N520 Hesi 30 Q's
A client has been on a hunger strike for 5 days. Which hormones are providing glucose as energy through catabolism? Select all that apply. 1 Cortisol 2 Prolactin 3 Glucagon 4 Calcitonin 5 Aldosterone
1 Cortisol 3 Glucagon ---------------------- In states of fasting, cortisol and glucagon breakdown stored complex fuels to provide energy. Cortisol stimulates the liver to produce new glucose molecules, thereby providing energy to the body. Glucagon also stimulates the production of glucose, thereby supplying energy. Therefore, the hormones cortisol and glucagon may provide energy (insulin metabolizes the glucose molecules). Prolactin stimulates milk production in lactating women. Calcitonin maintains calcium and phosphorus balance in the blood. Aldosterone is a potent mineralocorticoid that promotes reabsorption of sodium and excretion of potassium from the renal tubule.
The nurse is assessing head growth in an 8-month-old infant. The nurse observes that the rate of the growth has been 0.5 cm per month since the 6-month check-up. What does the nurse tell the parents about the child's development? 1 "The child needs to be screened." 2 "The child's head growth is normal." 3 "The child's posterior fontanel is not fused." 4 "There may be some developmental issues."
2 "The child's head growth is normal." ---------------------------------------- After the sixth month, the infant's head grows at 0.5 cm every month. Therefore, the nurse informs the parents that the head growth rate is normal for the child. There is no need for screening, because the child has not received any head injuries. There may be developmental issues if the head growth is not normal. The posterior fontanel is fused at 6 to 8 weeks of age, so this is not a plausible finding at the 8-month mark.
Upon assessment of a client, the nurse discovers the following (see image). Which virus causes the condition indicated? 1 Papillomavirus 2 Epstein-Barr virus 3 Varicella-zoster virus 4 Herpesvirus 8 (HHV-8)
3 Varicella-zoster virus ------------------ The condition represents Herpes zoster (shingles). This is caused by varicella-zoster virus. Clinically it is manifested as a linear distribution along a dermatome of grouped vesicles and pustules on an erythematous base. It resembles chickenpox. Papillomavirus causes verruca vulgaris (common wart). Epstein-Barr virus causes oral hairy leukoplakia. HHV-8 is associated with Kaposi sarcoma in immunosuppressed clients.
A client with mumps reports pain, inflammation, and swelling of the testes. Which condition does the nurse suspect in the client? 1 Orchitis 2 Salpingitis 3 Ductal ectasia 4 Fibroadenoma
1 Orchitis ------------------------- Orchitis is characterized by painful inflammation and swelling of the testes. Clients with mumps are at an increased risk of orchitis, which can lead to testicular atrophy and sterility. Salpingitis is a uterine tube infection caused by chlamydia that can result in female infertility. Ductal ectasia is a hard, irregular mass with nipple discharge, enlarged axillary nodes, redness, and edema that is difficult to distinguish from cancer. Fibroadenoma is the most common benign lesion of connective tissue that is unattached to the surrounding breast tissue.
The parents of a 12-year-old boy with cystic fibrosis (CF) ask the nurse why he needs a glucose tolerance test. What information should the nurse consider before replying? 1 Pancreatic scarring predisposes the child to diabetes. 2 The thickened mucus blocks the insulin-secreting glands. 3 The test reveals the degree to which the child adheres to the diet. 4 Adjustments of the dosage of pancreatic enzymes are based on the results of the test.
1 Pancreatic scarring predisposes the child to diabetes. ----------------------------- Pancreatic scarring affects the ability of the islets of Langerhans to produce insulin; about half of all children with CF have altered glucose tolerance. The endocrine glands, which produce insulin, are ductless and are not affected by the thickened mucus in the ducts. However, the general scarring throughout the pancreas does affect the insulin-producing glands. The glucose tolerance test is a measure of the body's ability to produce and metabolize carbohydrates, not a measure of the child's adherence to the diet. The dosage of pancreatic enzymes is based on food consumption, not the blood glucose level.
