Hesi Medical Surgical 1

Correct Answer A: Assist the client with learning how to set priorities and pace activities.

Explanation of the correct answer:

Fatigue in clients with rheumatoid arthritis (RA) is often exacerbated by the inability to rest comfortably due to joint pain and inflammation. One of the most effective interventions is to assist the client in learning how to set priorities and pace their activities. This approach helps the client balance rest with necessary tasks, which can reduce fatigue and prevent overexertion. By pacing activities, the client can manage energy more effectively, reducing the overall burden of fatigue.

Why the other options are incorrect:

B. Instruct the client about the importance of maintaining bedrest:

While rest is important for individuals with RA, prolonged bedrest is not recommended as it can lead to muscle weakness, joint stiffness, and overall deconditioning. Instead of encouraging bedrest, the nurse should focus on providing guidance on how to rest effectively while also engaging in light activities that promote mobility and muscle strength.

C. Consult the discharge planner about transferring the client to an assisted living center:

Transferring a client to an assisted living center is not immediately necessary for a client with rheumatoid arthritis unless there is a significant decline in their ability to function independently. The nurse should focus on managing the client's current needs, such as teaching strategies for managing fatigue, rather than making assumptions about long-term care requirements. This decision would be based on a thorough assessment of the client’s condition and the presence of other complications.

D. Offer assurance that the fatigue-inducing stage of the disease does not last:

Rheumatoid arthritis is a chronic condition, and fatigue may be a persistent issue, even during periods of remission. Offering reassurance that fatigue will not last is misleading and fails to acknowledge the chronic nature of the disease. Instead, the nurse should focus on helping the client manage fatigue through effective strategies, such as pacing activities and prioritizing rest.

Correct Answer D: Instruct the client to stop taking the antibiotics.

Explanation of the correct answer:

The client is exhibiting signs of an allergic reaction to the antibiotic, including a rash, itchy skin, wheezing, and an elevated heart rate. These symptoms are consistent with an allergic reaction or anaphylaxis, which can occur with antibiotic use, particularly with drugs like penicillin or cephalosporins. The nurse should instruct the client to stop taking the antibiotic immediately and notify the healthcare provider to avoid further complications. If the reaction progresses to anaphylaxis, it can be life-threatening, so prompt action is necessary.

Why the other options are incorrect:

A. Apply a hypoallergenic cream to the rash:

Although a rash can occur with an allergic reaction, applying a hypoallergenic cream is not the priority intervention in this case. The rash, in combination with wheezing and an elevated heart rate, suggests a more serious systemic allergic reaction that could worsen. Stopping the antibiotic is the first priority before considering topical treatments.

B. Provide a mask for the client to wear:

While the client may need a mask if they are coughing or have a contagious condition like a respiratory infection, the symptoms described here are more consistent with an allergic reaction rather than an infectious disease. Providing a mask will not address the immediate concern of the allergic reaction.

C. Swab the throat for a rapid strep test:

The client has already been diagnosed with a Streptococcal throat infection and has been on antibiotics for three days. The symptoms described (rash, wheezing, elevated heart rate) are not related to the strep infection but to a possible allergic reaction to the prescribed antibiotic. Re-testing for strep is unnecessary at this point.

Correct Answer A: Reports muscle twitching in hands and feet.

Explanation of the correct answer:

After a total thyroidectomy, a common complication is hypocalcemia, which occurs due to inadvertent damage to the parathyroid glands. The parathyroid glands regulate calcium levels in the blood, and damage to them can lead to decreased calcium levels. One of the classic signs of hypocalcemia is muscle twitching or spasms, particularly in the hands and feet, as well as tingling sensations (also known as tetany). Therefore, muscle twitching in the hands and feet should be reported as a possible complication after thyroidectomy.

Why the other options are incorrect:

B. Diaphoretic, but denies any headache:

While diaphoresis can be a symptom of a variety of conditions, including thyroid imbalances or stress, it is not specifically indicative of a complication immediately following a thyroidectomy. Since the client denies headache, this finding alone is not sufficient to suggest a complication like hypocalcemia or other common postoperative issues such as hemorrhage or infection.

C. Denies muscle spasms in extremities:

The absence of muscle spasms is not a concern following a thyroidectomy. In fact, it is reassuring to know that the client does not report muscle spasms, as this would suggest that hypocalcemia (which causes spasms) is not present. Therefore, this finding does not indicate a complication.

