HESI RN
Leadership HESI
1. During a physical assessment of a client with type 2 DM, a nurse notes the following findings: fasting blood glucose of 120 mg/dl, temperature of 101°F, pulse 88 bpm, respirations 22/min, and BP 140/84 mmHg. Which finding should concern the nurse the most?
- A. Pulse
- B. BP
- C. Respiration
- D. Temperature
Correct answer: D
Rationale: The correct answer is 'Temperature.' A temperature of 101°F indicates a fever, which can be a sign of infection. In individuals with diabetes, infections can lead to significant complications and affect blood glucose control. Monitoring and addressing infections promptly are crucial in individuals with diabetes to prevent worsening of their condition. Choice A, 'Pulse,' is within the normal range (60-100 bpm) and does not indicate an immediate concern. Choice B, 'BP,' while slightly elevated, is not as acutely concerning as an elevated temperature in this scenario. Choice C, 'Respiration,' falls within the normal range (12-20 breaths/min) and is not the most concerning finding among the options provided.
2. A client with Addison's disease is at risk for which of the following complications?
- A. Hypertension
- B. Hypovolemia
- C. Hypernatremia
- D. Hypokalemia
Correct answer: B
Rationale: A client with Addison's disease is at risk for hypovolemia. Addison's disease is characterized by adrenal insufficiency, particularly cortisol and aldosterone deficiency. Aldosterone deficiency leads to impaired sodium and water retention, resulting in decreased blood volume and hypovolemia. This condition can cause hypotension, not hypertension (Choice A), as reduced blood volume leads to decreased pressure. Hypernatremia (Choice C) is unlikely in Addison's disease because of the loss of sodium along with water in hypovolemia. Hypokalemia (Choice D) can occur due to aldosterone deficiency, but it is not the primary complication associated with Addison's disease.
3. A healthcare provider is educating a client with DM on recognizing symptoms of hypoglycemia. Which symptom should the healthcare provider mention?
- A. Increased thirst
- B. Frequent urination
- C. Sweating
- D. Weight loss
Correct answer: C
Rationale: The correct symptom to mention when educating a client with diabetes mellitus (DM) on hypoglycemia is sweating. Sweating is a common symptom of hypoglycemia as it occurs due to the activation of the sympathetic nervous system in response to low blood sugar levels. Increased thirst (Choice A) and frequent urination (Choice B) are more indicative of hyperglycemia (high blood sugar) rather than hypoglycemia. Weight loss (Choice D) is not a typical symptom associated with hypoglycemia.
4. A healthcare professional reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the healthcare professional note on the electrocardiogram as a result of the laboratory value?
- A. U waves
- B. Absent P waves
- C. Elevated T waves
- D. Elevated ST segment
Correct answer: A
Rationale: The correct answer is A: U waves. A low potassium level (hypokalemia) can manifest as U waves on an ECG. U waves are small, extra deflections seen after the T wave and may indicate cardiac irritability. Absent P waves (Choice B) are associated with conditions like atrial fibrillation. Elevated T waves (Choice C) can be seen in hyperkalemia, not hypokalemia. Elevated ST segment (Choice D) is not typically associated with low potassium levels but can be seen in conditions like myocardial infarction.
5. When instructing the female client diagnosed with hyperparathyroidism about diet, Nurse Gina should stress the importance of which of the following?
- A. Restricting fluids
- B. Restricting sodium
- C. Forcing fluids
- D. Restricting potassium
Correct answer: C
Rationale: The correct answer is C: Forcing fluids. Nurse Gina should stress the importance of forcing fluids to help prevent kidney stones and hypercalcemia in clients with hyperparathyroidism. Restricting fluids (choice A) is not recommended as dehydration can worsen the condition. Restricting sodium (choice B) is not directly related to the management of hyperparathyroidism. Restricting potassium (choice D) is not typically necessary in hyperparathyroidism unless hyperkalemia is present.
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