The nurse is examining a teenage client who has a gawky, long-legged appearance. What is the sequence of growth changes that lead to this characteristic early adolescent appearance? 1. Increase in the length of the trunk 2. Increase in the width of the shoulders 3. Increase in the depth of the chest 4. Increase in the breadth of the hips and chest 5. Growth of the neck, hands, and legs in length
1. Growth of the neck, hands, and legs in length 2. Increase in the breadth of the hips and chest 3. Increase in the width of the shoulders 4. Increase in the length of the trunk 5. Increase in the depth of the chest ------------------------------------------- There is a characteristic sequence in the growth changes that occur during adolescence. The lengthwise growth of the neck and extremities occurs first before growth in other areas of the body. This is followed by an increase in the breadth of the hips and chest. Months later there is increase in shoulder width. Then the trunk increases in length, and finally there is an increase in the depth of the chest. This sequential growth pattern results in the characteristic gawky, long-legged appearance of early adolescence.
A client at 24 weeks' gestation is admitted in early labor. What should the nurse take into consideration regarding this client's early gestation? 1 If contractions are regular, labor cannot be stopped effectively. 2 Birth at this gestational age usually results in a severely compromised neonate. 3 Attempts will be made to sustain the pregnancy for 2 or 3 more weeks to ensure neonatal survival. 4 Infants born at 30 to 34 weeks' gestation have a low morbidity rate because of advances in neonatal health care.
2 Birth at this gestational age usually results in a severely compromised neonate. --------------------------------------------- Morbidity and mortality rates among preterm neonates are highest between 24 and 26 weeks' gestation; complications include immature lung tissue, altered cardiac output, patent ductus arteriosus, intraventricular hemorrhage, necrotizing enterocolitis, and infection. Depending on the status of cervical effacement and dilation the decision may be made to try halting labor with the use of tocolytic medications and limited activity. If possible, the pregnancy should be maintained past 37 weeks' gestation. Neonates born at 34 weeks' gestation are still at high risk.
A primary healthcare provider prescribes a tap water enema for a 6-month-old infant with suspected Hirschsprung disease. What rationale causes the nurse to question this prescription? 1 Necessary nutrients could be lost. 2 It could cause a fluid and electrolyte imbalance. 3 It could increase the fear of intrusive procedures. 4 The result could cause shock from a sudden drop in temperature.
2 It could cause a fluid and electrolyte imbalance. ----------------------------------------------------- Tap water enemas are hypotonic and are contraindicated; they may cause increased absorption of fluid through the bowel and may upset the balance of fluid in the body. Such enemas also interfere with the potassium ion balance; this electrolyte can be lost by way of the large intestine. The enema removes waste products from the bowel, not nutrients. Fear of intrusive procedures is typical of preschoolers, not infants. The temperature of the water is regulated, so shock from a temperature drop is not a concern.
A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made, and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care? 1 Place in a warm, dry environment. 2 Maintain standard and contact precautions. 3 Administer prescribed antibiotic immediately. 4 Allow parents and siblings to room in with the infant.
2 Maintain standard and contact precautions --------------------------------------------------- RSV is highly contagious. The infant should be isolated or placed with other infants with RSV. Standard and contact precautions are instituted to limit the spread of pathogens to others. The infant should receive cool, humidified oxygen by nasal cannula or mask or in a croup tent. Because RSV is extremely contagious, the number of visitors should be limited. Uninfected children should not be allowed near the infant, and as few personnel as possible should care for the infant. Antibiotics are not effective against RSV, and their use is contraindicated.
A nurse is caring for a child with the diagnosis of lead poisoning. For which problem should the nurse assess the child initially? 1 Constipation resulting from the excretion of lead 2 Neurologic injury caused by the ingestion of lead 3 Delayed development resulting from parental neglect 4 Inadequate nutrition resulting from decreased iron intake
2 Neurologic injury caused by the ingestion of lead ------------------------------------------------------ The most serious and irreversible effects of lead toxicity are in the nervous system; lead encephalopathy causes seizures, cognitive impairment, paralysis, blindness, and ultimately coma and death. Although constipation may occur, it is not caused by the excretion of lead; lead is excreted by way of the urinary tract. Although some studies have identified that some children with plumbism have received less-than-adequate care, a cause-and-effect relationship between plumbism and parental neglect has not been established. Inadequate nutrition is not caused by a decrease in the intake of iron; a high serum blood level of lead interferes with the biosynthesis of heme, preventing the formation of hemoglobin, which results in anemia.
