Question

A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.

Answer 1

Correct Answers:

Affirm that a person with shingles has a history of chickenpox infection.
Distinguish the difference between herpes varicella and herpes zoster.

Rationale :

🧬Shingles is caused by reactivation of the varicella-zoster virus, which lies dormant in nerve ganglia after a chickenpox infection.

🦠It is accurate to affirm that shingles only develops in people previously infected with chickenpox, clarifying the client’s assumption.

🔍Distinguishing herpes varicella (chickenpox) from herpes zoster (shingles) helps the client understand they are different manifestations of the same virus.

📚While prior chickenpox infection is necessary for shingles, it does not prevent the virus from reactivating, especially in older or immunocompromised individuals.

📌Core Message

Clients should be taught that prior chickenpox does not guarantee protection from shingles, which results from reactivation of the dormant varicella-zoster virus.

Answer 2

Correct Answers:

Higher doses of insulin.

Rationale :

📈Infections cause the body to release stress hormones, such as cortisol, which increase blood glucose levels.

💉This hyperglycemic response often necessitates temporary insulin dose adjustments in diabetic clients to maintain proper glucose control.

🩺The nurse should prepare the client for the possibility of higher insulin needs during illness, even if their usual regimen is well-managed.

⚠️Failure to adjust insulin can result in hyperglycemia or diabetic ketoacidosis, especially during systemic infections.

📌Core Message

During infections, clients with diabetes may need increased insulin due to the body’s stress-induced rise in blood glucose.

Answer 3

Correct Answers:

Dyspnea and sinus tachycardia.

Rationale :

😮Dyspnea and tachycardia are signs of fluid overload or cardiac strain, common in acute kidney injury.

⚠️These symptoms require immediate attention as they may indicate life-threatening complications like pulmonary edema or heart failure.

🩺AKI leads to impaired fluid excretion, causing excess volume and placing strain on the cardiovascular system.

💡Prompt intervention is necessary to prevent respiratory compromise and further clinical deterioration.

📌Core Message

In acute kidney injury, symptoms like dyspnea and tachycardia suggest fluid overload and require urgent intervention.

Answer 4

Correct Answers:

Provide an eye shield to be worn while sleeping.

Rationale :

🛡️An eye shield is essential to protect the surgical site from trauma during sleep.

😴It helps avoid accidental rubbing or pressure, which can impair healing or cause infection.

🦠Post-operative eye care focuses on minimizing irritation and exposure to contaminants.

📚Immediate protective interventions are prioritized over teaching or general assessments.

📌Core Message

Post-eye surgery, using an eye shield during sleep is key to protecting the eye and promoting safe healing.

Answer 5

Correct Answers:

Peritonitis.

Rationale :

🔥Redness, tenderness, and drainage at the catheter site are signs of localized infection that can lead to peritonitis.

⚠️Peritonitis is a serious complication of peritoneal dialysis and can result in sepsis if untreated.

🧪Prompt recognition and intervention can prevent widespread abdominal infection and protect peritoneal function.

🩺Nurses must closely monitor and act on any signs of infection at the catheter exit site to avoid this critical outcome.

📌Core Message

Peritonitis is a serious risk in peritoneal dialysis when exit site infections are present and demands immediate action.

Answer 6

Correct Answers:

Structured exercise.

Rationale :

🚶‍♂️Structured exercise improves circulation and reduces symptoms of intermittent claudication in PAD.

💪It promotes arterial collateral development, helping oxygen reach tissues more efficiently.

📋Regular walking plans can increase pain-free walking distance and improve quality of life.

⚠️Interventions like leg elevation or massage do not target the underlying arterial obstruction.

📌Core Message

Clients with peripheral artery disease benefit from structured exercise to enhance circulation and reduce pain with walking.

Answer 7

Correct Answers:

Continuous cardiac monitoring.

Rationale :

⚡Electrical injuries can disrupt the heart's electrical activity, causing arrhythmias.

💓Continuous cardiac monitoring is vital to detect life-threatening rhythm disturbances early.

🩺Entry and exit wounds indicate that electric current passed through the body, likely crossing the heart.

🧭Early detection allows for rapid intervention to prevent cardiac arrest or complications.

📌Core Message

Clients with electrical injuries require continuous cardiac monitoring due to the risk of arrhythmias from current exposure.

Answer 8

Correct Answers:

Serum sodium of 185 mEq/L (185 mmol/L).

Rationale :

💧A sodium level of 185 mEq/L indicates severe hypernatremia, which can cause neurologic impairment or death.

🧠Symptoms may include seizures, confusion, and coma, requiring immediate correction.

💉This is a hallmark complication of diabetes insipidus, due to excessive water loss and concentration of serum sodium.

⚠️Among all findings, this is the most urgent because it reflects a critical electrolyte imbalance needing immediate treatment.

📌Core Message

A severely elevated sodium level in diabetes insipidus signals life-threatening dehydration and requires immediate correction.

Answer 9

Correct Answers:

A grandson and his new dog recently visited.

Rationale :

🐾Exposure to new environmental allergens like pet dander is a common trigger for eczema flare-ups.

🏡A visit from someone with a new pet introduces novel irritants or allergens that may not be present in the client’s usual environment.

📋This history provides useful and relevant information to identify the cause of an exacerbation.

🔬The presence of an animal can lead to contact dermatitis or airborne allergen reactions, worsening eczema symptoms.

📌Core Message

Pet exposure is a potential external trigger for eczema and should be investigated when symptoms worsen.

Answer 10

Correct Answers:

Increases the amount of dopamine available for muscles to function correctly.

Rationale :

🧪Parkinson’s disease is associated with low dopamine levels in the brain, affecting movement.

💊Carbidopa-levodopa helps by supplementing dopamine, which improves motor control.

📉Carbidopa prevents peripheral breakdown of levodopa, allowing more dopamine to reach the brain.

⚙️Improved dopamine availability leads to better muscle coordination and reduced tremors.

📌Core Message

Carbidopa-levodopa works by increasing dopamine levels, which helps restore motor function in Parkinson’s disease.

HESI RN Med- surg 2024 Exam-5

No.

1 :
A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.

2 :
A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the nurse tell the client to expect?

3 :
The nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?

4 :
A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

5 :
A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?

6 :
The nurse is developing home care instructions for a client with peripheral artery disease (PAD). Which intervention should the nurse include?

7 :
A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client's plan of care?

8 :
A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?
Reference Range: Sodium (136 to 145 mEq/L)

9 :
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

10 :
When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include?

HESI RN Med- surg 2024 Exam-5

No.

1 : A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.

2 : A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the nurse tell the client to expect?

3 : The nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?

4 : A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

5 : A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?

6 : The nurse is developing home care instructions for a client with peripheral artery disease (PAD). Which intervention should the nurse include?

7 : A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client's plan of care?

8 : A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?Reference Range: Sodium (136 to 145 mEq/L)

9 : During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

10 : When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include?

1 :
A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.

2 :
A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the nurse tell the client to expect?

3 :
The nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?

4 :
A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

5 :
A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?

6 :
The nurse is developing home care instructions for a client with peripheral artery disease (PAD). Which intervention should the nurse include?

7 :
A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client's plan of care?

8 :
A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?
Reference Range: Sodium (136 to 145 mEq/L)

9 :
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

10 :
When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include?