HESI Exit (Questions and answers) 2022 update. 100% pass rate.

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HESI Exit (Questions and answers) 2022 update. 100% pass rate. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complicati... on should the nurse monitor closely? A. Hypokalemia B. Ketonuria. C. Peripheral edema D. Elevated blood pressure - ✔✔A. Hypokalemia Pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias. A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned about this regression in toileting. Which information should the nurse provide the parents? A. A retraining program will need to be initiated when the child returns home. B. Diapering will be provided since hospitalization is stressful to preschoolers. C. Children usually resume their toileting behaviors when they leave the hospital. D. A potty chair will be brought from home so he can maintain his toileting skills. - ✔✔C. Children usually resume their toileting behaviors when they leave the hospital. The parents should be reassured that once the child is back in his familiar environment, he is likely to resume using the toileting behaviors (C). Retraining (A) is unlikely to be needed and such information might be distressing to the parents. (B) does not address the parents' concern. Bringing a potty chair from home (B) is likely to increase the child's stress because he is being encouraged to perform toileting skills while he remains in unfamiliar surroundings. The family of an older woman reports that they are no longer capable of caring for her at home. While performing the admission assessment at a long-term care facility, the nurse determines that the client is in continent of urine, has dry mucous membranes, and has a large bruise on the coccyx. What interventions should the nurse include in the plan of care? (Select all that apply.) A. Thicken liquids and provide pureed foods. B. Apply a barrier cream to perianal areas. C. Report suspicion of elder abuse. D. Implement toilet training program. E. Offer beverages at frequent intervals. - ✔✔B. Apply a barrier cream to perianal areas. D. Implement toilet training program. E. Offer beverages at frequent intervals. The plan of care should include measures to prevent skin breakdown due to the incontinence using a barrier cream (B) and a toileting program (D) to help reduce the incidence of incontinence. Dry mucous membranes indicate the need for increased fluids (E). Further assessment is needed before the other interventions are indicated. Sleep apnea - obesity - ✔✔Obesity is a risk factor for OSAS, and calculation of BMI provides data related to obesity. A BMI of 30.00 and above is considered obese. pyloric stenosis- preop - ✔✔Hydrating an infant prior to surgery with prescribed IV fluids is the highest priority bc vomiting associated with pyloric stenosis often contributes to dehydration. diabetes insipidus - ✔✔Pituitary tumors that suppress ADH result in DI, which can cause massive polyuria and serum electrolytes imbalances, including hypokalemia which can lead to lethal arrythmias. acute pancreatitis - care - ✔✔The pathophysiologic processes in AP result form oral fluid and food ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis of the pancreas. The main focus of nursing care is reducing pain caused by pancreatic destruction through interventions that decrease GI activity such as keeping the pt NPO. Sex in a hospital room - ✔✔Coming upon a client and visitor engaged in sexual activity requires the nurse to use clinical judgement and sensitivity. The nurse should leave and provide privacy. Eczema pruritis - ✔✔Antiinflammatory actions of topical corticosteroids and oral antihistamines provide relief from severe itching. (pruritis) Paralytic ileus- volvulus - ✔✔A paralytic ileus develops due to local inflammatory reactions of the bowel and its innervation that cause the failure of normal peristalsis action through the GI tract. The intestinal volvulus that occured due to surgery is the pathological mechanism associated with the pt presentation. Cardiac ablation- delegate - ✔✔Ablation therapy uses radiofrequency, microwave, laser or cryothermy to ablate areas of the cardiac system that are the source of ectopic cardiac dysrhythmias, which can cause syncope. Skin preparation including hair removal can be delegated to the UAP. TIAs- POC - ✔✔A TIA is an arterial event that causes temporary O2 deficit to the brain and manifests with signs of a stroke or CVA, which resolves in less than 24 hours without permanent damage. To assist in determining the course of treatment, the nurse should conduct focused neurological assessments every two hours to identify resolution of symptoms in the first 24 hours. Postpartum infection - ✔✔temperature 100.4 F or higher on any two consecutive postpartum days exclusive of the first 24 hrs; chills; tachycardia. Foul-smelling lochia (vaginal discharge after birth) is indicative of endometritis (infection of the lining of the uterus) Diaper rash- skin care - ✔✔Changing the diaper more often helps to decrease the amount of time the skin comes in contact with wet soiled diapers and helps heal the irritation. Addisons- teach - ✔✔During times of stress, something as simple as the common cold can require additional corticosteroids to avoid a life-threatening adrenal crisis for the client with Addison's disease, so it is important to include this information in the teaching plan. Psoriasis- psychosocial - ✔✔Touch, more than any other gesture communicates acceptance of the client with a sin problem such as psoriasis. While the other options are worthwhile nursing interventions, they do not address this client's need for acceptance. Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? a) Intermittent claudication b) Acute limb ischemia c) Dizziness d) Vertigo - ✔✔Intermittent claudication often reported as severe cramping pain in the extremities after activity is the hallmark symptom of peripheral arterial insufficiency. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease. Platelet inhibitor - urine monitoring - POC Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To reduce the risk of adverse effects from the medication, which assessment should the nurse include in this client's plan of care? A. Observe color of urine. [Show More]

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