N125 HESI Adaptive Quizzing - Health Assessment I
What is the maximum recommended length for enema tube insertion in an adolescent?
10 cm
which reaction is an example of a type I hypersensitivity reaction? A. Anaphylaxis B. Serum sickness C. Contact dermatitis D. Blood transfusion reaction
A Answer: Anaphylaxis
A nurse is teaching a high school student about scoliosis treatment options. On what should the nurse focus? A. Effect on body image B. Least invasive treatment C. Continuation with schooling D. Maintenance of contact with peers.
A Answer: Effect on body image
Which joint is an example of a condyloid joint? A. Wrist Joint B. Elbow Joint C. Shoulder Joint D. Sacroiliac Joint
A Answer: Wrist
Which manifestation indicates tertiary syphilis? A. Chancre B. Alopecia C. Gummas D. Condylomata lata
C Answer: Gummas Rationale: Gummas are chronic, destructive lesions affecting the skin, bone, liver and mucous membranes occur during tertiary syphilis.
A client is diagnosed as having acquired immunodeficiency syndrome (AIDS). The client states, "I'm not worried because they have a cure for AIDS." The best response by the nurse is: A: "Repeated phlebotomies may be able to rid you of the virus." B: "You may be cured of AIDS after prolonged pharmacological therapy." C:"Perhaps you should have worn condoms to prevent contracting the virus." D: "There is no cure for AIDS but there are drugs that can slow down the virus."
D ANSWER: "There is no cure for AIDS but there are drugs that can slow down the virus." RATIONALE: This honest response corrects the client's misconception about the effectiveness of the current antiviral medications.
Which sexually transmitted infection causes condylomata acuminate? A. Chlamydia B. Gonorrhea C. Herpes simplex D. Human papillomavirus (HPV)
D Answer: Human papillomavirus (HPV) Rationale: Condylomata acuminate are genital warts that are caused by HPV. Genital warts are not caused by chlamydia, gonorrhea, or herpes simplex.
The nurse instructs the parents of an adolescent with asthma on how to reduce the allergens in the child's bedroom The mother tells the nurse what she plans to do to make the room hypoallergenic. Which idea indicates that further teaching is needed? A. Removing a stuffed animal collection B. Storing off-season clothing in another room C. Covering the mattress with a plastic slipcover D. Using flat outdoor carpeting to cover hardwood floor
D Answer: Using flat outdoor carpeting to cover hardwood floors Rationale: Hardwood floors can be cleaned more easily than rugs can and are more hypoallergenic than outdoor carpeting.
Which product would the nurse instruct intravenous drug users (IUD's) to use for cleaning needles and syringes between uses? A. Bleach B. Hot Water C. Ammonia D. Rubbing alcohol
A Answer: Bleach Rationale: IDUs should be instructed to fill syringes with household bleach and shake the syringe for 30 to 60 seconds.
An adolescent girl is concerned about her body image after amputation of a leg for bone cancer. After the nurse has obtained the girl's consent, what nursing action is most therapeutic? A. Encouraging her peers to visit B. Keeping her lower body covered C. Placing her in a room by herself D. Limiting her visitors to the family
A Answer: Encouraging her peers to visit Rationale: Peer acceptance.
Which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by respiratory syncytial virus (RSV)? A. Humidified cool air and adequate hydration B. Postural drainage and oxygen by hood C. Bronchodilators and cough suppressants D. Corticosteroids and broad-spectrum antibiotics
A Answer: Humidified cool air and adequate hydration Rationale: Humidified cool air and hydration are essential to facilitating improvement in the child's physical status.
Which hormone is released from the posterior pituitary gland? A. Oxytocin B. Prolactin C. Growth Hormone D. Luteinizing Hormone
A Answer: Oxytocin
How do toddlers learn self-protection? A. Through trial-and-error strategies B. By imitating playmates and siblings C. By obeying orders from mother and father D. By playing with age-appropriate toys and puzzles
A Answer: Through trial-and-error strategies
What is the causative organism for syphilis? A. Treponema pallidum B. Campylobacter jejuni C. Trichomonas vaginalis D. Chlamydia trachomatis
A Answer: Treponema pallidum
The spouse of a client with pulmonary tuberculosis (TB) received a tuberculin skin test. The nurse examined the skin test and identified an area of induration greater than 10mm. Which response to this finding would the nurse implement? A. No further action is required at this time. B. Additional tests are necessary to determine infection status. C. Immediately repeat the skin test for confirmation. D. Results are positive, indicating an active infection.
