HESI: Fundamentals:
Which statement indicates a nurse has a correct understanding about trigeminal autonomic cephalalgia (cluster headaches)? 1 It is most common in women. 2 It is manifested by intense bilateral pain. Correct 3 It is caused by an overactive hypothalamus. Incorrect 4 It is associated with headaches of long duration.
According to neuroimaging studies, the etiology of cluster headaches is related to an overactive and enlarged hypothalamus. Cluster headaches are most commonly seen in men aged 20 to 50 years, and they cause intense unilateral headaches of short duration lasting 30 minutes to 2 hours.
What factors put a client at risk for bacterial infections? Select all that apply. 1 Dry skin 2 Underweight Correct 3 Atopic dermatitis Correct 4 Diabetes mellitus Correct 5 Systemic antibiotics
Atopic dermatitis, diabetes mellitus, and systemic usage of antibiotics and corticosteroids are predisposing factors for bacterial infections. Dry skin may not cause bacterial infections, as moisture on the skin is important for bacterial growth. Being underweight may not cause bacterial infections, whereas obesity is a risk factor for poor wound healing and diabetes mellitus.
The laboratory report of a client reveals increased serum cholesterol levels. Which other finding indicates growth hormone deficiency in the client? 1 Scalp alopecia 2 Intolerance to cold Correct 3 Pathological fractures 4 Increased urine outpu
Growth hormone deficiency results in thinning of bones and increases the risk for pathological fractures. Thyrotropin deficiency results in scalp alopecia and intolerance to cold. Marked increase in the volume of urine output is a sign of diabetes insipidus caused by vasopressin deficiency.
Which domain of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation? Incorrect 1 Domain 1 Correct 2 Domain 2 3 Domain 3 4 Domain 4
Domain 2 of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 includes care that supports psychosocial functioning and facilitates life style changes. Domain 4 includes care that supports protection against harm.
While obtaining the client's health history, which factor does the nurse identify that predisposes the client to type 2 diabetes? Incorrect 1 Having diabetes insipidus 2 Eating low-cholesterol foods Correct 3 Being 20 pounds (9 kilograms) overweight 4 Drinking a daily alcoholic beverage
Excessive body weight is a known predisposing factor to type 2 diabetes; the exact relationship is unknown. Diabetes insipidus is caused by too little antidiuretic hormone (ADH) and has no relationship to type 2 diabetes. High-cholesterol diets and atherosclerotic heart disease are associated with type 2 diabetes. Alcohol intake is not known to predispose a person to type 2 diabetes.
Which component of skin maintains optimal barrier function? Correct 1 Keratin 2 Melanin 3 Collagen 4 Adipose tissue
Keratin is a protein produced by keratinocytes that helps to maintain optimal barrier function. Melanin pigment is produced by melanocytes and gives color to the skin. Collagen is a protein produced by fibroblasts. Its production is increased during tissue injury and helps form scar tissue. Adipose tissue is the subcutaneous fat that insulates the body and absorbs shock.
Which organ has only beta1-receptors? 1 Liver Correct 2 Heart 3 Bladder 4 Pancreas
The heart has only beta1 receptors, which increase heart rate and contractility. The liver has only alpha receptors. The bladder and pancreas have both alpha and beta receptors
What gross motor skill is observed in children between 8 and 10 months old? 1 The child can creep on his or her hands and knees. 2 The child has predominant inborn reflexes. Incorrect 3 The child can sit alone without any kind of support. 4 The child can bear his or her weight on forearms when prone.
A child between 8 and 10 months old can creep on his or her hands and knees. A child between birth and 1 month old has predominant inborn reflexes. A child between 6 and 8 months old can sit alone without support. A child between 2 and 4 months old can bear his or her weight on his or her forearms when in the prone position.
A nurse educates a client about the role played by an individual in taking responsibility for health and wellness and its impact. What instructions should the nurse give? Select all that apply. 1 "An individual should use passive strategies for health promotion." Correct 2 "An individual should know that lifestyle choices affect his or her quality of life and well-being." Correct 3 "An individual should take responsibility of health and wellness by making proper lifestyle choices." Correct 4 "An individual should realize that illness prevention has a positive economic impact on his or her life." Incorrect 5 "An individual should understand that it is enough to make positive lifestyle choices in order to prevent illness."
