Nursing 246 HESI practice (Latest 2024/ 2025 Update) Questions and Verified Answers |100% Correct| Grade A The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) Diminished hair on legs Bruising on extremities Skin cool to touch Capillary refill less than 3 seconds Darkened skin on extremities Diminished hair on legs Skin cool to touch Capillary refill less than 3 seconds Rationale Diminished hair on the legs and skin that is cool to touch are symptoms of decreased arterial blood flow. The other options are not indicators for impaired peripheral circulation.The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) Diminished hair on legs.Bruising on extremities.Skin cool to touch.Capillary refill less than 3 seconds. 1 / 3
Darkened skin on extremities.Skin cool to touch.Capillary refill less than 3 seconds.Rationale Diminished hair on the legs and skin that is cool to touch are expectant signs of decreased arterial blood flow.The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk of diabetes insipidus (DI)?High fever.Low blood pressure.Muscle rigidity.Polydipsia.Polydipsia.Rationale A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia). DI can occur when there has been damage or injury to the pituitary gland or hypothalamus as a result of head trauma, tumor or an illness such as meningitis. This damage interrupts the ADH production, storage and release causing the excessive urination and thirst.The registered nurse (RN) is teaching a client who is being discharged after treatment of tuberculosis (TB). Which cultural issues should the RN assess when preparing the client for discharge? (Select all that apply.) Native language.Education level.Type of lifestyle.Financial resources.Previous medical history.Native language. 2 / 3
Education level.Type of lifestyle.Rationale To ensure compliance the client's native language, education level, lifestyle, and financial resources should be considered when preparing the client's discharge instructions about the continuation of treatment for TB.The registered nurse (RN) is caring for an older client who has been bedridden for two weeks.Which assessment findings indicate to the RN that the client is developing a complication related to immobility?Decreased pedal pulses.Edema in upper extremities.Loss of appetite for food.Stiffness in right ankle joint.Stiffness in right ankle joint.Rationale Stiffness in joints is an early sign of contractures and muscle atrophy related to inactivity and immobility.The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate?Reduced pain and minimized brusing.Lowering of body core temperature.Increased circulation around injury.Reabsorption of edema at injury.Reduced pain and minimized brusing.Rationale Cold applications produce a topical anesthetic effect to reduce pain as well as constricts blood vessels to minimize bruising.
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