A 4-day-old infant is admitted to the pediatric unit with a cleft lip and palate. Surgery to repair the lip is scheduled for later in the week. Which assessment finding requires notification of the surgeon and will probably result in cancellation of the surgery? 1 Hypotonia 2 Oral candidiasis 3 Facial paralysis 4 Cephalohematoma
2 Oral candidiasis -------------------------- Oral candidiasis (thrush) is a fungal infection of the mouth that can be acquired from the maternal vagina during the birth process. Surgery involving the mouth would be delayed until the infection has cleared. Hypotonia (diminished or flaccid muscle tone) is not a reason to postpone surgery. Because the infant would be anesthetized during surgery, hypotonia is expected. Facial paralysis (brachial plexus palsy) is a birth injury. The paralysis disappears in several days, but it can take as long as several months. Surgery need not be delayed. A cephalohematoma is a collection of blood between the skull bone and the periosteum that does not cross the suture line. It may contribute to an increased bilirubin level as it resolves, which can take several months. This is not a reason to delay surgery.
A nurse is discussing the care of an infant with colic. What should the nurse explain to the parents is the cause of colicky behavior? 1 Inadequate peristalsis 2 Paroxysmal abdominal pain 3 An allergic response to certain proteins in milk 4 A protective mechanism designed to eliminate foreign proteins
2 Paroxysmal abdominal pain ------------------------------------- The traditional efforts to explain and treat colic center on the paroxysmal abdominal pain; multiple factors appear to be involved, including immaturity of the intestinal nervous system and lack of normal intestinal flora. Peristalsis is effective because these infants thrive physically and gain weight. The origin of colic is unknown at this time.
Upon assessing a female client, the nurse discovers an abnormal endocrine finding. Which finding in the client supports the nurse's conclusion? 1 Facial hair 2 Protruding eyes 3 Pulse of 90 beats/min 4 Blood pressure of 120/80 mmHg
2 Protruding eyes --------------------------- Protruding eyes are a clinical manifestation of hyperthyroidism, wherein the fluid accumulates in the eye and retro-orbital tissue. Hyperthyroidism is a problem of the endocrine system. Therefore, protrusion of the eyes in the client helped the nurse in arriving at this conclusion. Presence of facial hair is common in women. However, an increase suggests an endocrine abnormality. A heartbeat of 90 beats/minute is a normal finding. A blood pressure value of 120/80 mmHg is normal.
Which screening report will help the nurse determine skeletal growth in a child? 1 Electroencephalogram reports 2 Radiographs of the hand and wrist 3 Magnetic resonance imaging (MRI) 4 Denver Developmental Screening Test
2 Radiographs of the hand and wrist ---------------------------------------- Skeletal growth in a child can be determined from the ossification centers. At 5 to 6 months of age, the capitate and hamate bones in the wrist are the earliest centers. Therefore radiographs of the hand and wrist will help determine skeletal growth in the child. Electroencephalogram reports will help assess a child's brain activity. MRI is used to scan the internal structures of a client. The Denver Developmental Screening Test is used to understand developmental issues of a child.
A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess? 1 Quality of the cry 2 Signs of dehydration 3 Coughing up of feedings 4 Characteristics of the stool
2 Signs of dehydration ----------------------------------- HPS causes partial and then complete obstruction. Nonprojectile vomiting progresses to projectile vomiting, which rapidly leads to dehydration. The infant's cry is not affected by HPS; pain, except for the pain of hunger, does not appear to be associated with this condition. An infant with a tracheoesophageal fistula, not HPS, is expected to cough up feedings. The characteristics of the stool are not relevant in the assessment of an infant with HPS.
