Question

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

Answer 1

Correct Answers:

Review food labels for sodium content.

Rationale :

🧂Clients with hypernatremia need to carefully limit their sodium intake, making it essential to review food labels for sodium content to prevent worsening of the condition.

📋Reading food labels helps clients identify hidden sources of sodium in processed and packaged foods, such as canned soups and frozen meals.

⚠️Avoiding high-sodium items supports correction of the electrolyte imbalance and prevents fluid retention or neurological complications.

💡Education about sodium sources empowers the client in managing their condition and supports adherence to dietary modification for hypernatremia control.

📌Core Message

Clients with hypernatremia must reduce sodium intake by carefully reading food labels, which helps avoid hidden sodium and supports electrolyte and fluid balance.

Answer 2

Correct Answers:

High levels of carbon dioxide have accumulated in the blood.

Rationale :

🌬️Respiratory acidosis results from the accumulation of carbon dioxide (CO₂) in the bloodstream due to ineffective ventilation.

🫁This buildup of CO₂ leads to a decrease in blood pH, creating an acidic environment in the body.

🧪The lungs normally remove CO₂, but when gas exchange is impaired, CO₂ retention occurs and acidity rises.

📉Unlike hyperventilation, which reduces CO₂ and causes alkalosis, this condition is caused by hypoventilation or respiratory failure.

📌Core Message

Respiratory acidosis occurs when CO₂ accumulates in the blood due to impaired ventilation, leading to a low pH and disruption of acid-base balance.

Answer 3

Correct Answers:

Administer a PRN IV antiemetic as prescribed.

Rationale :

💉Projectile vomiting places the client at risk for aspiration, which makes it a priority symptom requiring immediate action.

🚨Prompt administration of the prescribed IV antiemetic helps reduce the vomiting, stabilizes the patient, and facilitates further assessment.

🧑‍⚕️Although a neurological assessment is critical, it should follow once the acute symptom of vomiting has been addressed to minimize complications.

📊Knowing medication history or prior neurologic status is important but does not treat the current life-threatening complication.

📌Core Message

Managing projectile vomiting in a confused client is essential to prevent aspiration and reduce ICP, making the immediate use of a PRN antiemetic the priority.

Answer 4

Correct Answers:

Improved mental status.

Rationale :

🧠Lactulose lowers ammonia levels in the blood by promoting its excretion through the bowel.

🪠Its therapeutic goal in hepatic encephalopathy is not to form solid stools, but to cause loose stools to trap and expel ammonia.

🧾Improved cognitive and mental function signals that ammonia levels are decreasing effectively.

🚫Changes in urine output or ambulation ability are not the primary indicators of lactulose’s success in this context.

📌Core Message

Lactulose improves mental status in clients with hepatic encephalopathy by reducing blood ammonia levels, which is the primary therapeutic goal.

Answer 5

Correct Answers:

Escort the client to the cafeteria.

Rationale :

🧍Clients with Huntington’s disease often have cognitive and motor impairments that affect navigation and judgment.

🚶‍♂️Escorting the client ensures safety and accommodates their functional limitations more effectively than verbal or visual cues.

🗺️Tools like maps or color-coded signs may be confusing due to neurological deficits and are less reliable.

💬Verbal instructions alone may overwhelm the client or be easily forgotten due to cognitive impairment.

📌Core Message

Clients with Huntington’s disease benefit most from direct physical assistance due to cognitive and motor impairments, making escorting the safest approach.

Answer 6

Correct Answers:

Advise the client that healing typically takes several weeks to occur.

Rationale :

📆Proton pump inhibitors like lansoprazole require several weeks to achieve full therapeutic effect, especially in cases of erosive esophagitis.

💊Reassuring the client about the normal timeline supports medication adherence and reduces premature concern.

🕓Adjusting the dose or notifying the provider is premature at this stage unless symptoms worsen or adherence is poor.

📚Client education about realistic expectations helps prevent unnecessary medication changes and promotes continued use.

📌Core Message

Healing from erosive esophagitis takes time, so clients should be reassured that lansoprazole’s effects may take several weeks to fully resolve symptoms.

Answer 7

Correct Answers:

Topical corticosteroids.

Rationale :

🧴Topical corticosteroids are the first-line treatment for psoriasis, effectively reducing inflammation and plaque formation.

🔥They directly address the burning and bleeding symptoms by calming immune activity in affected skin areas.

🧊While analgesics may help discomfort, they do not reduce scaling or immune response like corticosteroids do.

🌿Other treatments like antifungals or oatmeal lotions may soothe but do not treat the underlying autoimmune cause of psoriasis.

📌Core Message

Topical corticosteroids are the standard for treating psoriasis, as they reduce inflammation, scaling, and discomfort caused by the autoimmune process.

Answer 8

Correct Answers:

For long-term control of normal eye pressure.

Rationale :

👁️Open-angle glaucoma is a chronic condition that requires lifelong management to prevent optic nerve damage.

💧Prescribed eye drops help maintain normal intraocular pressure (IOP) and must be used consistently for effectiveness.

📆Stopping the drops can cause pressure to rise again, leading to vision loss or progression of disease.

💬The goal is not temporary relief but ongoing control to preserve eyesight.

📌Core Message

Clients with open-angle glaucoma must use eye drops long-term to maintain normal IOP, preventing progressive vision loss.

Answer 9

Correct Answers:

Increase the daily intake of oral fluids to liquefy secretions.

Rationale :

💧Thick mucus in asthma and bronchitis can obstruct airflow and worsen shortness of breath.

🧃Increasing oral fluids helps loosen secretions, making them easier to expectorate and improving breathing.

💬While anxiety reduction is helpful, it does not directly address the airway clearance issue.

🏥Avoiding crowds may prevent infection but does not assist with the current symptom of thick mucus buildup.

📌Core Message

Oral fluid intake is critical for clients with respiratory conditions to thin mucus secretions, improving airway clearance and breathing.

Answer 10

Correct Answers:

Severity of nausea and vomiting and serum amylase results.

Rationale :

🧪Serum amylase is a key lab marker that reflects pancreatic inflammation, making it essential for confirming pancreatitis.

🤢Nausea and vomiting are classic signs of acute pancreatitis and indicate worsening gastrointestinal distress.

📞Reporting both findings allows the provider to assess the severity and determine the urgency of interventions.

📉Other findings like bowel sounds or H. pylori are less urgent or not directly related to the acute pancreatic process.

📌Core Message

The combination of serum amylase elevation and nausea/vomiting severity provides critical evidence for pancreatitis diagnosis and intervention planning.

WGU HESI RN D444 Adult health I Exam

No.

1 :
Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

2 :
A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

3 :
A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

4 :
A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

5 :
Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

6 :
A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

7 :
A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

8 :
A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

WGU HESI RN D444 Adult health I Exam

No.

1 : Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

2 : A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

3 : A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

4 : A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

5 : Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

6 : A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

7 : A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

8 : A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

1 :
Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

2 :
A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

3 :
A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

4 :
A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

5 :
Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

6 :
A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

7 :
A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

8 :
A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?