Hesi Final Exam Test 2
What is a normal systolic blood pressure for a 3 year old child? 105 mm Hg. 93 mm Hg. 120 mm Hg. 60 mm Hg.
105 mm Hg The normal systolic blood pressure for a 3 - 5 year old is 104 - 116 mm Hg.
Concepts of death change from infancy to old age. At about what age do children see death as inevitable? check all answers that apply 5 to 6 years 10 years adolescence teenage years
10 years Preschool children do not understand the finality of death. Children aged 5 to 6 see death as reversible. Children aged 6 to 9 begin to accept death as a final event. Children at about the age of 10 years realize that death is inevitable.
The nurse is developing a care plan for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable? 24 hours. 2 to 4 days. 7 to 14 days. 21 to 28 days.
7 to 14 days Bone marrow suppression becomes noticeable 7 to 14 days after fluxuridine administration. Bone marrow recovery occurs in 21 to 28 days.
Which blood type would the nurse identify as the rarest? A B AB O
AB . Group AB individuals comprise only about 4% of the population, and therefore are the rarest blood type. Type O is the most common (approximately 45% of the population), followed by Type A (41%) and Type B (10%).
A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify the assessment by: Shortening it Talking in a loud voice Addressing the client by the first name Allowing extra time for the assessment
Allowing extra time for the assessment When assessing an elderly client the nurse should: allow extra time to compensate for aging-related physiologic changes, address the client respectfully rather than by the first name, and should give simple instructions. Talking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.
You are working in the emergency room when a client calls and tells you that he was stung by a bumble bee while gardening. He is fearful of having a reaction because he had a neighbor that experienced a severe reaction recently. Your correct action would be to: Tell the client to call 911 to have an ambulance bring him to the emergency room immediately. Tell the client not to worry unless he is experiencing difficulty breathing. Advise the client to soak the site in hydrogen peroxide. Ask the client if he ever sustained a bee sting in the past.
Ask the client if he ever sustained a bee sting in the past. There are various allergies in which the reaction occurs only on the second and subsequent contacts with the allergen. Asking if he had a bee sting in the past will let you know what to further advise him. The client should not be told "not to worry." Answer (a) is unnecessary and Answer (c) is not appropriate advise.
The nurse is caring for a premature infant. Immediately after arrival, which nursing action is essential? Check the airway for patency Cleanse the skin of vernix Examine for anomalies Take the rectal temperature
Check the airway for patency The airway should be checked for patency immediately. Removing vernix is not a high priority. The temperature will be monitored, but this is not the highest priority. The nurse will check for anomalies, but this is not the highest priority. When the infant is stable, it will be bathed, and bloody material will be removed. Vernix is good for the skin.
You observe the physician tapping the patient's facial nerve just anterior to the ear. This produced a spasm of the patient's facial muscles. You understand that this is known as which of the following? check all answers that apply Cushing's syndrome Somogyi phenomenon Chvostek's sign Trousseau's sign
Chvostek's sign This is known as Chvostek's sign. It is a sign of hypocalcemia. Trousseau's sign is also a sign of hypocalcemia. It is a carpal spasm elicited by compressing the brachial artery with a blood pressure cuff for 3 minutes. Cushing's syndrome Somogyi phenomenon Chvostek's sign Trousseau's sign
An RN is working on a respiratory unit and is assigned a client with pulmonary embolism as a diagnosis. Which of the following is NOT an intervention for this client? Encourage the use of incentive spirometry as prescribed. Place the client in a high Fowler's position. Discourage deep breathing to avoid pain. Administer anticoagulation therapy as prescribed.
Discourage deep breathing to avoid pain. Deep breathing and use of the incentive spirometer should be encouraged as prescribed. The other answers (a, b, and d) are all interventions for the client with pulmonary embolism. Also, oxygen should be administered as prescribed, maintain bed rest and active and passive range-of-motion exercises, monitor pulse oximetry, monitor lung sounds, and monitor prothrombin time (PT), international normalized ration (INR), and partial thromboplastin time (PTT) closely.