A client should understand that making appropriate lifestyle choices can affect his or her quality of life and well-being. An individual should take responsibility for his or her health and wellness by making proper lifestyle choices. The client should also realize that illness prevention has a positive economic impact by decreasing health care costs. Passive health promotion strategies enable people to benefit from the activities of others. These strategies do not require the involvement of the clients. The client should understand that making positive lifestyle choices and discarding negative lifestyle choices contribute to illness prevention.
A client tells the nurse, "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." What does the nurse conclude about the nursing assistant's answer? 1 It shows empathy. 2 It uses distraction. Correct 3 It gives false reassurance. 4 It makes a value judgment.
A person cannot know the results of the biopsy until it is examined under a microscope. The response does not allow the client to voice concerns, shuts off communication, and provides reassurance that may not be accurate. This answer does not empathize with the client; it minimizes the client's concerns. This response is not a form of distraction; it minimizes the client's concern and shuts off communication. This response does not contain any value statements.
Which statement describes stage 2 of Kohlberg's theory? Correct 1 The child recognizes that there is more than one correct view. 2 An adolescent chooses to avoid a party where they know beer will be served. 3 An individual wants to win the approval of and maintain the expectations of one's immediate group. 4 A child's response to a moral dilemma is in terms of absolute obedience to authority and rules.
According to stage 2 of Kohlberg's theory, a child recognizes that there is more than one correct view. An adolescent who chooses not to attend a party where beer will be served because they know this is wrong is acting according to stage 4. Stage 3 states that an individual wants to win the approval of and maintain the expectations of one's immediate group. During stage 1, a child's response to a moral dilemma is in terms of absolute obedience to authority and rules.
Two days after having a cesarean birth, a client tells the nurse that she has pain in her right leg. After an assessment the nurse suspects that the client has a thrombus. What is the nurse's primary response at this time? Correct 1 Maintaining bed rest 2 Applying warm soaks Incorrect 3 Performing leg exercises 4 Massaging the affected area
Although thrombophlebitis is suspected, before a definitive diagnosis can be made the client should be confined to bed so that further complications may be avoided. Applying warm soaks may cause vasodilation, which could allow a thrombus to dislodge and circulate freely. If a thrombus is present, massage may dislodge it and lead to a pulmonary embolism.
A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error? 1 Labeling Incorrect 2 Collecting 3 Clustering Correct 4 Interpreting
An inaccurate match between clinical cues and the nursing diagnosis is an interpreting error. Interpreting errors include failing to consider conflicting cues, using an insufficient number of cues, and using unreliable or invalid cues errors. A labeling error is a failure to validate data. Collecting errors include inaccurate data, missing data, or disorganization. Errors at the clustering level include an insufficient cluster of cues, premature or early closure, or incorrect clustering.
Which role does a nurse play when helping clients to identify and clarify health problems and to choose appropriate courses of action to solve those problems? Incorrect 1 Educator Correct 2 Counselor 3 Change agent 4 Case manage
As a counselor, the nurse helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems. As an educator, the nurse teaches clients and their families to assume responsibility for their own health care. A nurse acts as a change agent within a family system or as a mediator for problems within a client's community; this involves identifying and implementing new and more effective approaches to problems. As a case manager, the nurse establishes an appropriate plan of care on the basis of assessment findings and coordinates needed resources and services for the client's well-being along a continuum of care. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except in the statement.
Which interview technique is the nurse using when asking a client to score the pain on a scale from 0 to 10? Incorrect 1 Probing 2 Back channeling 3 Open-ended questioning Correct 4 Closed-ended questioning
Asking a client to score pain on a scale of 0 to 10 is a type of closed-ended question. These types of questions specify the cause of the problem or the client's experience of the illness. Asking whether anything else is bothering the client is an example of probing. A response by the nurse such as "All right," or "Go on," when a client says something is called back channeling. This interview technique encourages a client to provide more details. The nurse asks open-ended, nonspecific questions such as "What brought you to the hospital today?" to elicit the client's side of story. Such questions are related to the client's health history and can strengthen the nurse-client relationship.
