a nurse is caring for a client who wanders through the halls yelling obscenities at staff other clients and visitors which of the following actions sh
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HESI Leadership and Management Quizlet

1. A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following actions should the nurse take?

Correct answer: B

Rationale: When dealing with a client exhibiting disruptive behavior like yelling obscenities, involving a family member can provide emotional support and help in de-escalating the situation. Keeping the client isolated in their room (Choice A) may lead to further agitation. Placing the client in a wheelchair (Choice C) or administering a sedative (Choice D) should not be the first interventions for managing behavioral issues.

2. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for further evaluation and possible intervention?

Correct answer: C

Rationale: A biophysical profile of 6 at 35 weeks of gestation indicates a need for further evaluation and possible intervention. A negative Coombs titer at 28 weeks gestation (Choice A) is within normal limits. A negative contraction stress test at 39 weeks gestation (Choice B) is expected as the pregnancy nears term. An L/S ratio of 2:1 at 37 weeks of gestation (Choice D) is consistent with fetal lung maturity.

3. Select the stage of shock that is accurately paired with its characteristic.

Correct answer: C

Rationale: The progressive stage of shock is accurately described as the stage where histamine is released, leading to fluid and proteins leaking into surrounding tissues and the blood thickening. In this stage, the body's compensatory mechanisms are overwhelmed, resulting in a cascade of events that worsen the shock state. Choice A is incorrect as hyperventilation and a rise in blood pH are more characteristic of the compensatory stage. Choice B is incorrect as hypoxia and a rise in lactic acid are more typical of the progressive stage. Choice D is incorrect as the described electrolyte imbalances and metabolic acidosis are more aligned with the refractory stage of shock.

4. What is idiopathic thrombocytopenia purpura?

Correct answer: C

Rationale: Idiopathic thrombocytopenic purpura is a bleeding disorder characterized by a low number of platelets in the blood. This condition is not highly similar to disseminated intravascular coagulation (DIC), which involves abnormal clotting throughout the body (coagulation), leading to depletion of platelets. Choice B is incorrect because idiopathic thrombocytopenic purpura is actually characterized by a decrease in platelet count, not an overproduction. While immune system-boosting medications may be used in some cases, the primary treatment for idiopathic thrombocytopenic purpura focuses on increasing platelet counts or managing symptoms.

5. A nurse is caring for a client who requests information about the prevalence of Tay-Sachs disease. Which of the following resources should the nurse use to obtain this information?

Correct answer: D

Rationale: An evidence-based nursing journal is the correct choice for the nurse to obtain information about the prevalence of Tay-Sachs disease. These journals contain peer-reviewed research and studies conducted by experts in the field, providing accurate and reliable information. Choice A, the client's health care provider, may have general information but may not provide detailed prevalence data. Choice B, a collaborative, user-edited website, is not a reliable source as the information may be inaccurate or outdated. Choice C, the facility's case manager, is unlikely to have specific prevalence data on Tay-Sachs disease.

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