Evolve HESI Practice

When a client with schizophrenia who is receiving an antipsychotic medication begins to exhibit a shuffling gait and tremors, and the primary health care provider prescribes the anticholinergic medication benztropine, 2 mg daily, which symptom would the nurse inquire about when assessing the client?

1. Constipation

2. Hypertension

3. Increased salivation

4. Excessive perspiration

1

Rationale

The anticholinergic activity of each medication is magnified, and adverse effects such as paralytic ileus may occur. Hypotension, not hypertension, occurs with anticholinergic medications. Dryness of the mouth, not increased salivation, occurs with anticholinergic medications. Decreased, not increased, perspiration occurs with anticholinergic medications.

Anticholinergics are a class of medications that block the action of acetylcholine, a neurotransmitter that plays a crucial role in the parasympathetic nervous system, which is responsible for "rest and digest" functions. By blocking acetylcholine, these drugs can inhibit various bodily functions, including muscle contractions, gland secretions, and heart rate.

Which postpartum complication would the nurse monitor for in a client with hydramnios?

1. Infection

2. Hemorrhage

3. Hypertension

4. Thromboembolism

2

Rationale

A client with hydramnios is at risk for hemorrhage in the postpartum period. Infection, hypertension, and thromboembolism are not specific risk factors related to hydramnios.

When evaluating fluid loss for a client with burns, which relationship between a clients burned body surface area and fluid loss would the nurse consider?

1. Equal

2. Unrelated

3. Inversely related

4. Directly proportional

4

Rationale

There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.

Which finding in older adult clients is associated with aging?

1. Decrease in height

2. Decreased neck rigidity

3. Increased fine-motor dexterity

4. Increased range of motion (ROM)

1

Rationale

Loss of height and deformity and shortening of the trunk are common in older adults because of vertebral compression and degeneration. Rigidity in the neck, shoulders, back, hips, and knees increases with age because of loss of elasticity in ligaments, tendons, and cartilage. A decline in fine-motor dexterity occurs in the older adult because of slow impulse conduction along motor units. Range of motion (ROM) is limited in the older adult because of cartilage erosion, increased friction between the bones, and overgrowth of bone around joint margins.

Which guideline would the nurse consider when planning care for a hospitalized older client with Alzheimer disease?

1. Physical contact will increase dependency needs.

2. Routines provide stability for clients with neurocognitive disorders.

3. Regressive behavior should be interrupted immediately.

4. Procedures do not have to be explained to clients with neurocognitive disorders.

2

Rationale

Routines provide stability for clients with neurocognitive disorders. Rituals and routines in activities of daily living provide a framework and structure for clients with Alzheimer disease, adding to their sense of safety and security. Touch is a universal message that denotes caring; it can be soothing and will not encourage dependency, and touch may have to be used judiciously depending upon the stage of Alzheimer disease.

Regressive behavior under stress has a calming effect and should be allowed. Care should be explained to all clients; simple declarative statements are usually understood by clients with Alzheimer disease.

Which test would the nurse identify as specific for the diagnosis of myasthenia gravis?

1. Electromyography

2. Pyridostigmine test

3. Edrophonium chloride test

4. History of physical deterioration

3

Rationale

The edrophonium chloride test uses a medication that is a cholinergic and an anticholinesterase; it blocks the action of cholinesterase at the myoneural junction and inhibits the destruction of acetylcholine. Its action of increasing muscle strength is immediate for a short time. The results of electromyography will be added to the database, but they are nonspecific. Pyridostigmine is a slower-acting anticholinesterase medication that is commonly prescribed to treat myasthenia gravis; edrophonium chloride is used instead of pyridostigmine to diagnose myasthenia gravis because, when injected intravenously, it immediately increases muscle strength for a short time. The results of a history and physical are added to the database, but the data collected are not as definitive as another specific test for the diagnosis of myasthenia gravis.

Which statement describes the goal of case management?

1. Maximizes the skill level of all care providers.

2. Integrates care with cost-effective approaches.

3. Eliminates the need for unlicensed assistive personnel (UAP).

4. Ensures all resources for client care are located within a geographical location.

2

Rationale

The goal of case management is to provide cost-effective care through integration of clinical services in combination with financial services. Maximizing the skill level of all care providers is a feature of team nursing. Eliminating the need for UAP is a feature of primary nursing. Ensuring all resources for client care are located within a geographical location is a feature of client-focused care.

The nurse is caring for a 9-month-old infant with gluten-induced enteropathy. Which common term for this disorder would the nurse use when discussing the infant's diagnosis with the parents?

1. Megacolon

2. Celiac disease

3. Cystic fibrosis

4. Intussusception

2

Rationale

Celiac disease, celiac sprue, and gluten-sensitive enteropathy are terms used interchangeably for the same pathophysiologic process. Aganglionic megacolon, also referred to as Hirschsprung disease, is characterized by chronic constipation; it is not a gluten-induced enteropathy. Although similar to celiac disease in many of its clinical manifestations, cystic fibrosis is an inherited disorder characterized by increased viscosity of mucous gland secretions throughout the body, not a gluten-induced enteropathy. Intussusception is an intestinal anomaly that causes invagination or telescoping of one portion of the intestine into another; it is an acute problem rather than a chronic disorder and is not a gluten-induced enteropathy.

A client is receiving haloperidol for agitation, and the nurse is monitoring the client for side effects. Which response identified by the nurse is unrelated to an extrapyramidal tract effect?

1. Akathisia

2. Opisthotonos

3. Oculogyric crisis

4. Hypertensive crisis

4

Rationale

A hypertensive crisis is not associated with extrapyramidal tract symptoms. Akathisia, characterized by restlessness and twitching or crawling sensations in the muscles, is an extrapyramidal side effect. Opisthotonos, characterized by hyperextension and arching of the back, is an extrapyramidal side effect. Oculogyric crisis, characterized by the uncontrolled upward movement of the eyes, is an extrapyramidal side effect.