twenty minutes after beginning a heat application the client states that the heating pad no longer feels warm enough what is the best response by the
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Nursing Elites

HESI RN

HESI Quizlet Fundamentals

1. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?

Correct answer: D

Rationale: Choice (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. The body's receptors adjust to the constant heat exposure, leading to a decreased sensation of warmth. Choices (A) and (B) provide inaccurate information regarding the situation, while choice (C) is not physiologically sound and could potentially harm the client by increasing the temperature unnecessarily.

2. An elderly patient has been living in a nursing home for several years. The nursing staff has begun to notice a change in her behavior. All of the following are symptoms of depression except:

Correct answer: D

Rationale: Hyperorality is not typically a symptom of depression. Symptoms of depression often include changes in sleep patterns, eating patterns with weight loss, and excessive fatigue. Hyperorality, which refers to the tendency to examine, chew, or ingest non-nutritive substances, is not a common symptom associated with depression.

3. When caring for an older incontinent client at risk for infection, which intervention is best for the nurse to implement based on the nursing diagnosis of risk for infection?

Correct answer: A

Rationale: The correct intervention for an older incontinent client at risk for infection is to maintain standard precautions. Standard precautions, which include proper handwashing, are essential in reducing the risk of infection transmission in vulnerable clients. Initiating contact isolation measures may not be necessary for all clients, and inserting an indwelling urinary catheter should be avoided unless medically necessary to prevent additional risks of infection. Instructing the client in the use of adult diapers is not an appropriate nursing intervention to prevent infection.

4. What information should the nurse offer a client who uses herbal therapies to supplement their diet and manage common ailments about the general use of herbal supplements?

Correct answer: C

Rationale: It is essential for clients using herbal therapies to obtain herbs from manufacturers with a history of quality control for their supplements. This recommendation is crucial because quality control processes help in maintaining the purity and effectiveness of the herbal supplements. Option A is incorrect as it provides a negative and inaccurate generalization about herbs. Option B is also incorrect as there is existing evidence on the safety and efficacy of certain herbal supplements. Option D is not the most relevant information to offer initially to a client seeking advice on the general use of herbal supplements.

5. The healthcare provider plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the healthcare provider administer? (Round to the nearest tenth.)

Correct answer: B

Rationale: To calculate the volume to administer, use the formula (1 mL × 4 mg) / 5 mg = 0.8 mL. The healthcare provider should administer 0.8 mL of diazepam for a dosage of 4 mg IV push. Choice A is incorrect because it results from an incorrect calculation. Choices C and D are incorrect as they do not align with the correct calculation based on the provided dosage.

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