which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia
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HESI RN

HESI Fundamentals Practice Test

1. Which instruction should be included in the discharge teaching plan for an adult client with hypernatremia?

Correct answer: D

Rationale: In hypernatremia, there is an excess of sodium in the blood. Reviewing food labels for sodium content is crucial as it helps the client identify and avoid high-sodium foods, which can contribute to elevated sodium levels. Monitoring urine output volume may be important for other conditions but is not directly related to managing hypernatremia. Drinking water whenever thirsty is generally good advice for staying hydrated but does not specifically address the issue of high sodium levels. Using salt tablets would worsen hypernatremia by further increasing sodium intake.

2. At 6-8 weeks of pregnancy, the breast changes include:

Correct answer: C

Rationale: At 6-8 weeks of pregnancy, one of the changes in the breast includes the prominence of Montgomery's tubercles. These sebaceous glands around the nipple become more noticeable at this stage. Colostrum production usually occurs later in pregnancy, typically closer to the third trimester. While breast tenderness is a common symptom of early pregnancy, it is not specific to the 6-8 week timeframe. Nipples becoming more prominent and mobile may happen later in pregnancy as the body prepares for breastfeeding, but it is not a typical change seen specifically at 6-8 weeks.

3. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?

Correct answer: B

Rationale: A fever of 103 degrees Fahrenheit indicates that the infection is not under control despite antibiotic therapy. Fever is a common sign of ongoing infection or inadequate response to treatment. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically indicative of the effectiveness of antibiotic therapy in treating infective endocarditis.

4. Which of the following is a key symptom of hyperthyroidism?

Correct answer: A

Rationale: The correct answer is weight loss. In hyperthyroidism, there is an excess production of thyroid hormones leading to an increased metabolic rate. This increased metabolism can result in weight loss despite normal or increased appetite. Choice B (Weight gain) is more commonly associated with hypothyroidism where the metabolic rate is decreased. Choice C (Tachycardia) is another common symptom of hyperthyroidism due to the effects of thyroid hormones on the heart, causing an increased heart rate. Choice D (Dry skin) is not a typical symptom of hyperthyroidism; instead, it is more commonly associated with hypothyroidism.

5. Basal body temperature rise of _____ is seen in the luteal phase due to the thermogenic effects of a metabolite of progesterone in a normal cycle:

Correct answer: B

Rationale: A basal body temperature rise of 0.2-0.5 degrees Celsius is typically seen in the luteal phase of the menstrual cycle due to the thermogenic effects of a metabolite of progesterone. This temperature rise helps to indicate ovulation has occurred. Choices A, C, and D are incorrect as they do not reflect the usual range of temperature increase observed during the luteal phase. A rise of 0.1-0.5 degrees Celsius is too narrow (eliminating choice A), while ranges of 1.0-2.0 and 1.5-2.0 degrees Celsius are too high and not consistent with the expected basal body temperature changes during the menstrual cycle.

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