HESI Diagnostic Exam- Integration (Answered)

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HESI Diagnostic Exam- Integration (Answered)-During a one-to-one session with the nurse, a female admitted for chronic depression and attempted suicide discloses experiences of sexual promiscuity and ... prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, "I don't remember, but my mother ran my father off when I was five." The nurse should recognize that the client may be using which defense mechanism? A. Denial B. Repression C. Regression D. Projection - A. Denial Two days after an abscess of the chin was drained, the client returns to the clinic with fever, chills, and a maculopapular rash with pruritus. The client has taken an oral antibiotic and cleaned wound today with providone-iodine solution. Which intervention should the nurse implement first? A. Review recent mediation history and allergies B. Assess airway latency and oxygen saturation C. Obtain samples for complete blood count and cultures. D. Determine if the client has a history of diabetes - B. Assess airway latency and oxygen saturation The nurse is evaluating a young child with atopic dermatitis. Which question should the nurse ask the parent while obtaining the child's history? A. What time of day does the rash appear on the body? B. Can any particular be associated with onset of the rash? C. Has the child displayed any symptoms of asthma or hay fever? D. Does the child have any nausea or vomiting? - C. Has the child displayed any symptoms of asthma or hay fever? Which client should the charge nurse assign to the care of a practical nurse (PN)? A. An adolescent with a chest tube that drained 500 mL in the past 8 hours. B. An adult who is receiving chemotherapy via an implanted venous access device. C. An older client who is receiving multiple antihypertensive medications. D. An adult type 1 diabetes mellitus who is receiving a titrated insulin infusion. - C. An older client who is receiving multiple antihypertensive medications. A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first? A. Test her urine for the presence of hematuria. B. Measure her temperature and pulse rate. C. Palpate the right flank for tenderness. D. Evaluate the urine for a strong odor. - A. Test her urine for the presence of hematuria. Following a disaster, which person should the nurse triage with a red tag, indicating that immediate attention is required? A. An older adult with emphysema who has a barrel chest and is coughing. B. A young adult with a history of asthma who is speaking in short sentences. C. A middle-aged man with acute coronary syndrome who has superficial facial lacerations. D. A frail elderly woman with degenerative disk disease who is complaining of back pain. - B. A young adult with a history of asthma who is speaking in short sentences. The nurse on the day shift receives report about a client with depression who was in bed most of the weekend. The nurse walks into the client's room in the morning and finds the client in bed. What intervention is best for the nurse to implement? A. Monitor the client's appetite and pattern of sleep B. Explain that staff will check on the client every 30 minutes C. Assist the client to get out of bed and involved in an activity D. Assess the client's feelings about hospital stay - C. Assist the client to get out of bed and involved in an activity Which action should the nurse take first when a client with systemic sclerosis (Scleroderma) exhibits symptoms of Raynaud's phenomenon? A. Initiate massage and stretching exercises B. Remove any pressure on the involved extremities C. Apply cool compresses to the involved area D. Elevate the involved extremities on pillows - A. Initiate massage and stretching exercises A client with partial-thickness and full-thickness burns over 50% of the body is admitted to the Emergency Department. The healthcare provider prescribes hydromorphone 4 mg IM every 4 hours for pain. The client is complaining of "9" on the 1 to 10 pain scale. Which intervention should the nurse implement first? A. Contact the healthcare provider and question the prescription B. Assist the client with relaxation techniques and guided imagery C. Rule out any complications prior to administering the medication D. Administer an additional dose of the medication into an unburned area - A. Contact the healthcare provider and question the prescription An adult with pneumonia is diaphoretic, tachycardia, and confused. The cardiac monitor indicates sinus tachycardia with frequent premature multifocal ventricular beats. Arterial blood gas (ABG) findings are: pH 7.26, PaCO2 66 mmHgl HCO3 23 mEq/L (22 mmol/L). Which intervention is most important for the nurse to include in this client's plan of care? A. Obtain a 12 lead electrocardiogram (ECG) daily B. Assess for apical-radial pulse deficit with vital signs C. Monitor the respiratory rate and depth continuously D. Maintain a patent IV catheter for antibiotic therapy - A. Obtain a 12 lead electrocardiogram (ECG) daily A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription would the nurse teach the client to use for the skin condition? A. Colloidal oatmeal-based lotion B. Topical corticosteroids C. Topical analgesics D. Topical antifungal - B. Topical corticosteroids [Show More]

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