a nurse is assessing a client with a suspected diagnosis of hypocalcaemia which of the following clinical manifestations would the nurse expect to not

HESI LPN

Leadership and Management HESI Test Bank

1. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

A. Twitching
B. Positive Trousseau's sign
C. Hyperactive bowel sounds
D. Hyperactive deep tendon reflexes

Correct answer: A

Rationale: The correct answer is A: Twitching. Hypocalcemia often presents with neuromuscular irritability, leading to manifestations such as twitching. Trousseau's sign is actually a positive indicator of hypocalcemia, not negative, making choice B incorrect. Hypoactive bowel sounds are not typically associated with hypocalcemia, making choice C incorrect. Similarly, hypoactive deep tendon reflexes are not a common finding in hypocalcemia, making choice D incorrect.

2. A client is in DKA, secondary to infection. As the condition progresses, which of the following symptoms might the nurse see?

A. Kussmaul's respirations and a fruity odor on the breath
B. Shallow respirations and severe abdominal pain
C. Decreased respirations and increased urine output
D. Cheyne-Stokes respirations and foul-smelling urine

Correct answer: A

Rationale: In diabetic ketoacidosis (DKA), as the condition progresses, the body tries to compensate for the acidic environment by increasing the respiratory rate, leading to Kussmaul's respirations. The accumulation of ketones in the body causes a fruity odor on the breath. Option A is correct because Kussmaul's respirations and a fruity odor on the breath are classic signs of DKA. Option B is incorrect because shallow respirations are not typically seen in DKA, and severe abdominal pain is more commonly associated with conditions like pancreatitis. Option C is incorrect as decreased respirations are not a typical finding in DKA, and increased urine output is more commonly seen in conditions like diabetes insipidus. Option D is incorrect because Cheyne-Stokes respirations are not characteristic of DKA, and foul-smelling urine is not a prominent symptom in this condition.

3. How do the public view nurses today?

A. Nurses are assistants to physicians.
B. Nurses view the person within the family and community.
C. Nurses are different from other health-care providers.
D. Nurses are closely involved in shaping the health care of the future.

Correct answer: A

Rationale: The correct answer is A: 'Nurses are assistants to physicians.' The public image of nurses, as portrayed by the media, often positions them as assistants to physicians. This perception stems from historical depictions and the traditional hierarchy within healthcare settings. Choice B is incorrect because it reflects how nurses perceive their patients, not how the public views nurses. Choice C is incorrect as nurses are part of the broader healthcare team but are not seen as fundamentally different from other healthcare providers by the public. Choice D is incorrect as while nurses play a crucial role in shaping healthcare, the public perception often focuses more on their supportive role in the healthcare system.

4. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. I can use another nurse's password as long as I log off after using the computer
B. I should encrypt personal health information when sending emails
C. I can post the client's vital signs in the client's room
D. I should discard personal health information documents in the trash before leaving the unit

Correct answer: B

Rationale: The correct answer is B because encrypting personal health information when sending emails is a crucial aspect of maintaining client confidentiality. This process ensures that sensitive information is protected during electronic communication. Choice A is incorrect as sharing passwords violates client confidentiality. Choice C is incorrect as posting client's vital signs breaches confidentiality. Choice D is incorrect as discarding personal health information in the trash can lead to unauthorized access.

5. Select the cranial nerve that is accurately paired with its name.

A. The fourth cranial nerve: The trochlear nerve
B. The twelfth cranial nerve: The hypoglossal nerve
C. The tenth cranial nerve: The olfactory nerve
D. The thirteenth cranial nerve: The auditory nerve

Correct answer: B

Rationale: The twelfth cranial nerve is the hypoglossal nerve, which controls the muscles of the tongue. The other choices are incorrect because the trochlear nerve is the fourth cranial nerve responsible for eye movement, the olfactory nerve is the first cranial nerve responsible for the sense of smell, and there are only twelve cranial nerves, so there is no thirteenth cranial nerve.