HESI RN Med-Surg Exam
VERSION 11
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INCORRECT
Tremors
INCORRECT
Obese extremities
Answer Rationale:
Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between the shoulders, is a common manifestation of Cushing's syndrome.Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are a common manifestation of Cushing's syndrome. This is due to the collection of body fat in these areas.Moon face is correct. Moon face is a common manifestation of Cushing's syndrome.Clients who have this manifestation present with a round, red, full face.Tremors is incorrect.Tremors are not a common finding of Cushing's syndrome.Obese extremities is incorrect.Clients who have Cushing's syndrome have truncal obesity, a protuberant abdomen, with thin extremities, which is due to an alteration in protein metabolism.A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) Encourage fluid intake.
Monitor the puncture site for hematoma.
INCORRECT
Insert a urinary catheter.
INCORRECT
Elevate the client’s head of bed.
INCORRECT
Apply a cervical collar to the client.
Answer Rationale: 2 / 4
Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to replace the cerebrospinal fluid that was removed during the procedure and reduce the risk for a headache.
Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a hematoma at the insertion site because this can indicate bleeding.
Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion.
Elevate the client’s head of bed is incorrect. The client should remain flat in bed for 1 hr or more to reduce the risk for a headache.
Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for this client.A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) Decreasing anxiety Controlling emesis
INCORRECT
Relaxing skeletal muscles
INCORRECT
Preventing surgical site infections
Reducing the amount of narcotics needed for pain relief
Answer Rationale:
Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective antianxiety agent and is used to decrease anxiety in surgical clients as well as in persons with moderate anxiety.
Controlling emesis is correct. The nurse should include that hydroxyzine is an effective antiemetic and is used to control nausea and vomiting in pre- and postoperative clients.
Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines, such as diazepam (Valium), are used to produce skeletal muscle relaxation. 3 / 4
Preventing surgical site infections is incorrect. The nurse should instruct the client that antibiotics administered prior to surgery are used to diminish the risk of surgical site infections; hydroxyzine, an antiemetic, does not have any effect on bacteria.
Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine increases the effects of narcotic pain medications. The nurse should instruct the client that when it is used for surgical clients, narcotic requirements may be significantly reduced.A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.)
INCORRECT
Polyuria Blurry vision Tachycardia
INCORRECT
Polydipsia Sweating
Answer Rationale:
Polyuria is incorrect. Hyperglycemia causes polyuria.
Blurry vision is correct. Manifestations of hypoglycemia include blurry vision, tremors, anxiety, irritability, headache, and hypotension.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia, tremors, anxiety, irritability, headache, and hypotension.
Polydipsia is incorrect. Hyperglycemia causes polydipsia.
Sweating is correct. Manifestations of hypoglycemia include sweating, tremors, anxiety, irritability, headache, and hypotension.A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)
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