The community nurse who teaches patients how to effectively solve problems and make sound decisions begins the learning process by doing which of the following? Health history, health risk assessment, and health beliefs review Emphasize teaching self-care activities Identify health goals and behavior change options Ask the client to re-order priorities
Emphasize teaching self-care activities Not everyone in a community setting understands at the same rate. It is important to offer a doable approach when promoting self-care.
Gladys is a 78-year-old patient who has been admitted to the hospital for cardiac issues. She has a habit of wandering the halls at night when she can't sleep. Every time she is led back to her room, she gets up and does the same thing all over again. What is the first thing that the nurse should do in considering some type of restraint for Gladys? check all answers that apply Establish the reason for the behavior and assess the risk to herself or others. Establish the reason for the behavior and decide whether restraints are necessary. Talk to the patient's family to find out why she is prone to wandering from her room at night. Talk to the health care provider before doing anything.
Establish the reason for the behavior and assess the risk to herself or others. The first thing that the nurse should do is establish why Gladys is prone to wandering the halls at night. As part of this investigation the nurse should determine whether Gladys is a risk to herself or others. These are the things to be considered before taking steps to put any type of restraint on her.
You are educating a group of menopausal women about hormone replacement therapy (HRT). In talking about the risks and benefits of HRT which of the following statements is NOT correct? check all answers that apply HRT is related to a decrease in deep vein thrombosis (DVT). HRT is related to an increased risk for coronary artery disease. HRT is related to an increased risk of breast cancer. HRT is related to an increased risk of stroke.
HRT is related to a decrease in deep vein thrombosis (DVT). This statement is NOT true. HRT is related to an increase in DVT. Recent studies have shown that it is also related to an increased risk of breast cancer, heart disease and stroke.
The client gives correct information regarding ways to prevent a recurrence of her urinary tract infection when she states: "I should wipe from back to front after urination." "I should urinate when I feel the urge." "I should try to restrict my intake of fruits." "I should use a diaphragm."
I should urinate when I feel the urge." Retention over distends the bladder, and can lead to infection. Wiping from back to front after urination may transfer bacteria from the anorectal area to the urethra. Organic acids from fruits inhibit bacterial growth. The use of a diaphragm does not prevent recurrence of a urinary tract infection.
Which of the following is not generally associated with aging? Chronic health problems Increased appetite Skin breakdown Reduction in muscle mass
Increased appetite Generally, as people age, appetite will decrease, not increase. However, A, C, and D will often occur during the aging process.
The community nurse who reviews and monitors nicotine, drugs and alcohol product usage, then passes this information on to the public, is practicing which of the following? Information dissemination Health risk appraisal and wellness assessment Lifestyle and behavior change Environmental control program
Information dissemination Knowledge is very important in controlling environmental issues. The best way to do this is through the public circulation and dispersement of information.
Which of the following statements about older adulthood (age 66 and older) is not accurate? check all answers that apply Intellectual abilities begin to fade. Older adults focus on a life review and acceptance of the worth of their life. Normal changes include minor short-term memory loss. Older adults experience decreased strength and endurance. Older adults have a decreased response time.
Intellectual abilities begin to fade. Older adults have a decreased response time. These are the least accurate statements. Intellectual abilities of those persons age 66 and older generally remain stable. Normal cognitive changes include increased response time and minor short-term memory loss. Other cognitive changes warrant investigation.
A newborn is thought to have toxoplasmosis. The nurse explains to the family that toxoplasmosis is most likely to have been transmitted to the infant in which manner? By contact with the maternal genitals during birth It crosses the placenta during pregnancy Through breast milk during breastfeeding Through a blood transfusion given to the mother
It crosses the placenta during pregnancy Toxoplasmosis is transmitted from the mother to the baby through the placenta. The mother most likely acquired it from cat feces or eating raw meat. The mother could contract HIV or hepatitis from a blood transfusion. HIV could then affect the fetus. HIV can probably be transmitted through breast milk. Gonorrhea, Chlamydia, and herpes can all be picked up by the infant during the birth process.
