Hesi Fundamentals

A nurse is caring for a teenage girl who has been in a motorcycle accident. The girl has deep abrasions on the right side of her body including on her face. In caring for this teenager, the nurse should know that the girl's primary concern will be? A. Her body image B. Getting well as quickly as possible C. How she will keep up with schoolwork D. How long she will be in the hospital

A. Her Body Image The nurse will know that teenage girls will be most concerned with body image. The patient will want to know if she will have permanent scars, she will be worried about how she looks to her friends when they come to visit, etc. Body image is of great importance to teens and adolescents.

A 75-year-old woman who has limited mobility tells you that she has trouble getting to sleep at night and is easily awakened during the night. She asks if it would help her to take a sleeping pill at night. What is the best response to her question? A. Sleeping pills can help you sleep but may create problems for you in terms of disorientation. B. I do not recommend them for a person of your age. C. It's up to you whether you want to take them or not. D. Sleeping pills may decrease your mobility even more.

A. Sleeping pills can help you sleep but may create problems for you in terms of disorientation.

The nurse should begin screening for lead poisoning when a child reaches which age? A. 6 months B. 12 months C. 18 months D. 24 months

C. 18 months The nurse should start screening a child for lead poisoning at age 18 months and perform repeat screening at ages 24, 30 and 36 months

Which of the following factors might increase the incidence of and susceptibility to depression? SELECT ALL A. being married B. being male C. age under 40 D. having a substance abuse problem

C. age under 40 D. having a substance abuse problem Depression is the most common reason for seeking mental health treatment. There are many factors that increase susceptibility to depression. Being single or divorced, having a substance abuse problem, being postpartum, or having inadequate social support are all contributing factors. Depression is twice as common in women as in men, and is more common in those under 40.

Nurse Jones conducts a carotid pulse check of her patient. On what part of the body is this done?

Neck; carotid pulse is palpate on the lateral side of the neck

The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse use to dilute this medication? A. Normal saline (0.9%) solution. B. Dextrose 5% and half-normal saline (0.45%) solution. C. Dextrose 5% solution. D. Lactated ringer's solution.

Normal saline (0.9%) solution is the preferred solution

A young man has come to the office for a physical examination. The nurse documents his pulse as +3. Which of the following best describes this pulse? A. full and brisk B. palpable, but diminished C. normal D. full and bounding

A. full and brisk Pulses are rated on a scale of 0 to +4. A +3 pulse is full and brisk. A palpable, but diminished pulse would be a +1, a normal or average pulse would be a +2, a full and bounding pulse would be a +4. 0 would indicate no pulse.

A person's reaction to pain is subjective. It is influenced by certain factors. Which of the following are factors that may influence a patient's pain experience? SELECT ALL A. gender B. culture C. religion D. acute hypotension

A. gender B. culture C. religion

A client will be undergoing a blood transfusion. Which of the following actions should the nurse perform first? A. verify the physician order to determine what type of blood product is administered B. explain the blood transfusion procedure to the client C. assess the client's vital signs D. obtain the blood cell components from the refrigerator

A. verify the physician order to determine what type of blood product is administered

The nurse interviews a 28-year-old client with a new medical diagnosis of endometriosis. Which of the following questions is MOST appropriate? A. "Are you having hot flashes?" B. "Are you experiencing pain during intercourse?" C. "Is a discharge present?" D. "Where are you having pain?"

B. "Are you experiencing pain during intercourse?" Primary symptoms of endometriosis include dysmenorrhea, dyspareunia, and infertility

A 23-year-old female has kidney stones. She is scheduled for an intravenous pyelogram. Which of the following client statements should stand out as a concern to the nurse? A. "I feel nauseated when I am injected with the dye used for the procedure." B. "When I eat crab meat, I get short of breath." C. "I am afraid of needles." D. "I am allergic to Tetanus shots."

B. "When I eat crab meat, I get short of breath." The client's statement should alert the nurse of a potential allergy to iodine. And, the nurse should report the client's reaction to crab meat to the physician immediately before the client undergoes the procedure. If the client proceeds and has the intravenous pyelogram performed, then the client may have an allergic reaction to the contrast material. The intravenous pyelogram's contrast material contains iodine. This contrast is injected into the client's veins where it is transported through the bloodstream to the kidneys, ureter and bladder. This dye highlights these areas on the x-ray so the physician can see where the kidney stones are located in the client's body.

All of the following statements about heart rate are accurate EXCEPT: A. The faster the heart rate, the less time the heart has for filling, and cardiac output decreases. B. An increase in heart rate decreases oxygen consumption. C. The normal sinus heart rate is 60 - 100 beats/minute. D. Sinus bradycardia is a rate more than 100 beats/minute.

