HESI/Saunders Review, HESI/Saunders Online Review- Module 10-Physiological Health Problems QUESTIONS AND ANSWERSLATEST UPDATE

extremities reflect improvement in the symptoms associated with Guillain-Barré but are not specific to a respiratory outcome.

A nurse on the telemetry unit is caring for a client who has had a myocardial infarction and is now attached to a cardiac monitor. The nurse, monitoring the client's cardiac rhythm, notes the rhythm depicted in the image. Which of the following nursing actions should the nurse take?
(Rhythm is continuous up and down in pic)
A) Calling the rapid response team
B) Preparing the client for cardioversion
C) Asking the client to bear down and cough
D) Preparing to administer diltiazem (Cardiazem)
- ANSWER>>Answer: A
Rationale: This pattern indicates ventricular fibrillation (VF). Clients who have sustained a myocardial infarction are at great risk for VF. With the onset of VF the client feels faint, then immediately loses consciousness and becomes pulseless and apneic. There is no blood pressure, and heart sounds are absent. The goals of treatment are to terminate VF promptly and convert it to an organized rhythm. Because defibrillation is the immediate treatment, the nurse must call the rapid response team and initiate cardiopulmonary resuscitation. The client would not be able to bear down or cough. Cardioversion is a synchronized countershock that may be performed in emergencies for unstable ventricular or supraventricular tachydysrhythmias or electively for stable tachydysrhythmias that are resistant to medical therapies such as the administration of diltiazem (Cardiazem).

A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which of the following interventions does the nurse incorporate into the plan to prevent this complication?
A) Keeping a fan running in the client's room
B) Keeping the linens wrinkle-free under the client
C) Limiting bladder catheterization to once every 12 hours
D) Avoiding the administration of enemas and rectal suppositories
- ANSWER>>Answer: B
Rationale: The most frequent causes of autonomic dysreflexia are a distended bladder and impacted feces in the rectum. Straight catheterization should be performed every 4 to 6 hours, and the Foley catheter should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize risk in these areas.

A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further instruction?
A) "I need to get more fluids and fiber into my diet."
B) "I should cut my food into small pieces before I eat."
C) "I need to put powder under the vest twice a day to prevent sweating."
D) "I have to check the pin sites every day and watch for signs of infection."
- ANSWER>>Answer: C
Rationale: The client should cleanse the skin under the lambs-wool liner each day to prevent rashes or sores. Powder or lotions should be used only sparingly or not at all because they may cake, resulting in skin irritation. The client should increase intake of fluid and fiber to help prevent constipation. Food should be cut into small pieces to facilitate chewing and swallowing. The client should also use a straw for drinking. The pin sites should be checked daily for signs of infection.

A nurse is caring for client with increased intracranial pressure (ICP). In which position should the nurse maintain the client?
A) Supine, with the head extended
B) Side-lying, with the neck flexed
C) Supine, with the head turned to the side
D) Head midline and elevated 30 to 45 degrees
- ANSWER>>Answer: D
Rationale: The client with increased ICP should be positioned with the head in a neutral midline position. It is the responsibility of the nurse to ensure that all those delivering care to the client maintain the proper positioning. The client should avoid flexing or extending the neck or turning the neck side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positioning promotes venous drainage from the cranium to keep ICP down.

A client with a basilar skull fracture has clear fluid leaking fro