D. Notes back and joint tenderness and pain:

Back and joint pain can occur due to various reasons, such as positioning during surgery or general discomfort following surgery. However, this type of pain is not specific to thyroidectomy complications and does not raise immediate concern. It is important to assess for more concerning symptoms like tetany or other signs of electrolyte imbalances after a thyroidectomy.

Correct Answer: B. Ensure that zidovudine is given within 6 hours after birth.

Why this is the correct answer:

B. Ensure that zidovudine is given within 6 hours after birth.

Infants born to HIV-positive mothers require antiretroviral prophylaxis to reduce the risk of vertical HIV transmission. Zidovudine should be initiated within 6 hours of birth and continued for several weeks. This intervention is the highest priority because it directly impacts the infant’s long-term risk of HIV infection.

Why the other options are incorrect:

A. Obtain consent for the hepatitis B vaccine.

Hepatitis B vaccination is important but unrelated to HIV exposure. It can be administered later as part of routine newborn care, not as the immediate priority.

C. Collect venous specimen for serum glucose level.

Serum glucose testing is indicated for infants at risk of hypoglycemia (such as infants of diabetic mothers or small/large for gestational age), but not for HIV-exposed infants unless clinically warranted.

D. Assess for the presence of the Moro reflex.

Neurological reflex assessment is part of the routine newborn exam but is not a priority when compared to administering antiretroviral prophylaxis to prevent HIV transmission.

Correct Answer A. The diaper area shows severe skin breakdown.

Why this is the correct answer:

A. The diaper area shows severe skin breakdown.

Severe diaper rash indicates a physical problem that can cause significant discomfort and pain. For a 3-month-old, this pain may explain why the infant wakes frequently at night and cannot settle. Addressing this skin breakdown is critical not only to relieve discomfort and restore sleep but also to prevent complications such as infection. Immediate intervention to treat the diaper area is essential in planning care.

Why the other options are incorrect:

B. The mother is a single parent and lives with her parents.

Although social factors influence caregiving, this does not directly explain the infant’s sleep disturbance. The most pressing issue is the infant’s physical discomfort, which needs immediate treatment before addressing family structure.

C. The infant's formula has been changed twice.

Frequent formula changes may cause mild gastrointestinal upset, but this is less urgent than severe skin breakdown. Formula changes should be reviewed, but they are not the most significant factor contributing to disrupted sleep in this situation.

D. The mother reports the baby is irritable during feedings.

Feeding irritability is concerning and warrants follow-up, but it is not as urgent as severe skin breakdown. Pain from skin irritation is more likely to cause immediate and ongoing distress, leading to poor sleep, making option A the priority.

Correct Answer B: Confirm that this is an effective technique to help with ambulation.

Why this is the correct answer:

The client with Parkinson’s disease is using a known and effective compensatory strategy to overcome freezing of gait, which is a common motor symptom. Techniques such as pretending to step over a line or crack, using visual cues, or counting can help initiate movement and prevent falls. This method is cognitively purposeful and appropriate, demonstrating that the client is aware of their limitations and has adopted a strategy to remain mobile. The nurse should validate and encourage this approach as it promotes safety and autonomy.

Why the other options are incorrect:

A. Assist the client to a carpeted area where he can walk more easily.

Carpeted surfaces may increase the risk of tripping and falling for clients with Parkinson’s due to uneven footing or increased resistance. There is no evidence that a carpeted area helps with freezing of gait; it could, in fact, make walking more difficult.

C. Plan to assess the client's cognition after returning to his room.

This response implies that the client’s behavior is inappropriate or cognitively impaired, which it is not. The client is demonstrating a deliberate and effective strategy, not confusion or disorientation. Planning a cognitive assessment would not be warranted based on this specific behavior.

D. Re-orient the client to his present location and circumstances.

Re-orienting is unnecessary and inappropriate here because the client is not disoriented. The action of pretending to step over a crack is intentional, not a sign of confusion. This response could discourage the use of a helpful coping strategy.

Correct Answer C: Determine the client's current glucose level.

Why this is the correct answer:

The client’s symptoms of diaphoresis (sweating), a rapid heartbeat, and feeling shaky suggest the possibility of hypoglycemia (low blood glucose), which is a common side effect of insulin therapy, especially in individuals with type 2 diabetes mellitus who may not be accustomed to insulin. The first priority is to confirm whether the symptoms are indeed due to hypoglycemia by checking the current glucose level. This will guide the nurse's subsequent actions. If the blood glucose is low, the appropriate interventions can be started immediately.