B Answer: Additional tests are necessary to determine infection status. Rationale: Additional tests are necessary to determine infection status. A client with an induration of 5 mm or greater is considered positive. If there is repeated close contact with a person diagnosed with pulmonary TB or if the client has a disease causing decreased resistance, this requires further diagnostic study, such as x-rays and sputum culture.
Which sexually transmitted infection (STI) is most commonly reported? A. Syplilis B. Chlamydia C. Gonorrhea D. Human immunodeficiency virus
B Answer: Chlamydia
A nurse revises the care plan when the client's responses indicate that goals have not been met. What phase of the nursing process is being applied? A. Planning B. Evaluation C. Assessment D. Implementation
B Answer: Evaluation
After a 4-year-old child undergoes craniotomy the nurse performs a neurologic assessment that includes level of consciousness, pupillary activity, and reflex activity. What else should the nurse include in this assessment? A. Blood pressure B. Motor function C. Rectal temperature D, Head circumference
B Answer: Motor function
After surgery, an adolescent has a patient-controlled (PCA) pump that is set to allow morphine delivery every 6 minutes. Which statement indicates to the nurse that the family understands instructions about the PCA pump? A. "I'll make sure that she pushes the PCA button every 6 minutes." B. "She needs to push the PCA button whenever she needs pain medication." C. "I'll have to wake her up on a regular basis so she can push the PCA button." D. "I'll press the PCA button every 6 minutes so she gets enough pain medication while she's sleeping."
B. Answer: "She needs to push the PCA button whenever she needs pain medication."
Which education would the nurse provide the parent of a preschool age child about how preschoolers view death? A. Universal B. Irreversible C. A form of sleep D. A frightening ghost
C Answer: A form of sleep Rationale: Between the ages of 3 and 5 years, death is viewed as a departure or sleep and as reversible. The universality and irreversibility of death are concepts held by children starting at 8 to 9 years of age.
Which term would the nurse use in a report to describe the absence of menstrual periods in a 35- year-old nonpregnant client? A. Rhinorrhea B. Meopause C. Amenorrhea D. Dyspareunia
C Answer: Amenorrhea Rationale: The absence of menstrual periods in a nonpregnant client younger than 55 years old is called amenorrhea. Rhinorrhea is an allergic state that is manifested by a runny nose. Menopause is cessation of menstruation after 55 years of age. Dyspareunia is pain during sexual intercourse.
The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective? A. Develop a basic teaching plan B. Ask the mother if she understands C. Observe the mother feeding the infant D. Determine the mother's readiness to learn
C Answer: Observe the mother feeding the infant
The nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client. Which is the volume of solution that would be prepared? A. 150 to 250 mL B. 250 to 350 mL C. 300 to 500 mL D. 500 to 750 mL
D Answer: 500 to 750 mL Rationale: In adolescents, the volume of solution required is 500 to 750 mL. The nurse would prepare 150 to 250 mL of warmed solution for infants. The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.
Which disorder would the nurse classify as neurodevelopment? A. Anxiety B. Bipolar disorder C. Schizophreniform disorder D. ADHD
D Answer: ADHD
Which surgery will a client undergo if pituitary gland must be removed? A.Mastectomy B. Prostatectomy C. Thyroidectomy D. Hypophysectomy
D Answer: Hypophysectomy A Hypophysectomy is the removal of the pituitary gland or its tumor.