The parents of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus are concerned about the prognosis. What information should the nurse give the parents? 1 The prognosis is excellent, and the valve is permanent. 2 The shunt may need to be replaced as the child grows older. 3 If any brain damage has occurred, it is irreversible even after the first year of life. 4 Hydrocephalus usually is self-limiting by 2 years of age, and then the shunt is removed.
2 The shunt may need to be replaced as the child grows older. --------------------------------------- Shunts are updated, with the length of the tubing increased as the child grows. Although treatment of hydrocephalus with shunt replacement is quite successful, there is always a danger of malfunction and infection of the shunt. Some brain damage may be reversible during the first year of life. Hydrocephalus necessitates treatment for the life of the child.
The nurse is caring for a client who may have Paget's disease and osteomalacia. Which laboratory tests can be conducted to confirm the nurse's suspicion? Select all that apply. 1 Aldolase 2 Serum calcium 3 Alkaline phosphatase 4 Lactic dehydrogenase 5 Aspartate aminotransferase
2 Serum calcium 3 Alkaline phosphatase ---------------------------------- Serum calcium and alkaline phosphate tests are used for musculoskeletal assessment. Elevated levels of serum calcium and alkaline phosphate are symptoms of Paget's disease and osteomalacia. Elevated aldolase levels indicate polymyositis, dermatomyositis, and muscular dystrophy. Elevated levels of lactic dehydrogenase levels indicate skeletal muscle necrosis, extensive cancer, and progressive muscular dystrophy. Elevated aspartate aminotransferase levels indicate skeletal muscle trauma and progressive muscular dystrophy.
A nurse discovers lower extremity pitting edema in a client with right ventricular heart failure. Which information should the nurse consider when planning care? 1 Client has decreased plasma colloid osmotic pressure. 2 Client has increased tissue colloid osmotic pressure. 3 Client has increased plasma hydrostatic pressure. 4 Client has decreased tissue hydrostatic pressure.
3 Client has increased plasma hydrostatic pressure. -------------------------------------------------------- In right ventricular heart failure, blood backs up in the systemic capillary beds; the increase in plasma hydrostatic pressure shifts fluid from the intravascular compartment to the interstitial spaces, causing edema. Increase in tissue (interstitial) colloid osmotic pressure occurs with crushing injuries or if proteins pathologically shift from the intravascular compartment to the interstitial spaces, pulling fluid and causing edema. In right ventricular heart failure, increased fluid pressure in the intravascular compartment causes fluid to shift to the tissues; the tissue hydrostatic pressure does not decrease. Although a decrease in colloid osmotic (oncotic) pressure can cause edema, it results from lack of protein intake, not increased hydrostatic pressure associated with right ventricular heart failure.
A client at her first visit to the prenatal clinic states that she has missed three menstrual periods and thinks that she is carrying twins because her abdomen is so large. She now has a brownish vaginal discharge. Her blood pressure is increased, indicating that she may have gestational hypertension. What condition does the nurse suspect the client may have? 1 Renal failure 2 Placenta previa 3 Hydatidiform mole 4 Abruptio placentae
3 Hydatidiform mole --------------------------- Hydatidiform mole develops in 15% of women with gestational hypertension during the first trimester. Renal failure is an unlikely complication unless the hypertension becomes severe or there was preexisting hypertension. The client's adaptations are not associated with placenta previa, a hemorrhagic condition that results in problems in the third trimester. Premature separation of the placenta is associated with uterine bleeding, uterine hypertonicity, abdominal pain, and a boardlike abdomen; usually it occurs in the last trimester.
When assessing a neonate immediately after birth, the nurse observes an inability to close the eyes completely. The nurse also observes drooping of the corner of the neonate's mouth, and the absence of wrinkling of the forehead and nasolabial fold. What does the nurse infer from these findings? 1 The neonate has bleeding in the subgaleal layer from labor. 2 The neonate's cranial nerve V was pressurized during labor. 3 The neonate's cranial nerve VII was pressurized during labor. 4 The neonate was exposed to vaginal gonorrheal infection during labor.
