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MDA 224 2019 HESI EXIT V2 NEW

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22. A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? A) Converse with the... client to determine if the mucous membranes are impaired B) Report hourly outputs of less than 30 ml/hr C) Monitor client's ability for movement in the bed D) Check skin turgor every 4 hours The correct answer is B: Report output of less than 30 ml/hr 23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? A) Our child had chickenpox 6 months ago. B) Strep throat went through all the children at the day care last month. C) Both ears were infected over 3 months age. D) Last week both feet had a fungal skin infection. The correct answer is B: Strep throat went through all the children at the day care last month. 24. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcement of the manipulative behaviorC) Confront the client about the negative effects of behaviors on other clients and staff D) Develop a behavior modification plan that will promote more functional behavior The correct answer is A: Discuss the feeling of reluctance with an objective peer or supervisor 25. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C) Was appropriate in view of the client’s history of violence D) Was necessary to maintain the therapeutic milieu of the unit The correct answer is A: May result in charges of unlawful seclusion and restraint 26. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety related to pain The correct answer is A: Pain related to ischemia [Show More]

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