Which response by the nurse during a client interview is an example of back channeling? Correct 1 "All right, go on..." 2 "What else is bothering you?" 3 "Tell me what brought you here." 4 "How would you rate your pain on a scale of 0 to 10?"
Back channeling involves the use of active listening prompts such as "Go on...", "all right", and "uh-huh." Such prompts encourage the client to complete the full story. The nurse uses probing by asking the client, "What else is bothering you?" Such open-ended questions help to obtain more information until the client has nothing more to say. The statement, "Tell me what brought you here" is an open-ended statement that allows the client to explain his health concerns in his or her own words. Closed-ended questions such as, "How would you rate your pain on a scale of 0 to 10?" are used to obtain a definite answer. The client answers by stating a number to describe the severity of pain.
A client weighs 150 lb and is 5 feet 7 inches tall. What is this client's body mass index (BMI)? Record your answer using two decimal places. _____
Body mass index (BMI) can be calculated by dividing the client's weight in kilograms by the height in meters squared. Therefore, a client who weighs 150 lb (68 kg) and stands 5 feet 7 inches (1.7 m) tall will have a BMI of 23.52: 68/1.72 = 23.53.
Which term describes the practice of placing clients with the same infection in a semi-private room? Incorrect 1 Isolating Correct 2 Cohorting 3 Colonizing 4 Cross-referencing
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 bacteria colonies are commonly found in a client's large intestine? Correct 1 Escherichia coli 2 Neisseria gonorrhoeae 3 Staphylococcus aureus 4 Haemophilus influenzae
Escherichia coli are bacteria that are part of the normal flora in the large intestine. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease. Staphylococcus aureus secretes toxins that damage cells and causes skin infections, pneumonia, urinary tract infections, acute osteomyelitis, and toxic shock syndrome. Haemophilus influenzae causes nasopharyngitis, meningitis, and pneumonia. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly because there usually is no pattern to the answers.
What services do community health centers provide in preventive and primary care services? Select all that apply. 1 Day care Correct 2 Health screenings Correct 3 Physical assessments Correct 4 Disease management 5 Acute and chronic care management
Health screenings, physical assessments, and disease management services are provided by community health centers in preventive and primary care services. Day care and acute and chronic care management services are provided by nurse-managed clinics.
Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins? 1 Drug eruption 2 Atopic dermatitis Correct 3 Contact dermatitis 4 Nonspecific eczematous dermatitis
In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins. In drug eruption, bright-red erythematosus macules and papules are seen. In atopic dermatitis, lichenification with scaling and excoriation is observed. Lichenification with weeping papules and macules is seen in nonspecific eczematous dermatitis. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.
A registered nurse is educating a nursing student about the stages of changes in a client's health behavior. Which statement describes the stage of contemplation? Correct 1 "The client considers a change within the next 6 months." 2 "The client does not intend to make changes within the next 6 months." 3 "The client is actively engaged in strategies to change behavior; this lasts up to 6 months." 4 "The client displays sustained change over time; this begins 6 months after action has started and continues indefinitely."
In the contemplation stage, the client considers a change within the next 6 months. In the precontemplation stage, the client does not intend to make changes within the next 6 months. In the action stage, the client is actively engaged in strategies to change behavior. This stage lasts up to 6 months. When sustained change is noticed over time and begins 6 months after action has started and continues indefinitely, the client has reached the maintenance stage.
Arrange the hierarchy of needs in ascending order beginning with the highest priority needs as defined by Maslow. Incorrect 1. Self-actualization Incorrect 2. Self-esteem Correct 3. Love and belonging needs Incorrect 4. Safety and security Incorrect 5. Physiological need
Maslow's hierarchy of needs helps the nurse understand the interrelationships of basic human needs. These basic needs are a major factor in determining a person's level of health. The first level includes basic physiological needs such as oxygen, fluids, nutrition, body temperature, elimination, shelter, and sex. The second level is safety and security needs, which involve physical and psychological security. The third level is the need of love and belonging. The fourth level encompasses self-esteem needs. The fifth level is the need for self-actualization. It is the highest expression of one's individual potential and allows for continual discovery of self.