The loss of ability of a supine client to straighten the leg completely when it is fully flexed at the knee and hip is which of the following? check all answers that apply Babinski reflex Brudzinski's sign flaccid posturing Kernig's sign
Kernig's sign Kernig's sign is the loss of ability of a supine client to straighten the leg completely when it is fully flexed at the knee and hip. It indicates meningeal irritation.
The community care nurse plans a program offering weight management to include diet and exercise. This is an example of which of the following? Information dissemination Health risk appraisal and wellness assessment Lifestyle changes and behavioral modifications Environmental control program
Lifestyle changes and behavioral modifications Weight loss programs alone are not sufficient to help a client reach his or her optimal weight. Healthy, permanent weight loss requires lifestyle changes and behavioral modifications to include exercise and healthy food choices.
Opioids are most commonly used to treat which of the following types of pain? Mild None of these Moderate to severe Mild to moderate
Moderate to severe When a patient experiences mild pain, he or she should use nonopiod medications. With moderate to severe pain, more potent medications such as Morphine and Fentanyl are used.
You have been asked to educate a group of young women about breast cancer and breast self-examination. In the course of your talk which of the following statements would you make? check all answers that apply If you are premenopausal, lumps in the breast are normal because of hormonal changes. Part of self-examination is to stand before a mirror to inspect both breasts. It is not necessary to palpate armpit area. Discharge from the nipple is a reason for concern.
Part of self-examination is to stand before a mirror to inspect both breasts. Discharge from the nipple is a reason for concern. A woman should inspect both breasts before a mirror as well as palpate the breasts with three or four fingers and include in this the area of the armpit and between the breast and armpit. Discharge from the nipple and lumps are a reason for concern.
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? Sleeping pills can help you sleep but may create problems for you in terms of disorientation. I do not recommend them for a person of your age. It's up to you whether you want to take them or not. Sleeping pills may decrease your mobility even more.
Sleeping pills can help you sleep but may create problems for you in terms of disorientation. The most appropriate response is to tell this woman that even though they may help her sleep, the sleeping pills can make her disoriented. This can be a safety risk for her with her limited mobility.
A patient is suffering from hyperthermia. Which of the following statements about hyperthermia is accurate? check all answers that apply The patient's temperature is higher than 105° F. Hyperthermia decreases the cerebral metabolism. Hyperthermia decreases the risk of hypoxia. Shivering should be prevented.
The patient's temperature is higher than 105° F. Shivering should be prevented. These are both accurate statements. Hyperthermia increases the cerebral metabolism and increases the risk of hypoxia. The patient's temperature is higher than 105° F. Hyperthermia decreases the cerebral metabolism. Hyperthermia decreases the risk of hypoxia. Shivering should be prevented.
During a rectal examination, which finding would provide further evidence of a urethral injury? A low riding prostate. The presence of a boggy mass. Absent sphincter tone. A positive Hemoccult.
The presence of a boggy mass When the urethra is ruptured, a hematoma or collection of blood separates the two sections of urethra. This may feel like a boggy mass on a rectal examination. Because of the rupture and hematoma, the prostate becomes high riding. A palpable prostate gland usually indicates a nonurethral injury. Absent sphincter tone would refer to a spinal cord injury. The presence of blood would probably correlate with GI bleeding or a colon injury.
The newborn to which you are attending exhibits Mongolian spots. All of the following pertain to Mongolian spots EXCEPT: check all answers that apply They have a bluish black pigmentation. They do not fade with time. They are on the lumbar dorsal area and the buttocks. They are common in Asian and dark-skinned individuals.
They do not fade with time. This is not true of Mongolian spots. The gradually fade during the first and second years of life.
Which of the following statements about antihistamines is NOT accurate? check all answers that apply They compete with histamine for receptor sites. They increase nasopharyngeal, gastrointestinal, and bronchial secretions. They are used for the common cold and rhinitis. They are especially helpful for persons with COPD. They can cause CNS depression if taken with alcohol.
