HESI RN EVOLVE Medical-Surgical Assignment Exam.

Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing? A: Respiratory effort. B: Unsteady gait. C: Intensity of pain. D: ...

Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing? A: Respiratory effort. B: Unsteady gait. C: Intensity of pain. D: Ability to eat. A: Respiratory Effort (Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition progresses, the nurse must ensure that the client is able to breathe effectively.) A male client comes into the clinic with a history of penile discharge with painful, burning urination. Which action should the nurse implement? A: Collect a culture of the penile discharge. B: Palpate the inguinal lymph nodes gently. C: Observe for scrotal swelling and redness. D: Express the discharge to determine color. A: Collect a culture of the penile discharge. (Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of the penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed through culture to identify the organism and ensure effective treatment.) A client with history of atrial fibrillation is admitted to the telemetry unit with sudden onset of shortness of breath. The nurse observes a new irregular heart rhythm and should perform which assessment at this time? A: Check for a pulse deficit. B: Palpate the apical impulse. C: Inspect jugular vein pulse. D: Examine for a carotid bruit. A: Check for a pulse deficit. (A client with a past history of atrial fibrillation may return to that rhythm. Any signs of atrial fibrillation, such as sudden onset shortness of breath, requires further investigation. The nurse should assess this client for a pulse deficit because this condition occurs with atrial fibrillation.) Which client should be further assessed for an ectopic pregnancy? A: A 24-year-old with shoulder and lower abdominal quadrant pain. B: A 33-year-old with intermittent lower abdominal cramping. C: A 20-year-old with fever and right lower abdominal colic. D: A 40-year-old with jaundice and right lower abdominal pain. A: A 24-year-old with shoulder and lower abdominal quadrant pain. (A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for an ectopic pregnancy. The pain can also be referred to the shoulder and may be associated with vaginal bleeding.) Which dietary assessment finding is most important for the nurse to address when caring for a client with diabetic nephropathy? A: Drinks a six pack of beer every day. B: Enjoys a hamburger once a month. C: Eats fortified breakfast cereal daily. D: Consumes beans and rice every day. A: Drinks a six pack of beer every day. (Drinking six beers every day is the dietary assessment finding most important for the nurse to address when caring for a client with diabetic nephropathy. The usual can of beer is 12 ounces (355 mL). Clients with diabetes are recommended to drink no more than 12 ounces of beer per day because beer contains carbohydrates that can create unhealthy fluctuations in blood glucose and promote poorglucose control. Nephropathy is exacerbated by poor blood glucose control.) Which assessment finding is of greatest concern to the nurse who is caring for a client with stomatitis? A: Cough brought on by swallowing. B: Sore throat caused by speaking. C: Painful and dry oral cavity. D: Unintended weight loss. A: Cough brought on by swallowing. A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular concern in a client with stomatitis. Dysphagia can cause numerous problems, including airway obstruction, and should be reported to the healthcare provider immediately. The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system complication should the nurse include in the teaching? A: Altered sexual response. B: Sterility. C: Urinary incontinence. D: Decreased pelvic muscle tone. A: Altered sexual response. Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing of the arteries and reduced blood flow to the extremities. PAD is known to alter the blood flow to the male's penis and is associated with erectile dysfunction in men. A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk factor for myocardia infarction? A: Oral contraceptives. B: Senile osteopenia. C: Levothyroxine therapy. D: Pernicious anemia. A: Oral contraceptives. Women older than 35 years old who smoke and take oral contraceptives have an increased risk of myocardial infarction or stroke. A client has been told that there is cataract formation over both eyes. Which finding should the nurse expect when assessing the client? A: Decreased color perception. B: Presence of floaters. C: Loss of central vision. D: Reduced peripheral vision. A: Decreased color perception. Decreased color perception occurs with cataract formation. Cataract formation is also associated with blurred vision and a global loss of vision so gradual that the client may not be aware of it. Which assessment finding should most concern the nurse who is monitoring a client two hours after a thoracentesis? A: New onset of coughing. B: Low resting heart rate. C: Distended neck veins. D: Decreased shallow respirations. A: New onset of coughing. A pneumothorax (partial or complete lung collapse) is the potential complication of a thoracentesis. Manifestations of a pneumothorax include new onset of a nagging cough, tachycardia, and an increased shallow respiration rate. While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? A: Monitor infusing IV fluids and any replacement blood products. B: Prepare for esophagogastroduodenoscopy (EGD). C: Maintain the client on strict bedrest. D: Insert a nasogastric tube (NGT) for intermittent suction. A: Monitor infusing IV fluids and any replacement blood products (Maintaining hemodynamic stability in a client with esophageal varices can precipitate a life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products.) The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? A: Urine output of 40 mL/hour. B: Apical pulse 100 and blood pressure 76/42. C: Urine specific gravity 1.001. D: Tented skin on dorsal surface of hands. A: Urine output of 40 mL/hour. A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal range, 40 mL/hour, the client's kidneys are perfusing adequately and indicates the client's status is stablizing Upgrade to remove ads Only $3.99/month After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? A: Position client on left side with pillow placed under the costal margin. B: Assist the client with voiding immediately after the procedure. C: Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. D: Ambulate client 3 times in first hour with pillow held at abdomen. C: Evaluate vital signs q10 to 20 minutes for 2 hours after procedure.