3 The neonate's cranial nerve VII was pressurized during labor. ---------------------------------- Inability to close the eyes completely, drooping of the corner of mouth, and absence of wrinkling of the forehead and nasolabial fold indicate facial paralysis. When the facial nerve, or cranial nerve VII, is pressurized during labor, it can result in facial paralysis. Bleeding in the subgaleal layer indicates subgaleal hemorrhage in a neonate. Subgaleal hemorrhage is not characterized by inability to close the eyes, drooping of the corner of mouth, or absence of wrinkling of the forehead and nasolabial fold. Cranial nerve V does not innervate the face, so damage to cranial V does not result in facial paralysis. A neonate who is exposed to vaginal gonorrheal infections during labor may develop ophthalmia neonatorum, not facial paralysis.
What growth changes are observed in a male client during adolescence? Select all that apply. 1 Development of broader hips 2 Development of deep and fuller voice 3 Increase in length of vocal cords by 0.4 inch (1 cm) 4 Increase in length of vocal cords by 0.17 inch (0.4 cm) 5 Uncontrollable shifting of the voice from deep to high tones
3 Increase in length of vocal cords by 0.4 inch (1 cm) 5 Uncontrollable shifting of the voice from deep to high tones ------------------------------------ There are marked differences in growth patterns in males and females during adolescence. On average, the length of the vocal cords in males increases by approximately 0.4 inch (1 cm). The increased length of the vocal cords, accompanied with hypertrophy of the laryngeal mucosa, results in changes in the voice. Males generally have voices that shift uncontrollably between deep to high tones during a conversation. A characteristic feature of skeletal growth in females is the development of broader hips. The female voice during adolescence becomes deeper and fuller because of an average increase in vocal cord length of 0.17 inch (0.4 cm), enlargement of the larynx, and hypertrophy of the laryngeal mucosa.
A parent brings a 6-month-old child to the well-baby clinic and asks about the introduction of new foods. What should the nurse suggest? 1 "Provide a new food every day until he likes one." 2 "Give a new food after he has his regular feeding." 3 "Puree a new food, mix it with breast milk or formula, and give it to him in a bottle." 4 "Offer a new food after he has some breast milk or formula and while he is still hungry."
4 "Offer a new food after he has some breast milk or formula and while he is still hungry." ------------------------------------------------ Offering a new food after giving some breast milk or formula helps the infant associate the new food with eating and takes advantage of the infant's unsatisfied hunger. New foods should be initiated one at a time and continued for 4 to 5 days to enable assessment for an allergic reaction. Offering food after the regular feeding decreases the chance of success because the infant's hunger is satisfied. Solid food should be introduced by spoon to acquaint the infant with new tastes and textures, as well as the use of the spoon.
A nurse is assessing a group of children. Which child is underdeveloped according to the table? 1 Child A 2 Child B 3 Child C 4 Child D
4 Child D -------------- Child D is underdeveloped, because the average height and weight of a 5-year-old child are 110 cm and 19 kg, respectively. The average height of and weight of a 3-year-old child are 95 cm and 14.5 kg. Therefore, child A and child B show normal growth and development. The average height and weight of a 4-year-old child are 103 cm and 16.7 kg. Therefore child C is not underdeveloped.
Which client would the nurse state shows symptoms of influenza? 1 Client 1 2 Client 2 3 Client 3 4 Client 4
4 Client 4 ------------------ Headache, muscle aches, fever, chills, fatigue, weakness, sore throat, cough, watery nasal discharge lasting for more than a week, nausea, vomiting, and diarrhea are the signs and symptoms of seasonal influenza, which is an acute, viral respiratory infection. Headache, nasal irritation, sneezing, nasal congestion, watery drainage from the nose, and itchy and watery eyes are the symptoms of rhinitis, an infection of the nose. A client with sinusitis, which is an infection of the sinuses, will show symptoms such as pain over the cheek, pain to the back of the head, and general facial pain that worsens when bending forward, purulent nasal drainage, and fever. Throat soreness and dryness, throat pain, pain on swallowing, difficulty swallowing, and fever are symptoms that may be experienced by a client with tonsillitis, which is an infection of the tonsils.