They increase nasopharyngeal, gastrointestinal, and bronchial secretions. They are especially helpful for persons with COPD. These statements are not accurate. Antihistamines decrease nasopharyngeal, gastrointestinal, and bronchial secretions. They should be used with caution in clients with COPD because of their drying effect.
As an RN, you are working in an outpatient clinic, supervising LPNs. One LPN is going to administer influenza vaccinations to clients. You should question the administration of the vaccine in which of the following clients? A 67-year-old male who lives in a group home. A 42-year-old female who is allergic to shellfish. A 72-year-old male with congestive heart failure. A 63-year-old female who says she has a sore throat and cough.
a 63-year-old female who says she has a sore throat and cough The vaccine should be rescheduled for the client with an acute respiratory infection. Persons living in group homes are at high risk and vaccination should only be deferred if the client has active immunity. There is no contraindication for a client, male or female, with congestive heart failure. Allergy to eggs is contraindicated, not allergy to shellfish.
Which of the following are warning signs of cancer? check all answers that apply a sore that does not heal indigestion fever hypertension nagging cough
a sore that does not heal indigestion nagging cough These are all warning signs of cancer. Other signs include: change in bowel or bladder habits, obvious change in a wart or mole, thickening or lump in breasts or elsewhere, and unusual bleeding or discharge. a sore that does not heal indigestion fever hypertension nagging cough
A fellow nurse who was under a lot of pressure made an inappropriate remark to a patient. She admitted her mistake and made apologies to the patient. This is an example of which of the following? check all answers that apply autonomy management controlling accountability
accountability Accountability means that a person takes responsibility for his or her actions. It involves admitting mistakes and evaluating the outcomes of one's own actions.
Your patient has had a cast applied on his leg. Your interventions for this client would include all of the following EXCEPT: check all answers that apply allowing a wet plaster cast 6 - 8 hours to dry preparing for bivalving or cutting the cast if circulatory impairment occurs applying moleskin to the edges of the cast monitoring for signs of infection
allowing a wet plaster cast 6 - 8 hours to dry A wet plaster cast needs 24 - 72 hours to dry. Handle the wet plaster cast with the palms of the hands until dry. A hair dryer can be used on a cool setting to dry a plaster cast.
A nurse is coming on duty and receives a report for the change of shift. Of the following which patient should be attended to first? check all answers that apply a 40-year-old patient recovering from a hysterectomy who indicates a pain level of 5 on a 0-10 scale an 85-year-old woman recovering from cardiac by-pass surgery who has developed delirium an 8-year-old child who has a new order for a nasogastric tube a 50-year-old woman who has questions about her type 2 diabetes
an 85-year-old woman recovering from cardiac by-pass surgery who has developed delirium The age of this woman and the fact that she is recovering from a major surgery require that her delirium be addressed. This may be the symptom of a complication from the surgery. She may be suffering a stroke or a pulmonary embolism.
The physician orders a bland, full-liquid diet for a client. The nurse understands that this client's diet may include: orange juice, farina, and coffee apple juice, cream of chicken soup, and vanilla ice cream pineapple juice, a bran muffin, and milk orange juice, custard, and tea
apple juice, cream of chicken soup, and vanilla ice cream ple juice, cream of chicken soup, and vanilla ice cream. A bland, full-liquid diet may include fruit juices and foods from all of the food groups. On this diet, the client should avoid gastric irritants, such as coffee, tea, colas, cocoa, breads, bran (fiber), and highly seasoned foods. orange juice, farina, and coffee apple juice, cream of chicken soup, and vanilla ice cream pineapple juice, a bran muffin, and milk orange juice, custard, and tea
You are counseling a patient about dietary requirements. This patient has an iron deficiency. Which of the following food sources would NOT be included in your suggestions to him for improving his iron deficiency? eggs beef apricots pork
apricots All of the food choices are recommended for an iron deficiency except apricots. They are a choice for a Vitamin A deficiency, not an iron deficiency.