B. An increase in heart rate decreases oxygen consumption. D. Sinus bradycardia is a rate more than 100 beats/minute.

Which task can the nurse delegate to a nursing assistant? A. Irrigating a nasogastric (NG) tube. B. Assisting a client who had surgery three days ago walk down the hallway. C. Helping a client who just returned from surgery to the bathroom. D. Administering an antacid to a client complaining of heartburn.

B. Assisting a client who had surgery three days ago walk down the hallway. Because the client had surgery three days ago, the nurse can safely delegate the task of helping the client walk down the hallway. Irrigating an NG tube, administering medications, and assisting a client who just returned from surgery are tasks that must be performed by licensed nursing personnel.

You are caring for a patient who has just been diagnosed with type 1 diabetes. This patient needs to be educated as to how to be able to cope with this diagnosis. What is the first thing that you should do for this patient? A. Show the patient how to inject himself with insulin. B. Evaluate what this patient already knows about diabetes and the administration of insulin. C. Establish a plan for management of the diabetes with the patient. D. Observe the patient as he administers an insulin injection himself.

B. Evaluate what this patient already knows about diabetes and the administration of insulin. The first thing that you should do is find out what this patient already knows. Only then can you set a goal and plan for management. Teaching the patient how to administer insulin and observing the patient doing this are important, but not until you have assessed the patient's level of knowledge.

Which of the following IV fluids is as equally concentrated as the body's natural intracellular fluid? A. Hypertonic B. Isotonic C. Hypotonic D. None of these

B. Isotonic

The nurse is caring for a client under great stress. The client describes feeling nervous and having difficulty focusing on her work. Pulse and respiratory rate are slightly elevated. The nurse recognizes this client is experiencing what level of anxiety? A. Mild B. Moderate C. Panic D. Severe

B. Moderate Moderate anxiety produces tension, nervousness, or concern, and focuses perception, making it difficult to concentrate. Vital signs might be slightly elevated. Mild anxiety heightens mental alertness and improves concentration. Severe anxiety takes all of the client's energy, and vital signs are likely to be more acutely elevated. Panic is overpowering, with increased motor activity, agitation, and unpredictability.

A client has undergone an ileostomy. Which of the following postoperative care approaches is the nurse's top priority? A. Check the client's dressing for surgical stitching. B. Place the client in the physician ordered position. C. Check the type of tube placed. D. Assess the type of indwelling urinary catheter.

B. Place the client in the physician ordered position

Which of the following solutions may consist of water in oil (w/o) or oil in water (o/w)? A. suspension B. emulsion C. ointment D. lotion

B. emulsion An emulsion is a solution in which one liquid is dispersed in another liquid. It may be water in oil or oil in water. Emulsions are stabilized though the use of an emulsifying agent.

Which of the following situations is an example of behavioral therapy? SELECT ALL A. organized group activities B. operant conditioning C. group meetings D. desensitization

B. operant conditioning D. desensitization These are both forms of behavioral therapy. Operant condition is the use of rewards to reinforce positive behavior. Desensitization is used to treat phobias.

Which of the following devices would the nurse use to identify hypoxemia? A. stethoscope B. pulse oximeter C. sphygmonanometer D. doppler ultrasound

B. pulse oximeter

A couple demonstrates understanding of the consequences of not treating Chlamydia when they state what? A. "She could become pregnant." B. "She could cause our 1-month-old baby to get an eye infection." C. "He could get an infection in the tube that carries out the urine." D. "It could cause us to develop a rash."

C. "He could get an infection in the tube that carries out the urine."

You are caring for an infant born to a diabetic mother. The infant is receiving IV medication to manage blood glucose levels. Which of the following blood glucose levels would cause you concern? SELECT ALL A. 45 mg/dL B. 50 mg/dL C. 35 mg/dL D. 75 mg/dL

C. 35 mg/dL D. 75 mg/dL An infant of a diabetic mother who is receiving IV therapy to maintain acceptable glucose levels should maintain a blood glucose level between 45 mg/dL and 65 mg/dL.

A nurse has several patients in her care. Which of the following patients will be limited in their right to autonomy? SELECT ALL A. A patient with end stage renal failure who wants to refuse any further medication B. A patient with breast cancer who refuses a mastectomy C. A patient with an intestinal parasitic infection who refuses treatment D. A patient who has been in a car accident who refuses blood transfusions based upon religious reasons

C. A patient with an intestinal parasitic infection who refuses treatment When a patient has a communicable disease that can affect others his or her right to autonomy can be limited by the health care providers. This is the case with the parasitic infection that could be transmitted to others.

