lower extremities
extend and the upper arms and wrists and the knees and feet are internally rotated. A
progression from decorticate to decerebrate posturing usually indicates deterioration
in neurological status and should be reported to the physician. The remaining options
provide incorrect interpretations.
The nurse is performing a client's annual eye exam and measures the client's intraocular
, pressure. The right eye measures 12 mm Hg and the left eye measures 19 mm Hg. The
nurse can tell the client that: - Answer C. The intraocular pressure of both eyes is within
normal limits.
Rationale: Normal intraocular pressure ranges from 10 to 21 mm Hg. Therefore this
client's intraocular pressure is normal. Fluid intake has no correlation with an increase
in intraocular pressure.
The nurse is teaching a client with COPD about positions that are most helpful to
diminish dyspnea. Which of the following statements made by the client indicates that
the nurse should provide further instruction? ANSWER B "I should lie on my right side in
bed."
Rationale: Positions that will facilitate easy breathing for the client with COPD include
sitting up and leaning on an overbed table, sitting up and resting with the elbows on the
knees, sitting up in a chair, and standing and leaning against the wall. With these
positions there is maximum expansion of the lungs and the respiratory cage in all
directions. Lying on the side is not effective.
The client is having a stapedectomy due to otosclerosis. Which of the following home
care instructions would the nurse instruct this client during discharge preparation? -
Answer B. Avoid sudden head movements and bending for at least 3 weeks.
Rationale: The client should avoid sudden head movements, bouncing, and bending for
at least 3 weeks to prevent any disruption of the surgical site. The client is to keep the
affected ear dry at all times and avoid wetting the head, washing the hair, or showering
for 1 week. The client should not rinse out the ear. The client will also need to avoid
drinking through a straw for 2 to 3 weeks because the sucking action necessary to use
the straw could cause disruption of the surgical site. The client should be educated to
notify the nurse if there is excessive drainage of the ear.
If the nurse were educating the nursing assistant on how to clearly communicate with a
hearing-impaired client, which of the following actions would the nurse direct the
nursing assistant to perform?
Answer D: Stand facing the client while speaking and keep hands away from mouth.
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