You have a 23-month-old patient. According to Erickson's stages of psychosocial development this child is in which stage? check all answers that apply autonomy versus shame and doubt trust versus mistrust initiative versus guilt industry versus inferiority
autonomy versus shame and doubt This child is in the second stage of psychosocial development according to Erikson. It takes place in early childhood when the child is gaining some basic control over self and environment.
An X-ray of the left femur shows a fracture that extends through the midshaft of the bone and multiple splintering fragments. What is this type of fracture called? compression fracture greenstick fracture comminuted fracture impacted fracture
comminuted fracture mminuted fracture. A comminuted fracture typically is transverse to the shaft of the bone and has multiple splintered bone fragments. A closed fracture implies that the skin integrity at or near the point of fracture is intact. A greenstick fracture occurs when the bone buckles or bends and the fracture line does not extend through the entire bone. An impacted fracture occurs when the distal and proximal portions of the fracture are wedged into each other. A compression fracture occurs when a severe force presses the bone together on itself.
The parents of a elementary school-age child request anticipatory guidance. When developing a care plan to address this matter, the nurse should keep in mind that this child's cognitive development is characterized by magical thinking transductive reasoning abstract thought conservation skills
conservation skills A school-age child acquires cognitive operations to understand concepts related to objects, including conservation skills, classification skills, and combinational skills. Magical thinking and transductive reasoning are characteristic of the preschooler's preoperational thought. Abstract thought is characteristic of the adolescent's period of formal operations.
Elisabeth Kübler-Ross identified five stages that a person has in response to death and dying. Which of the following is a stage? check all answers that apply abandonment denial anger discussion
denial anger Abandonment and discussion are not one of Kübler-Ross's stages of dying. These five stages in order are: denial and isolation; anger; bargaining; depression; and acceptance
Which of the following acts would be considered negligence? check all answers that apply restraining a patient against his will failure to use sterile technique when indicated threatening a patient who refuses to take his medication administering an injection without the patient's consent
failure to use sterile technique when indicated This is considered negligence. Negligence is conduct that falls below the standard of care. The other choices are intentional torts, not negligence.
The diet for your patient who is suffering from uremic syndrome would include all of the following EXCEPT: check all answers that apply limited high-quality protein diet high nitrogen foods high potassium foods limited sodium
high nitrogen foods high potassium foods Nitrogen and potassium would be limited. The patient would be provided a limited but high-quality protein diet and a limited sodium, nitrogen, potassium, and phosphate diet.
The school nurse is approached by a mother who explains that her kindergarten child is constantly scratching the perianal area and that the area is irritated. The RN understands that she should instruct the mother to obtain a rectal specimen by a tape test and that the mother should obtain the specimen when? After bathing. When the child is put to bed. In the morning, when the child awakens. After toileting.
in the morning, when the child awakens Visualization of pinworms by means of a tape test is necessary for the diagnosis. Transparent tape is lightly touched to the anus and then applied to a slide for microscopic examination. The best specimen is obtained as the child awakens, before toileting or bathing.
You have a patient with a severe burn that will require a skin graft. She has a twin sister and the graft will be obtained from the twin. You understand that this type of graft is known as which of the following? check all answers that apply autograft isograft homograft xenograft
isograft An isograft is obtained from an identical twin. An autograft is obtained from undamaged parts of the patient's body. A homograft is obtained from a person other than the patient, not a twin. A xenograft is obtained from a different species such as a pig.
Which of the following is a self check to assess for melanoma? monitor lesions that contract into the skin monitor lesions with a shade of red monitor small lesions that do not spread or get larger monitor hard, flat lesions
monitor lesions with a shade of red. Individuals who are at risk for melanoma can assess themselves and identify any changes in the skin to catch the development of cancer early. The nurse can teach clients to look for lesions that have a dark color or comes in shades of red, brown, tan or black. Also, the client can look for lesions that get large and spread. Further, the shape of the lesion that is melanoma will extend out from the skin. Also, the lesion may be soft, itchy, have ulcerations or drainage.
