HESI RN
Adult Health 2 HESI Quizlet
1. An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
- A. K+ 3.4 mEq/L (3.4 mmol/L)
- B. Ca+2 7.8 mg/dL (1.95 mmol/L)
- C. Na+ 154 mEq/L (154 mmol/L)
- D. PO4-3 4.8 mg/dL (1.55 mmol/L)
Correct answer: C
Rationale: The correct answer is C. The elevated serum sodium level (154 mEq/L) is consistent with the patient's neurologic symptoms of restlessness, agitation, and weakness, indicating a need for immediate action to prevent complications like seizures. The potassium level (3.4 mEq/L) and calcium level (7.8 mg/dL) are slightly off from normal but do not require immediate action. The phosphate level (4.8 mg/dL) is normal and not related to the symptoms presented by the patient.
2. A client with borderline personality disorder is admitted to the psychiatric unit. Which behavior should the nurse prioritize in the care plan?
- A. Self-harming behavior.
- B. Difficulty with interpersonal relationships.
- C. Impulsive spending and substance abuse.
- D. Inconsistent adherence to the treatment regimen.
Correct answer: A
Rationale: Self-harming behavior is the priority in the care plan for a client with borderline personality disorder. This behavior poses an immediate risk to the client's safety and requires prompt intervention. Difficulty with interpersonal relationships, impulsive spending, and substance abuse are also common in borderline personality disorder; however, self-harming behavior takes precedence due to its potential for severe harm. Inconsistent adherence to the treatment regimen, though important, is not as urgent as addressing the immediate safety concerns related to self-harm.
3. A seriously ill female client tells the nurse, 'I am so tired and in so much pain! Please help me to die.' Which is the best response for the nurse to provide?
- A. Administer the prescribed maximum dose of pain medication.
- B. Talk with the client about her feelings related to her own death.
- C. Collaborate with the healthcare provider about initiating antidepressant therapy.
- D. Refer the client to the ethics committee of her local healthcare facility.
Correct answer: B
Rationale: The nurse should prioritize addressing the client's emotional needs by engaging in a conversation to understand the underlying feelings behind her statement. By exploring the client's thoughts about death, the nurse can provide appropriate support and interventions tailored to the client's concerns. Rushing to administer pain medication may not address the emotional distress expressed by the client. Initiating antidepressant therapy is not suitable without assessing the client's feelings further. Referring the client to the ethics committee is premature and does not address the immediate emotional needs of the client. Therefore, empathetic communication and assessment of the client's feelings regarding her situation are crucial for providing holistic care.
4. Which of the following is a symptom of menopause?
- A. Bleeding per vagina
- B. Sleeping all the time
- C. Insomnia
- D. Increased concentration
Correct answer: C
Rationale: Insomnia is a common symptom of menopause. During menopause, hormonal changes can lead to sleep disturbances, including difficulty falling asleep or staying asleep. Choice A, 'Bleeding per vagina,' is not a typical symptom of menopause but should prompt further evaluation. Choice B, 'Sleeping all the time,' is not a common symptom of menopause; in fact, insomnia, rather than excessive sleep, is more prevalent. Choice D, 'Increased concentration,' is not a symptom of menopause; cognitive changes like forgetfulness or difficulty concentrating may occur, but increased concentration is not a typical manifestation.
5. An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?
- A. Destruction of joint cartilage.
- B. Inflammation of synovial membrane.
- C. Formation of bone spurs.
- D. Reduction of joint space.
Correct answer: A
Rationale: Corrected Rationale: Osteoarthritis typically involves the destruction of joint cartilage, leading to pain and stiffness. This destruction of joint cartilage results in bone rubbing against bone, causing pain and reduced mobility. Choices B, C, and D are incorrect. Inflammation of the synovial membrane (choice B) is more commonly associated with rheumatoid arthritis. Formation of bone spurs (choice C) and reduction of joint space (choice D) are manifestations that can occur as a result of osteoarthritis but are not the primary pathology responsible for the symptoms of pain and stiffness.