While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. What is this condition known as? 1 Osteoarthritis 2 Osteoporosis 3 Muscle atrophy 4 Contracture
4 Contracture ------------------------ Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints caused by wear and tear. Osteoporosis is a metabolic disease process in which the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles because of a lack of physical activity or a neurologic or musculoskeletal disorder.
A 15-year-old adolescent is found to have type 1 diabetes. What should the nurse include when teaching the adolescent about type 1 diabetes? 1 It does not always require insulin. 2 It involves early vascular changes. 3 It occurs more often in obese adolescents. 4 It has a more rapid onset than does type 2 diabetes.
4 It has a more rapid onset than does type 2 diabetes ------------------------ A characteristic difference between type 1 and type 2 diabetes is the rapid onset of type 1 diabetes. Type 1 diabetes often is first diagnosed during an episode of acute ketoacidosis. Children, adolescents, and adults with type 1 diabetes are insulin dependent. Vascular changes are complications associated with long-standing diabetes. Maturity-onset diabetes of the young (MODY), similar to type 2 diabetes, is more often seen in obese teenagers. Adolescents with type 1 diabetes tend to be at or below the expected weight for their height and bone structure.
A nurse is planning home care for a 6-month-old infant who has just been placed in a hip spica cast. What should the nurse emphasize to the parents about cast cleanliness? 1 The entire cast should be wrapped in plastic. 2 Special precautions are unnecessary for diapering. 3 Baby powder should be sprinkled lightly around the diaper area. 4 The cast edges in the perineal area should be covered with plastic wrap.
4 The cast edges in the perineal area should be covered with plastic wrap. --------------------------------------- Covering the edges with plastic wrap is the preferred method of protecting the cast from soiling with excreta. The cast should not be completely covered with occlusive material because this can cause condensation and wetness, which could damage the cast. Special precautions are required to keep the cast clean. Baby powder should not be used because of the risk of aspiration; also, clumping of the powder, with resultant irritation, may occur.
The nurse is assessing a newborn immediately after birth. Which finding indicates normal development? 1 A body weight of 3500 g 2 Blood pressure of 70/60 mm Hg 3 A core body temperature of 96° F (35.6° C) 4 Head circumference 3 cm less than chest circumference
1 A body weight of 3500 g --------------------------------- The newborn has a body weight of 3500 g, which is within the normal range of 2700 to 4000 g. Therefore this indicates normal development. The core body temperature of the newborn is 96° F (35.6° C), which is less than the normal range of 97.7° F to 99.7° F (36.5° C to 37.6° C). Therefore the core body temperature of 96° F (35.6° C) indicates hypothermia. The normal blood pressure of a newborn on the first day of birth is 65/45 mm Hg. A blood pressure finding of 70/60 mm Hg indicates very high blood pressure. The head circumference of the newborn is less than the chest circumference, which indicates that the newborn may have microcephaly.
A 6-year-old child undergoes supratentorial craniotomy for evacuation of a subdural hematoma. In what position should the nurse place the child during the first 24 hours after surgery? 1 At a 45-degree angle 2 At a 90-degree angle 3 In the supine position 4 In the side-lying position
1 At a 45-degree angle ---------------------------------- A potential problem after supratentorial surgery is increasing intracranial pressure; elevating the head of the bed facilitates cerebral drainage by way of gravity. Sitting upright is uncomfortable after surgery. Keeping the child flat in bed, either supine or side-lying, inhibits cerebral drainage and contributes to increasing intracranial pressure.
A nurse is caring for a client who has been admitted with right-sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8 mm depression after release. How should the edema be documented? 1 1+ 2 2+ 3 3+ 4 4+
4 4+ ------------------------------------ Dependent edema around the area of feet and ankles often indicates right-sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds, then releasing to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2+ indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression.