2022 RN HESI EXIT EXAM - Version 1 (V1) All 160 Qs & As Included - Guaranteed Pass A+ (All Brand New Q&A Pics Included) 1. A client with gout experiences an acute attack. The client reports he has been trying to lose weight. Which client information is most important for the nurse to obtain? Serum cholesterol level (not related to the acute attack gout) Capillary glucose level (not related to the acute attack gout) Daily caloric intake (Starvation diet can cause an acute attack of gout) Daily calcium intake (not related to the acute attack gout) 2. A male client with a C-6 spinal cord injury is in rehabilitation. In the middle of the night he reports a severe, pounding headache, and has observable goose bumps. The nurse should assess for which trigger? Loud hallway noise (Not manifestation of autonomic hyperreflexia) Fever (Not manifestation of autonomic hyperreflexia) Full bladder Frequent cough (Not manifestation of autonomic hyperreflexia) * A pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high-level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder. 3. After learning that she as terminal pancreatic cancer, a female client becomes very angry and says to the nurse, “God has abandoned me. What did I do to deserve this”? Based on this response, the nurse deicides to include Which nursing problem in the client’s plan of care? Acute pain (physical pain less than 6 month) Spiritual distress (indicates anger toward God for her disease) Ineffective coping (not reflect) Complicated grieving (not reflect) 2022 RN HESI EXIT EXAM - Version 1 (V1) All 160 Qs & As Included - Guaranteed Pass A+ (All Brand New Q&A Pics Included) 2 4. A nurse working on an Endocrine Unit should see which client first? An Adolescent male with type 1 diabetes who is arguing about his insulin dose (dealt with at a later time) A older client with Addison’s disease whose current blood sugar level is 62 mg/dl (blood sugar level is low (normal 60 -110 mg/dl, but is not critical) An adult with a blood sugar of 384 mg/dl and a urine output of 350 ml in the last hour (exhibiting sign of diabetes insipidus, which include hyperglycemia & urine output, but this patient can be seen after corticosteroid pt) A client taking corticosteroids who has become disoriented in the last two hours (safety) * Rationale: safety is a priority intervention. Mania & psychosis can occur during corticosteroid therapy, which places the client at risk for injury, so this should be first seen. 5. A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and that she is going to take him home when he is discharged. Which action should the nurse implement next? Report the incident to the local Child Protective Service (further assessment is needed before implementing) Find a home health agency that specializes in brain injuries (further assessment is needed before implementing) Determine the mother’s basic skill level in providing care (client is manifesting disease syndrome complications, and the mother’s skill in providing basic care should be determined) Consult the ethics committee to determine how to proceed (further assessment is needed before implementing)read more
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