a male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight which additional information

HESI LPN

Medical Surgical Assignment Exam HESI Quizlet

1. A male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?

A. What time he took his medication?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours he slept last night?

Correct answer: B

Rationale: The correct answer is B: 'Has his weight changed in the last several days?' Sudden weight gain can indicate fluid retention, which is a common symptom of worsening heart failure. The inability to put on tight shoes can be due to fluid retention leading to swelling in the feet and ankles. Choices A, C, and D do not directly address the potential fluid retention issue and are less relevant in this scenario.

2. A client with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What do these symptoms indicate?

A. Hypoglycemia
B. Diabetic ketoacidosis (DKA)
C. Hyperosmolar hyperglycemic state (HHS)
D. Insulin shock

Correct answer: B

Rationale: Polyuria, polydipsia, and polyphagia are classic signs of diabetic ketoacidosis (DKA), which occurs due to a combination of hyperglycemia and ketone production. Hypoglycemia (Choice A) is characterized by low blood sugar levels, leading to symptoms like confusion, shakiness, and sweating, which are different from the symptoms described in the scenario. Hyperosmolar hyperglycemic state (HHS) (Choice C) typically presents with severe hyperglycemia, dehydration, and altered mental status, rather than the triad of symptoms mentioned. Insulin shock (Choice D) refers to a severe hypoglycemic reaction due to excessive insulin, manifesting with confusion, sweating, and rapid heartbeat, not the symptoms seen in the client with diabetes mellitus described in this scenario.

3. What is a causative factor of Hirschsprung disease?

A. Frequent evacuation of solids, liquid, and gases
B. Excessive peristaltic movement
C. The absence of parasympathetic ganglion cells in a portion of the colon
D. One portion of the bowel telescoping into another

Correct answer: C

Rationale: The correct answer is C: The absence of parasympathetic ganglion cells in a portion of the colon is a causative factor of Hirschsprung disease. This absence leads to the inability of the affected segment of the colon to relax, causing a functional obstruction. Choices A, B, and D are incorrect. Frequent evacuation of solids, liquid, and gases, excessive peristaltic movement, and one portion of the bowel telescoping into another are not causative factors of Hirschsprung disease.

4. What is the best position for a client experiencing a nosebleed?

A. Sitting up and leaning forward
B. Lying flat with a pillow under the head
C. Sitting up and leaning back
D. Lying on the side with the head elevated

Correct answer: A

Rationale: The best position for a client experiencing a nosebleed is sitting up and leaning forward. This position helps prevent blood from flowing down the throat and reduces the risk of aspiration. Choice B is incorrect as lying flat can lead to blood flowing down the throat. Choice C is also incorrect because leaning back may cause blood to flow backward into the throat. Choice D is incorrect as lying on the side with the head elevated is not the optimal position to manage a nosebleed effectively.

5. Since children with attention deficit hyperactivity disorder (ADHD) take medication for long periods of time, side effects must be considered. How often should children be assessed for side effects of the drug therapy?

A. Every 2 months
B. Every 4 months
C. Every 6 months
D. Every 8 months

Correct answer: C

Rationale: Children with ADHD who are on long-term medication therapy should be assessed for side effects every 6 months. This timeframe allows healthcare providers to monitor the effects of the medication and make any necessary adjustments. Checking every 2 months (Choice A) may be too frequent and not practical for routine monitoring, while checking every 4 or 8 months (Choices B and D) may lead to missing potential side effects or delays in addressing them.