HESI

Lithium levels range

0.5-1.4

The registered nurse (RN) is educating a new RN on the "law and order orientation" found in level 2 of Kohlberg's theory of moral development. Which statement by the new RN indicates that the teaching has been effective? An example of this is: If I skip down the hall, will the teacher be mad at me?" 2."An example of this is: We will spend time talking about the activities for the week." 3."An example of this is: I don't like it when you yell while I am talking to my friend. Here are some activities to do until I am finished talking." 4."An example of this is: If you do all of your classwork today without bothering others in the class, you will get an extra 'seed' for your good behavior garden."

1

The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell that staff that which child behavior is characteristic of the formal operations stage? The child has the ability to think abstractly. 2. The child begins to understand the environment. 3. The child is able to classify, order, and sort facts. 4. The child learns to think in terms of past, present, and future.

1 (in the formal operations stage, the child has the ability to think abstractly and logically. Option 2 identifies the sensorimotor stage. Option 3 identifies the concrete operational stage. Option 4 identifies the preoperational stage)

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? Sternal rub 2.Nail bed pressure 3.Pressure on the orbital rim 4.Squeezing of the sternocleidomastoid muscle

2

The primary health care provider has prescribed clonidine for a client with hypertension. The nurse should inform the client that which is a side effect of this medication? Restlessness 2.Constipation 3.Hypertension 4.Increased salivation

2

The nurse at a well-baby clinic is assessing the language and communication developmental milestones of a 4-month-old infant. On the basis of the age of the infant, what should the nurse expect to note as the highest-level developmental milestone? Cooing sounds 2. Use of gestures 3. Babbling sounds 4. Increased interest in sounds

3

The nurse is providing instructions about treatment for hemorrhoids to a client in the second trimester of pregnancy. Which statement made by the client indicates a need for further teaching? "Cool sitz baths will help in relieving the discomfort." 2. "I should perform Kegel exercises as you have instructed." 3. "I should apply heat packs to the hemorrhoids to help them shrink." 4. "I can apply ice packs to the hemorrhoids to assist in relieving discomfort."

3

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. The contractions are regular. 2.The membranes have ruptured. 3.The cervix is dilated completely. 4.The client begins to expel clear vaginal fluid. 5.The spontaneous urge to push is initiated from perineal pressure.

3 5

A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which disorder? Hyperthyroidism 2.Pernicious anemia 3.Cardiopulmonary disorders 4.Systemic lupus erythematosus (SLE)

4

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn, and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized 2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor 4. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection

4

The nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn. Which statement, if made by the mother, demonstrates understanding of why this medication is used? The medication will make my baby's eyes sterile." 2. "The medication will help my baby to see more clearly." 3. "The medication will guard my baby's eyes from any infection that occurred during pregnancy." 4. "The medication will help protect my baby's eyes from certain infections transmitted during the labor and delivery process."

4

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? Tapping the Achilles tendon using the reflex hammer 2.Gently pricking the client's skin on the dorsum of the foot in 2 places 3.Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument 4.Holding the sides of the client's great toe and, while moving it, asking what position it is in

4

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions? "If I experience any sweating during the night, I should call the primary health care provider." 2."If I have uterine cramping while breast-feeding, I should contact the primary health care provider." 3."If I'm still having vaginal drainage in a week, I should contact the primary health care provider." 4."If I notice any pain, redness, or swelling in my breasts, I should contact the primary health care provider."

4

Babbling sounds are common between the ages of 3 and 4 months. In addition, at this age crying becomes more differentiated. Between the ages of 1 and 3 months, the infant will produce cooing sounds. The use of gestures occurs between 9 and 12 months. An increased interest in sounds occurs between --- months.

6 and 8

A nurse is a client who is taking lithium to treat bipolar disorder and has a lithium level of 2.2 mEq/L Which of the following findings should the nurse expect?

Blurry vision ataxia clonic twitching severe hypotension polyuria

The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply. 1.Station 2.Dilation 3.Effacement 4.Bloody show 5.Contraction effort Correct

Correct Answer: 1, 2, 3

clonidine is an ---- medication. Side effects include:

antihypertensive medication dry mouth, drowsiness, constipation, and hypotension

remedies for hemorrhoids include:

ice packs warm or cold sitz baths gentle cleansing topical ointments anesthetic agents

Hot packs will --- blood flow to the area and worsen the discomfort from hemorrhoid's.

increase

Early manifestations of lithium toxicity (1.0-1.5mEq/L)

muscle weakness fine hand tremors

What pressure tests a basic motor and sensory peripheral response?

nail bed pressure

Cerebral responses to pain are tested using:

sternal rub placing upward pressure on the orbital rim squeezing the clavicle or sternocleidomastoid muscle