HESI RN Fundamentals Exam I | Nurselytic

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HESI RN Fundamentals Exam I Questions

Extract:

History and physical

The client is a 44-year-old male with cerebral palsy who is non-verbal and has severe intellectual disability. He requires total care at home, which is provided by his two sisters, a home health nurse, and an unlicensed home health aide. The client is currently in the hospital for a lower respiratory infection.
Nurses notes
1000
Noted the client's clothes and sheets are wet. The client voided approximately 75 mL of urine. The client's sister says that he usually wears adult diapers at home as he is unable to communicate when he needs to void.


Question 1 of 5

Review H and P and nurse's note.Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Action to Take

Create a toilet training program;Place an indwelling catheter;Place an incontinence containment product under the client;Teach the client to use mobility aids;Provide skin care

Potential Condition

Urge incontinence;Reflex urinary incontinence;Overflow urinary incontinence;Functional incontinence

Parameter to Monitor

Intake and output;Blood pressure;Postvoid residual volume;Skin integrity;Blood glucose

Correct Answer:

Rationale: Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.

Extract:


Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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