Why the other options are incorrect:

A. Give the client one-half cup of fruit juice.

While fruit juice is a common treatment for hypoglycemia, it should only be administered after confirming the low blood glucose level. If the blood glucose level is already normal or high, giving fruit juice could be harmful. Therefore, it is important to first check the glucose level before administering anything.

B. Give the client skim milk and crackers.

This is another appropriate treatment for hypoglycemia (because it contains both carbohydrate and protein), but, like the fruit juice, it should only be given after confirming the client’s blood glucose level. Administering it without knowing the glucose level could result in inappropriate treatment.

D. Assess the client's oxygen saturation level.

While oxygen saturation might be important to assess in certain situations (e.g., respiratory distress or heart failure), hypoglycemia is most likely the cause of the client’s symptoms in this case. The first step should be to confirm whether hypoglycemia is the issue by checking the blood glucose level. If the glucose level is low, oxygen saturation would not be the priority in this scenario.

Correct Answer:

A. Designate an established area for study

E. Maintain a consistent home schedule

F. Create an organization chart for tasks

Why this is the correct answer:

A. Designate an established area for study.

Children with ADHD benefit from studying in a structured, distraction-free environment. A designated study area reduces interruptions and helps the child focus on tasks. It also establishes a routine, which is essential for maintaining attention and completing schoolwork consistently.

E. Maintain a consistent home schedule.

Predictability in daily activities helps children with ADHD regulate behavior and reduces frustration. A consistent schedule provides security and minimizes distractions by letting the child know what to expect. This structure supports time management and improves both academic and social functioning.

F. Create an organization chart for tasks.

Breaking tasks into smaller steps using an organization chart helps children with ADHD complete assignments and chores more effectively. It gives them visual reminders, promotes independence, and prevents feelings of being overwhelmed. Structured task management is a proven behavioral strategy in ADHD care.

Why the other options are incorrect:

B. Know that medication is the best approach to treatment.

Medication can be helpful, but it is not always the best or only approach. Behavioral therapy and structured interventions are equally important, especially for long-term management.

C. Understand that nonstimulant medications show little benefit in treatment.

This is incorrect because nonstimulant medications, such as atomoxetine or guanfacine, can be effective alternatives when stimulants are not tolerated or contraindicated.

D. Anticipate being automatically entered into a specialized education plan.

ADHD does not guarantee an IEP. Some children qualify for accommodations under a 504 plan instead, depending on their academic needs and how ADHD affects their performance.

Correct Answer D: Discuss with the client that these levels are likely temporary.

Explanation of the correct answer:

A decrease in insulin requirements can sometimes be observed in clients with type 1 diabetes, especially during the initial phase of the disease or in response to treatment adjustments. However, such a change is typically temporary and can be associated with factors like insulin sensitivity, improved management, or changes in lifestyle. In some cases, this can also signal that the client is nearing a phase where insulin production may further decline, or that other factors (e.g., stress, illness) may be affecting their insulin needs. Therefore, the most appropriate response is to explain that these changes are likely temporary and that close monitoring of blood glucose levels is essential to adjust insulin needs as necessary.

Why the other options are incorrect:

A. Advise the client to include more carbohydrates in the diet:

Recommending increased carbohydrate intake is not appropriate in this situation. While carbohydrate intake affects insulin needs, advising increased carbohydrates without proper monitoring may lead to hypoglycemia or an imbalance in the client’s overall blood glucose management. The focus should be on the observation of insulin requirements and blood glucose levels, not immediate dietary changes.

B. Graph the client's blood glucose testing results for a week:

Although tracking blood glucose levels is a useful tool for monitoring diabetes, the current concern is about a change in insulin requirements. Rather than focusing on the graphical representation of the data, it is more important to address the client’s question and discuss the potential temporary nature of the insulin change with clear reasoning.

C. Explain that the client is experiencing glycemic control:

While improved glycemic control may be an outcome of better management, simply telling the client that this is glycemic control could be misleading. The decrease in insulin requirements may not necessarily be due to improved long-term control but rather could reflect temporary changes in the body or management of diabetes. This does not confirm that the diabetes is improving in the long run.