In a patient with leukemia, infection can occur through autocontamination or cross-contamination. The WBC count is extremely low during the period of greatest bone marrow depression. This is known as which of the following? check all answers that apply bone marrow deficiency baseline sub-standard depression nadir
nadir The white blood cell count can be extremely low during the period of greatest bone marrow depression which is known as the nadir. Common sites of infection are the skin, respiratory tract, and gastrointestinal tract.
Brian has difficulty leaving his apartment because he has to check that all appliances are unplugged. He does this several times even though he has seen that they are all unplugged. Brian is suffering from which of the following disorders? check all answers that apply moderate anxiety disorder obsessive-compulsive disorder agoraphobia panic disorder with agoraphobia
obsessive-compulsive disorder A person with obsessive-compulsive disorder (OCD) may have repetitive behaviors that he feels driven to perform in order to reduce distress or prevent a dreaded event or situation. The person knows that the obsessions/compulsions are excessive but still must perform them. This can cause increased distress and is time-consuming.
A 6-month-old infant has a fever. Which of the following helps to reduce fever? tepid bath warm blankets cold packs on the skin administer aspirin
tepid bath. Tepid baths help to reduce fever, especially in infants. Other methods to reduce a fever in infants are infant strength acetaminophen. Aspirin based products are never given to children because of the risk for developing Reye Syndrome.
A 60 year old client presents with shortness of breath, wheezing, complaints of tightness in the chest and a productive cough with secretions. The physician diagnosed the client with COPD. The nurse is developing a discharge plan for the client. Which of the following should the nurse encourage the client to do? avoid breathing from the diaphragm use aerosol spray only as an air freshener at home obtain a flu shot every year exhale quickly to minimize mucus build up
obtain a flu shot every year. A top priority for a nurse when caring for a client with chronic obstructive pulmonary disease (COPD) is keeping the client's airways clear and open so clients can breathe better and help with gas exchange. Manifestations of COPD can include bronchitis and emphysema. And, these conditions such as bronchitis can cause a build up of thick mucus, which can obstruct the client's airways. With emphysema, the tissues of the lungs are damaged, resulting in the bronchioles of the lungs caving in and blocking the airflow instead of the lungs expanding and contracting during normal breathing in healthy lungs. Clients should be encouraged to get an influenza (flu) shot every year because the flu can make COPD symptoms worse.
In the course of talking to your student nurses about pregnancy, labor and delivery you cite the 5 Ps of a difficult birth (dystocia). You tell them that dystocia can result from all of the following EXCEPT: check all answers that apply passage passenger pain psyche powers
pain Pain is not one of the 5 Ps of dystocia. The 5 Ps are: powers - primary uterine contractions and secondary abdominal bearing-down efforts; passage - maternal pelvis, uterus, cervix, vagina, perineum; passenger - fetus and placenta; psyche - response to labor by woman; and position - position of the laboring woman.
Which of the following may be signs of renal transplant (graft) rejection? check all answers that apply pain over the grafted kidney dehydration temperature over 100° F diminished BUN and serum creatinine levels elevated white blood cell count
pain over the grafted kidney temperature over 100° F elevated white blood cell count These are all signs of renal transplant (graft) rejection. Other signs include: 2 - 3 lb weight gain in 24 hours; edema; hypertension; malaise; elevated BUN and serum creatinine levels; and decreased creatinine clearance.
Your roles as a nurse will include which of the following? check all answers that apply promoting health and preventing disease examining, testing, and treating disabled clients acting as a resource person formulating and dispensing medication
promoting health and preventing disease acting as a resource person These are roles of a nurse. Examining, testing, and treating disabled clients is a role of the physical therapist. Formulating and dispensing medication is a role of the pharmacist.
Which of the follow laxatives is classified as a stimulant? check all answers that apply methylcellulose senna bisacodyl psyllium
senna bisacodyl These are both stimulant laxatives. They stimulate the motility of the large intestine. The other two choices are bulk-forming laxatives.