Which antibody forms first, after exposure to an antigen? A. Immunoglobulin A (IgA) B. Immunoglobulin E (IgE) C. Immunoglobulin G (IgG) D. Immunoglobulin M (IgM)
D Answer: Immunoglobulin M (IgM)
A 3-month-old infant is admitted to the pediatric unit with a diagnosis of tetralogy of Fallot. The nurse's infant's weight has declined from the 25th percentile to the 5th. The nurse concludes that the most likely reason for this inadequate weight gain is: A. Cyanosis resulting in cerebral changes B. Decreased arterial oxygen level resulting in polycythemia C. Pulmonary hypertension resulting in recurrent respiratory infections. D. Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse
D Answer: Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse
An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. What should the nurse tell the girl that may help her wear the bracelet consistently? A. Hide the bracelet under long-sleeved clothes B. Wear the bracelet when engaging in contact sports. C. Ask her friends to wear bracelets that look like hers. D. Select a bracelet similar to bracelets worn by her peers
D Answer: Select a bracelet similar to bracelets worn by her peers
Which of these age groups has the highest incidence of lead poisoning A. Adults B. Toddler C. Adolescent D. School-age Child
B Answer: Toddler
A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement? A: "I'll start to have symptoms when I drink less fluid." B: "I'll start to have symptoms when I have fewer platelets." C: "I'll start to have symptoms when I decrease the iron in my diet." D: "I'll start to have symptoms when I have fewer white blood cells.
A Answer: "I'll start to have symptoms when I drink less fluid." Rationale: Dehydration precipitates sickling of rbc and is a major causative factor for painful episodes associated with sickle cell anemia.
Which hormone does the nurse state has both inhibiting and releasing action? A. Prolactin B. Somatostatin C. Somatotropin D. Gonadotropin.
A Answer: Prolactin
The parents of a 15-year-old adolescent who is being treated for allergies privately tell a nurse that they suspect that their child is a hypochondriac. What is the most therapeutic response by the nurse? A. Discussing developmental behaviors of adolescents B. Explaining potentially serious complications of allergies C. Discussing some of the underlying causes of hypochondriasis D. Explaining that the parents may be transferring their fears to their adolescent
A Answer: Discussing developmental behaviors of adolescents
While in the playroom of a pediatric unit the nurse sees several toddlers seated at a table trying to copy the same picture from a book. They are not talking to each other or sharing their crayons. What does the nurse conclude about this behavioral interaction? A. It is a typical expression of toddlers' social development B. This is an example of antisocial behavior found in some children C. It is a lack of parental role models to demonstrate acceptable behavior D. This is an illustration of separation anxiety typical of hospitalized toddlers
A Answer: It is a typical expression of toddlers' social development Rationale: parallel play
An adolescent visits the allergy clinic because of seasonal environmental allergies, and blood is drawn for testing. Which laboratory finding indicates to the nurse that an allergic response is in progress? A. Decreased platelet count B. Increased eosinophil level C. Increased lymphocyte count D. Decreased immunoglobulin level
B Answer: B. Increased eosinophil level Rationale: Eosinophils increase to inhibit the inflammatory response to histamine, which is released in allergic reactions.
Which structure protects a client's internal organs, supports blood cell production, and stores minerals? A. Joints B. Bones C. Muscles D. Cartilages
B Answer: Bones
Which disorder is caused by the deficiency of antidiuretic hormone? A. Acromegaly B. Diabetes insipidus C. Cushing syndrome D. Syndrome of inappropriate antidiuretic hormone
B Answer: Diabetes insipidus Rationale: Diabetes insipidus is caused by the deficiency of antidiuretic hormone.
Which component of the human personality, according to Freud, allows an individual to judge reality accurately? A. Id B. Ego C. Superego D. Oedipus complex
B Answer: Ego Rationale: The ego allows an individual to judge reality accurately.
Why is a multiple-gestation pregnancy considered a high risk? A. Postpartum hemorrhage is an expected complication. B. Perinatal mortality is two to three times more likely in multiple than in single births. C. Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. D. Maternal mortality is higher during the prenatal period in the setting of multiple gestation.
B Answer: Perinatal mortality is two to three times more likely in multiple than in single births. Rationale: Perinatal morbidity and mortality rates are higher with multiple-gestation pregnancies, because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increase the risk for complications.
