a nurse is preparing to discharge a client who as end stage heart failure the clients partner tells the nurse she can no longer handle caring for the

HESI LPN

Leadership and Management HESI Quizlet

1. A nurse is preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?

A. Request another family member to assist the client's partner with care
B. Recommend the partner to place the client in a long-term care facility
C. Contact the case manager to discuss discharge options
D. Ask the provider to delay the client's discharge home for a few more days

Correct answer: C

Rationale: The nurse should contact the case manager to discuss discharge options and support the client's partner. This action is appropriate as it involves seeking professional guidance and support for the client's partner who is struggling to care for the client. Option A is not the best choice as it solely focuses on involving another family member without addressing the partner's concerns directly. Option B is premature as recommending long-term care should be a well-considered decision involving multiple healthcare professionals. Option D delays the inevitable without providing a solution to the partner's current challenges.

2. Which patient is exercising their right to autonomy in the context of patient rights?

A. An 86-year-old female who remains independent in terms of the activities of daily living.
B. An unemancipated 16-year-old who chooses to not have an intravenous line.
C. A 32-year-old who does not need the help of the nurse to bathe and groom themselves.
D. A 99-year-old who wants CPR despite the fact that the nurse and doctor do not think that it would be successful.

Correct answer: D

Rationale: The correct answer is D. A 99-year-old exercising their right to autonomy in the context of patient rights by choosing CPR. Autonomy in healthcare refers to the patient's right to make their own decisions about their care, even if healthcare providers may disagree. In this scenario, the 99-year-old patient is exercising autonomy by making an informed choice about their medical treatment, despite healthcare professionals having a different opinion. Choices A, B, and C do not directly demonstrate the exercise of autonomy in decision-making regarding medical treatment, making them incorrect.

3. Which anatomic malformations are associated with Tetralogy of Fallot?

A. A sub-aortic septal defect, an overriding aorta, left ventricular hypertrophy, and right ventricular outflow
B. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and left ventricular outflow
C. A sub-aortic septal defect, an overriding aorta, pulmonary atresia, and right ventricular outflow
D. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow

Correct answer: D

Rationale: Tetralogy of Fallot is characterized by a combination of four heart defects: a sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow obstruction. This leads to mixing of oxygen-poor and oxygen-rich blood, resulting in cyanosis. Therefore, the correct answer is D. Choices A, B, and C are incorrect because they do not accurately describe the specific combination of anatomic malformations seen in Tetralogy of Fallot.

4. Which manifestation should the nurse expect to assess in a patient with fluid volume deficit?

A. Headache and muscle cramps
B. Dyspnea and respiratory crackles
C. Increased pulse rate and blood pressure
D. Orthostatic hypotension and flat neck veins

Correct answer: D

Rationale: Orthostatic hypotension and flat neck veins are classic manifestations of fluid volume deficit. When the body loses fluid, blood volume decreases, leading to decreased venous return to the heart, resulting in orthostatic hypotension and flat neck veins. Choices A, B, and C are more indicative of other conditions such as dehydration, respiratory issues, or compensatory mechanisms in response to hypovolemia, respectively.

5. Which of the following joints normally allows 360-degree circumflexion?

A. The knee
B. The shoulder
C. The elbow
D. The fingertips

Correct answer: B

Rationale: The correct answer is B: The shoulder. The shoulder joint is a ball-and-socket joint that allows for a wide range of motion, including 360-degree circumflexion. This joint provides flexibility and mobility in various directions. Choice A, the knee joint, primarily allows flexion and extension but does not have a 360-degree circumflexion. Choice C, the elbow joint, is a hinge joint that permits flexion and extension but not circumflexion. Choice D, the fingertips, do not form a specific joint that allows circumflexion; rather, they have joints that enable bending and straightening movements.