Which of the following is NOT a component of a normal EKG? A. P wave < 0.11 second. B. QRS complex: Normal = 0.06-0.10 second. C. D wave. D. P-R Interval: Normal = 0.12-0.20.

C. D wave. Choices A, B and D are stated correctly. There is no such measurement as "D wave". The proper phrase is T wave

You are instructing an elderly client on home safety during her discharge process. The client is at high risk for falls due to her neurological status. Which of the following will NOT be an appropriate measure to prevent falls? A. Teach her to keep all of her personal items within reach. B. Encourage her to keep adequate lighting in her bathroom area. C. Discuss keeping her bed up high to allow for ease of rising. D. Explain to her to avoid clutter in her pathways at home.

C. Discuss keeping her bed up high to allow for ease of rising.

Which of the following defense mechanisms is when an individual deals with an emotional issue through a short-term change in identity? A. Rationalization. B. Reaction formation. C. Dissociation. D. Regression.

C. Dissociation Choice A is defined as an individual excusing his or her own negative behavior in order to avoid responsibility. Choice B is when an individual acts in a manner opposite of the way he or she feels. Choice D is when in individual reverts to a previous developmental stage in order to feel safe.

After a gastrectomy, the nurse should evaluate the client carefully for which of the following complications? A. Septicemia. B. Gangrene of the bowel. C. Dumping syndrome. D. Postprandial hyperglycemia.

C. Dumping syndrome. The most common complication after a gastrectomy is dumping syndrome, which affects 50 percent of the clients. Dumping syndrome is fluid from a bolus of gastric chyme and hypertonic fluid entering the intestine.

A client is seen in the emergency department with a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps. With each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term? A. Ataxic. B. Dystrophic. C. Helicopod. D. Steppage.

C. Helicopod A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step. An ataxic gait is staggering and unsteady. In a dystophic gait, the client waddles with the legs far apart. In a steppage gait, the feet and toes rise high off the floor and the heel comes down heavily with each step.

A nurse who is preparing a patient for eye surgery takes his intraocular pressure. She finds that the pressure in the right eye is 12 mm Hg and the pressure in the left eye is 17 mm Hg. The nurse would tell the patient that? A. The pressure in the right eye is low, but the pressure in the left eye is normal. B. The pressure in both eyes is high. C. The pressure in both eyes is normal. D. The pressure in the right eye is normal, but the pressure in the left eye is high.

C. The pressure in both eyes is normal. In this patient's case the pressure is normal in both eyes. Normal intraocular pressure ranges from 8 mm Hg to 21 mm Hg.

For a patient with a vitamin B12 deficiency, you might suggest foods rich in this vitamin. This would include all of the following foods EXCEPT: SELECT ALL Brewer's yeast carrots liver nuts green peppers

Carrots; Green peppers These foods are not rich in vitamin B12. The other choices are foods rich in this vitamin. Other foods to recommend include: citrus fruits, dried beans, and organ meats.

You have been assigned to be leader of a task that involves several other nurses and nursing assistants. You feel that connective leadership is the approach to use for this task. This means that you want to achieve results by which of the following? SELECT ALL Cooperation A Hands-off Approach Strong Control Collaboration

Cooperation Collaboration

The nurse is caring for a client with anorexia nervosa. Which of the following is the first priority? A. Address perceptions of distorted body image B. Address vitamin deficiencies C. Address the client's self-concept D. Address fluid volume deficit

D. Address fluid volume deficit The first priority when caring for a client with anorexia nervosa is the client's physical needs. Clients with anorexia do not eat or drink sufficiently because they have a distorted view about their body. They usually think they are overweight and need to loose weight. These clients will limit how much they eat or drink and this reduction in fluids, especially, leads to dehydration. Also, the client has a loss of essential vitamins in the body. Correcting the fluid imbalance is critical as dehydration can cause kidney damage.

In what way does Schizophrenia differ culturally? A. The prevalence of schizophrenia is higher in some countries than in others. B. The form of expression of schizophrenia varies across cultures. C. The stressors that trigger the onset of schizophrenia may be culturally specific, such as fearing that one is the victim of witchcraft. D. All of the above statements are true.

D. All of the above statements are true.

Which group of clients is at an increased risk for developing a wound infection? A. clients who require frequent pain medication B. clients who are 15 lbs overweight C. clients who ambulate after the first postoperative day D. clients who are undernourished

D. clients who are undernourished Nutrition plays an important role in wound healing. Vitamins and protein are essential for wound healing; therefore, a malnourished client is at an increased risk for developing a wound infection.

A client is in the recovery unit after having an ileostomy. The nurse finds the client has bulging surrounding the stoma. The nurse understands this is an abnormal finding as this may indicate

Herniation