What services do nurse-managed clinics provide in preventive and primary care services? Select all that apply. Incorrect 1 Crisis intervention Correct 2 Wellness counseling Correct 3 Health risk appraisal Correct 4 Employment readiness Incorrect 5 Communicable disease control
Nurse-managed clinics provide wellness counseling, health risk appraisal, and employment readiness. Crisis intervention services are provided by school health centers. Communicable disease control services are provided by occupational health centers.
A nursing student is listing examples of active and passive health promotion strategies. Which strategy is an example of a passive health promotion strategy? 1 Weight-reduction program Incorrect 2 Smoking-cessation program 3 Drug abuse prevention strategy Correct 4 Fluoridation of municipal drinking water
Passive strategies of health promotion help people benefit from the activities of others without direct involvement. The fluoridation of municipal drinking water is an example of a passive health promotion strategy. Active strategies of health promotion require clients to adopt specific programs for improving health. Weight-reduction programs, smoking-cessation programs, and drug abuse prevention strategies are examples of active health promotion activities. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses
Which is the definition of photophobia? 1 Double vision 2 Foreign body sensation Correct 3 Persistent abnormal intolerance to light 4 Gradual or sudden inability to see clearly
Photophobia is a persistent abnormal intolerance to light. Diplopia is double vision. Foreign body sensation results in pain. A gradual or sudden inability to see clearly is called blurred vision.
The nurse is providing care to a client being treated for bacterial cystitis. What is the goal before discharge for this client? 1 Understand the need to drink 4 L of water per day, an essential measure to prevent dehydration 2 Be able to identify dietary restrictions and plan menus Correct 3 Achieve relief of symptoms and maintain kidney function 4 Recognize signs of bleeding, a complication associated with this type of procedure
Relief of symptoms and continued urine output are measurable responses to therapy and are the desired outcomes. Four liters of water per day is too much fluid; 2 to 3 liters a day is recommended to flush the bladder and urethra. Dietary restrictions are not necessary with cystitis. Bleeding is not a complication associated with this procedure.
Kohlberg's theory
Stage 1: a child's response to a moral dilemma is in terms of absolute obedience to authority and rules. Stage 2: A child recognizes that there is more than one correct view. Stage 3: An individual wants to win the approval of and maintain the expectations of one's immediate group. Stage 4: An adolescent who chooses not to attend a party where beer will be served because they know this is wrong.
Which statement made by a nursing student about Swanson's theory of caring needs correction? 1 The components of Swanson's theory of caring provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. 2 Swanson's theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. Correct 3 Swanson's theory of caring provides a basis to help nurses understand how clients cope with uncertainty and the illness response. Incorrect 4 Swanson's theory of caring was developed by Kristin Swanson by conducting extensive interviews with clients and their professional caregivers.
Swanson's theory of caring provides a basis for identifying and testing nurse caring behaviors to determine if caring will improve client health outcomes. Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. The components of Swanson's theory of caring provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. Swanson's theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. Swanson's theory of caring was developed by Kristin Swanson by conducting extensive interviews with clients and their professional caregivers. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except in the statement.
Which theory provides a basis for identifying and testing nursing care behaviors to determine if caring improves patient health outcomes? 1 Neuman's system theory Correct 2 Swanson's theory of caring 3 Orem's self-care deficit theory 4 Mishel's theory of uncertainty in illness
Swanson's theory of caring provides a basis for identifying and testing nursing care behaviors to determine if caring improves patient health outcomes. Neuman's system theory focuses on stressors perceived by the client or caregiver. Orem's self-care deficit theory explains the factors within a client's living situation that support or interfere with his or her self-care ability. Mishel's theory of uncertainty in illness focuses on a client's experiences with cancer while living with continual uncertainty.
Which condition will the nurse monitor for in a client with interruption of venous return? 1 Tenting Correct 2 Varicosity Incorrect 3 Petechiae 4 Ecchymosis
Varicosity is the interruption of venous return that will cause a bulge and prominence of superficial veins. Tenting is the failure of skin to return immediately to normal position after gentle pinching, which occurs because of aging, dehydration, and cachexia. Petechiae are flat, pinpoint (<1 to 2 mm in size), discrete deposits of blood found on the extravascular tissues that result from decreased platelet count in blood. Ecchymosis is a small, bruise-like lesion, larger than a petechia, caused by the collection of extravascular blood in the dermis and subcutaneous tissue that occurs due to trauma and bleeding disorders.
