HESI Assessment Exam 3

Which transformation occurs during mid-puberty state of a normally developing adolescent female? A. Scanty and irregular menstrual periods B. Appearance of pubic hair and an increase in normal vaginal discharge C. Breast enlargement and the growth of pubic hair D. Changes in the nipple and areola and the development of a small bud of breast tissue

C rationale: C- mid puberty stage A- late puberty stage, B and D- early puberty stage

Which clinic manifestation would the nurse expect to find in a client who has acute HIV infection? Select all A. Malaise B. Confusion C. Constipation D. Swollen lymph glands E. Oropharyngeal candidiasis

A, D rationale: think flu like symptoms, malaise, swollen lymph glands, fever, sore through, headache, nausea, diarrhea, muscle or joint pain or a diffuse rash

Which information would the nurse provide to the parent of an 8 year old child regarding sports safety? A. use a helmet B. avoid contact sports C. get a physical every 3 years D. ensure parental supervision during games

A rationale: helmets minimize the risk of concussions and brain injuries.

Which statement describes the rationale for palpation of the trachea after a client has had a pneumonectomy? A. Examining for any mediastinal shift B. Assessing for subcutaneous emphysema C. Monitoring for possible tracheal edema D. Checking for endotracheal tube cuff inflation

A. rationale: after pneumonectomy, the mediastinum may shift toward the affected side because of the absence of lung tissue on that side after surgery. Subcutaneous emphysema around chest incision site, tracheal edema occurs inside the trachea, cuff of endotracheal tube cannot be assessed through palpation.

Which skin condition would the nurse expect when performing a physical assessment on a client with a history of hypothyroidism? A. dry B. moist C. flushed D. smooth

A. rationale: decrease in thyroid hormone decreased the function of sebaceous glands

Which client statement indicates a risk of breast cancer? select all that apply. A. I had a late onset of menarche B. My first Child was born when I was 32 C. I noticed a slight discharge from a nipple D. I perform breast self-examinations frequently E. I consume two or four glasses of alcohol a day

B,C,E Rationale: Risks of breast cancer include having your first child after the age of 30, discharge from the nipples, consuming two to four glasses of alcohol daily, an early onset of menarche. Breast self examinations help identify breast cancer.

Which complication would the nurse suspect in a client with genital herpes disease? A. Infertility B. cold sores C. Reactive arthritis D. Bartholin abscess

B. Rationale: cold sores are a complication of genital herpes disease. Infertility and reactive arthritis are complications of chlamydial infection. Bartholin abscess is a complication of gonorrhea.

Which assessment finding would indicate to the nurse that a client may have a hyper-functional thyroid gland? SATA A. Anemia B. Diarrhea C. Weight loss D. Decreased appetite E. Distant heart sounds

B,C rationale: Hyper-functional thyroid gland- diarrhea and weight loss Hypo-functional thyroid gland- anemia, decreased appetite and distant hear sounds

Which manifestation would the nurse expect to find when assess a client with hyperthyroidism? SATA A. dry skin B. Weight loss C. Tachycardia D. restlessness E. Constipation F. Exophthalmos

B,C,D,F

A client with hyperthyroidism asks the nurse about the tests that will be ordered. Which diagnostic tests would the nurse include in a discussion with this client? A. T4 and x-ray films B. TSH and T3 C. Thyroglobulin level and Po2 D. protein-bound iodine and sequential multichannel auto analyzer

B

Which finding requires the nurse to further assess a client at 40 weeks gestation who reports a lump in their breast? A. darkening of nipple areolae B. nodularity in an outer quadrant C. Clear fluid leaking from nipple D. Prominence of the superficial veins

B rational: nodularity of the breasts may occur during pregnancy as a response to increase hormone levels. the greatest number of malignant tumors is located in the tail of Spence area and further assessment is needed.

The nurse performed physical assessment for four female clients during their general check up. Which client is most at risk of developing breast cancer? A. 60, hx of BC, 2 children, menopause at 45 B. 60, hx of BC, no children, menopause at 50 C. 60, no hx of BC, no children, menopause at 50 D. 60, no hx of BC, 2 children, menopause at 45

B rationale: client B exibits the most signs of BC, late menopause, history of BC, and over 40. Also women with excessive oral contraceptives use are at risk of developing breast cancer.

Which assessment finding reflects increased intracranial pressure? A. tachycardia B. unequal pupil size C. decreasing body temp D. decreasing systolic BP

B rationale: pressure on III cranial nerve

Which vaccine is used to prevent human papilloma virus infection? A. Varivax B. Rota Teq C. Gardasil D. Hep A Vaccine

C rationale: Gardasil is a vaccine used to prevent gential cancers and warts caused by human papilloma virus. Varivax is associated with protection from varicella virus, sometimes combined with MMR vaccine. Rota Teq vaccine is used to vaccinate against a rotavirus infection. Hep A vaccine protects against Hep A virus.

Which statement made by the nursing student about cluster headaches indicated a need for further teaching? A. each episode of a cluster headache may last up to 3 hours B. Pupillary constriction occurs during the period of cluster headaches C. Pulsating pain is the characteristic type of pain that occurs in cluster headaches D. Cluster headaches occur for weeks to months followed by a period of remission

C rationale: sharp stabbing pain is the characteristic of a cluster headache

Which inference would the nurse make upon noting a newborn is unable to close their eyes completely, has drooping to the corner of the mouth, and absent wrinkling of the forehead and nasolabial fold? A. The neonate has bleeding in the subgaleal layer from labor B. The neonate's cranial nerve V was pressurized during labor C. The neonate's cranial nerve VII was pressurized during labor D. The neonate was exposed to gonorrheal infection during labor

C. Rationale: Cranial nerve VII or facial nerve can result in facial paralysis if compressed during labor.

The nurse finds swelling in front of the left ear of a client reporting ear pain. The nurse would suspect involvement of which lymph node? A. Mastoid B. Occipital C. Submental D. preauricular

D

To check a client's carotid pulse, which area would the nurse palpate? A. below the mandible B. In the lateral neck region C. Along the clavicle at the base of the neck D. At the anterior neck, lateral to the trachea

D

Which condition would the nurse suspect in a client who complains of nocturia, bladder pain, urinary frequency, urgency and dribbling at the end of urination with a digital rectal examination report indicating smooth, firm and enlarged prostate tissue surrounding the urethra? A. prostatitis B. paraphimosis C. prostate cancer D. benign prostatic hyperplasia (BPH)

D rationale BPH is a benign enlargement of the prostate gland caused by excessive accumulation of dihydrotestosterone in prostate cells

Which condition is associated with human papillomavirus type 16? A. Balantitis B. Posthitis C. Gential warts D. Penile carcinoma

D rationale: Penile carcinoma is associated with type 16. Gential warts are associated with type 11 and type 6.

Which disorder would the nurse suspect in a client reporting dysuria, hesitancy, urinary urgency and urinary leakage whose serum prostate-specific antigen (PSA) level is 5ng/mL with an elevated prostatic acid phosphatase (PAP) level? A. Orchitis B. Hydrocele C. Prostatitis D. Prostate cancer

D. rationale: Prostate cancer is associated with PSA and PAP levels.