Question

While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

Answer 1

Correct Answers:

Weakened cough effort.

Rationale :

🔷 In amyotrophic lateral sclerosis (ALS), progressive muscle weakness can affect respiratory muscles, including those responsible for coughing.

🔷 A weakened cough effort indicates impaired ability to clear secretions, increasing the risk for aspiration and respiratory failure.

🔷 This finding demands immediate intervention as it may precede respiratory compromise.

🔷 Other signs like inappropriate laughter or asymmetrical weakness are concerning but less urgent.

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Answer 2

Correct Answers

Renal dysfunction [ Chronic Gout ]
Visible tophi [ Chronic Gout ]
Low grade fever [ Acute Gout Attack ]
Pain at the affected joint [ Acute Gout Attack ]
Occur in more than 1 joint Chronic Gout [ Acute Gout Attack ]

Rationale :

🔶 Acute gout presents with intense joint pain and fever and may affect multiple joints.

🔶 Chronic gout is associated with tophi (urate crystal deposits) and renal involvement due to long-term uric acid accumulation.

🔶 Both stages can involve multiple joints, especially in advanced or untreated disease.

🔶 Distinguishing acute vs. chronic helps guide treatment strategies and dietary education.

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Answer 3

Correct Answers:

A. Obesity
Hypertension
Drinks beer nightly
Daily aspirin
Type 2 diabetes mellitus

Rationale :

💠 Obesity, hypertension, and alcohol intake (beer) are well-documented risk factors for hyperuricemia and gout.

💠 Daily aspirin impairs renal uric acid excretion, increasing urate levels.

💠 Type 2 diabetes also contributes to metabolic disturbances, increasing gout risk.

💠 Identifying modifiable risk factors helps reduce attack frequency and severity.

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Answer 4

Correct Answers:

Liver
Shrimp
Sardines

Rationale :

🔴 These foods are high in purines, which are metabolized into uric acid—the main culprit in gout attacks.

🔴 Clients with gout should avoid organ meats, shellfish, and anchovy-type fish.

🔴 Foods like garlic, quinoa, and oranges are generally safe.

🔴 Diet education is key in preventing flare-ups and chronic complications.

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Answer 5

Correct Answers:

Eating patterns of dietary intake

Rationale :

🟣 Chronic pancreatitis pain is often triggered or worsened by eating, especially fatty meals.

🟣 Assessing dietary intake helps determine if symptoms are related to enzyme deficiency or meal composition.

🟣 Diet modification (low-fat, small meals) is essential for pain control and nutrient absorption.

🟣 Stool color or bowel sounds are helpful but not directly linked to pain origin.

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Answer 6

Correct Answers:

Morphine.

Rationale :

🟡 Morphine is the analgesic of choice in acute myocardial infarction (MI) due to its ability to relieve pain, reduce anxiety, and decrease cardiac workload.

🟡 It also causes venodilation, reducing preload and oxygen demand.

🟡 Other opioids like fentanyl or oxycodone are not preferred in this setting.

🟡 Early use supports cardiac stability and symptom relief.

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Answer 7

Correct Answers:

Confirm that this is an effective technique to help with ambulation

Rationale :

🔶 Freezing episodes in Parkinson’s can be overcome using cueing strategies, like imagining lines or stepping over cracks.

🔶 This technique helps patients initiate movement and is a validated self-management strategy.

🔶 Encouragement enhances mobility confidence and independence.

🔶 No need to assess cognition unless other symptoms present.

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Answer 8

Correct Highlights :

he just couldn't catch his breath.
his inhaler was expired and was worried the medication was not working.

Rationale :

💎 The client’s inability to breathe and expired rescue inhaler indicate ineffective asthma control and need for urgent care.

💎 These are key subjective cues of deteriorating respiratory status.

💎 Other statements provide context but do not directly affect intervention urgency.

💎 Timely inhaler access and updated action plans are crucial.

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Answer 9

Correct Answers:

Acute pain related to renal calculus

Rationale :

✳️ Renal colic causes severe, unrelenting pain, which is a priority concern.

✳️ Pain can increase sympathetic responses, complicating vital signs and delaying treatment.

✳️ Nausea and vomiting are secondary to pain; aspiration is not the most immediate risk here.

✳️ Pain management improves comfort and diagnostic cooperation.

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Answer 10

Correct Answers

Blank 1 Correct Option: impaired gas exchange
Blank 2 Correct Option: "I just can't catch my breath."

Rationale :

✔️ The client’s oxygen saturation (88%) and visible dyspnea point to impaired gas exchange, not just bronchospasm or anxiety.

✔️ The statement “I just can’t catch my breath” reflects air trapping and poor alveolar ventilation.

✔️ Prompt oxygen administration, bronchodilators, and steroids are indicated.

✔️ Clinical findings take priority over emotional or contextual comments.

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Options	Acute Gout Attack	Chronic Gout
Renal dysfunction
Visible tophi
Low grade fever
Pain at the affected joint
Occur in more than 1 joint Chronic Gout

RN-Hesi Medical Surgical Exam

No.

1 :
While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

Correct Answers

Answer Options

Answer Options

5 :
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

6 :
A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider

7 :
The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

8 :
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack that began after jogging through a local park.

Correct Highlights :

9 :
A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

10 :
A nurse caring for a male patient in the ED.

Correct Answers

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RN-Hesi Medical Surgical Exam

No.

1 : While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

Correct Answers

Answer Options

Answer Options

5 : The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

6 : A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider

7 : The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

8 : A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack that began after jogging through a local park.

Correct Highlights :

9 : A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

10 : A nurse caring for a male patient in the ED.

Correct Answers

1 :
While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

5 :
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

6 :
A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider

7 :
The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

8 :
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack that began after jogging through a local park.

9 :
A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

10 :
A nurse caring for a male patient in the ED.