According to the Erikson's theory, which stage in a young adult describes the development of the sense of caring for others? 1 Initiative versus guilt 2 Integrity versus despair Correct 3 Intimacy versus isolation 4 Identity versus role confusion
The development of a sense of caring for others in a young adult occurs at the stage of intimacy versus isolation. During the initiative versus guilt stage, a child likes to pretend and try out new roles. At the integrity versus despair stage, many older adults view their lives with a sense of satisfaction. During the identity versus role confusion stage, a child's identity development begins with the goal of achieving some perspective or direction. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.
What is the best advice a nurse can provide to a pregnant woman in her first trimester? 1 "Cut down on drugs, alcohol, and cigarettes." Correct 2 "Avoid drugs and don't smoke or drink alcohol." 3 "Avoid smoking, limit alcohol consumption, and don't take aspirin." 4 "Take only prescription drugs, especially in the second and third trimesters."
The first trimester is the period when all major embryonic organs are forming; drugs, alcohol, and tobacco may cause major defects. Cutting down on these substances is insufficient; they are teratogens and should be eliminated. Even 1 oz of an alcoholic drink is considered harmful; baby aspirin may be prescribed to some women who are considered at risk for pregnancy-induced hypertension; however, not during the first trimester. Medications, unless absolutely necessary, should be avoided throughout pregnancy; however, the first trimester is most significant.
Which Korotkoff sound represents the diastolic pressure in children? Incorrect 1 First 2 Second Correct 3 Fourth 4 Fifth
The fourth Korotkoff sound represents the diastolic pressure in children. The first Korotkoff sound represents the systolic pressure. The fifth Korotkoff sound represents the diastolic pressure in adults and adolescents. A blowing or swishing sound occurs in the second Korotkoff sound.
According to Erikson's theory, at which stage does a child start to have fantasies and an active imagination? 1 Trust versus mistrust Correct 2 Initiative versus guilt Incorrect 3 Identity versus role confusion 4 Autonomy versus sense of shame and doubt
The initiative versus guilt stage is characterized by a child having fantasies and imaginations that motivate the child to explore the environment. The stage from birth to one year old when an infant develops trust towards his or her parents or caregivers is known as the trust versus mistrust stage. The identity versus role confusion stage begins after adolescence; during this stage, an individual tries to figure out his or her own identity. Between the ages of one to three years old, a child starts walking, feeding, using the toilet, and handling some basic self-care activities. This stage is one of autonomy versus sense of shame and doubt. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
A client is in a state of ambivalence. Which of these stages of health behavior will the nurse suspect? 1 Preparation 2 Maintenance Correct 3 Contemplation Incorrect 4 Precontemplation
The nurse will suspect the stage of contemplation. This stage of health behavior is characterized by a client's attitude towards a change; the client is most likely to accept that change in the next six months. The stage of preparation is when a client believes that a change in his or her behavior is advantageous. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to hear any information about the changes in the behavior.
The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term best describes the findings? 1 Rhonchi Correct 2 Wheezes 3 Pleural friction rub 4 Bronchovesicula
Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse, rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae.
A nursing student notes that a nurse is required to integrate best current research with clinical expertise and client preferences and values in order to provide quality healthcare. Which Quality and Safety Education for Nurses (QSEN) competency does this comply with? 1 Safety 2 Quality improvement 3 Patient-centered care 4 Evidence-based practice
the QSEN competency evidence-based practice states that a nurse should integrate best current research with clinical expertise and client's preferences and values in order to provide quality healthcare. Safety involves nursing actions aimed at minimizing the risk of harm to clients and healthcare workers by ensuring system effectiveness and improving individual performance. Quality improvement involves the use of data to monitor outcomes of processes and implementation of methods to improve the healthcare delivery system. Patient-centered care states that the client is the source of control in providing healthcare. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.