Which stage of HIV would a client with a CD4+ T-cell count of 325 cells/mm 3 be classified? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
B Answer: Stage 2 Rationale: Stage 2 describes a client with a CD4+ T-cell count between 200 and 499 cells/mm3. Stage 1 describes a client with a CD4+ T-cell count of greater than 500 cells/mm3. Stage 3 describes a client with a CD4+ T-cell count of less than 200 cells/mm3. Stage 4 describes a client with a confirmed HIV infection but no information regarding CD4+ T-cell counts is available.
How many hours of sleep should the nurse recommend for the 11-year-old client? A. 8 B. 9 C. 11 D. 12
B Answer: 9
Which hormone is formed from cholesterol? A. Insulin B. Cortisol C. Prolactin D. Growth Hormone
B Answer: Cortisol Rationale: all lipid-soluble hormones are synthesized from cholesterol.
Which term describes the practice of placing clients with the same infection in a semi-private room? A. Isolating B. Cohorting C. Colonizing D. Cross-referencing
B Answer: Cohorting Rationale: Cohorting is the practice of grouping clients who are colonized or infected with the same pathogen. Isolating is limiting the exposure to individuals with an infection. Colonizing refers to the development of an infection in the body. Cross-referencing has nothing to do with an infectious process.
Which explanation will the nurse give when a client asks about what causes varicose veins? A. Abnormal configurations of the veins. B. Incompetent valves of superficial veins C. Decreased pressure within the deep veins D. Atherosclerotic plaque formation in the veins
B Answer: Incompetent valves of superficial veins Rationale: Incompetent valves results in retrograde venous flow and subsequent dilation of veins.
Which is the cause of milk anemia in toddlers? A. Drinking skim milk B. Drinking fruit juice C. Increased milk intake D. Increased intake of fruits
C Answer: Increased milk intake Rationale: Toddlers who consume more than 24 ounces of milk daily in place of other foods sometimes develop milk anemia because milk is a poor source of iron. Child
Which criteria would the nurse consider when determining if an infection is a health care-associated infection? A. Originated primarily from an exogenous source B. Is associated with a medication-resistant microorganism C. Occurred in conjunction with treatment for an illness D. Still has the infection despite completing the prescribed therapy
C Answer: Occurred in conjunction with treatment for an illness Rationale: Health care-associated infections are classifed as those that are contracted within a health care environment (e.g. hospital, long term care facility) or results from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care)
Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery? A. Maintain muscle strength B. Reduce leg discomfort C. Prevent clot formation D. Improve wound healing
C Answer: Prevent clot formation Rationale: Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis.
A nurse is caring for a child who has an external fixation device on the leg. What is the nurse's priority goal when providing pin care? A. Easing pain B. Minimizing scarring C. Preventing infection D. Preventing skin breakdown
C Answer: Preventing infection Rationale: Pin sites provide a direct avenue for organisms into the bone. Pin care will not ease pain. Some scarring will occur at the pin insertion site regardless of pin site care. Skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented.
An 8-year-old child has experienced the death of a sister. The child begins to ask many questions about what happens to the body after death. The parents wonder whether this is abnormal or morbid behavior picked up from playing video games. What is the best response by the nurse? A. "Playing video games can cause morbid behaviors." B. "Children handle the vent of death more realistically than adults do." C. "School-aged children are inquisitive and ask a lot of questions about death." D. "Giggling, attracting attention, and playing are the usual ways of dealing with death."
C Answer: "School-aged children are inquisitive and ask a lot of questions about death."
To which client should the nurse provide education regarding the pubertal growth spurt? A. An 8-year-old school-age male client B. A 16-year-old adolescent male client C. A 12-year-old school-age female client D. An 18-year-old adolescent female client
C Answer: A 12-year-old school-age female client
Which statement is true for collaborative problems in a client? A. They are the identification of a disease condition. B. They include problems treated primarily by nurses. C.They are identified by the primary health care provider. D.They are identified by the nurse during the nursing diagnosis stage.
D Answer: They are identified by the nurse during the nursing diagnosis stage.