CAQ HESI questions

a, b, e Irritation of cerebral tissue can cause seizures. Pressure on vital centers can cause vomiting. Pressure on the respiratory center results in a decreased respiratory rate. A 2-year-old child's fontanels are closed, so bulging fontanels are not a sign of increased intracranial pressure in this case. The inflammatory process of meningitis causes an increase in temperature.

For which clinical manifestations of increasing intracranial pressure would the nurse assess the child diagnosed with meningitis? Select all that apply. One, some, or all responses may be correct. a. seizures b. vomiting c. bulging fontanels d. subnormal temperature e. decreased respiratory rate

B the surface of a stoma is a mucous membrane and should be dark pink to red, moist, and shiny; the stoma is usually raised above the skin surface pale pink indicated low hemoglobin levels. purple indicates compromised circulation. a depressed stoma is retracted and unexpected. a stoma should not be painful.

On the second day after an abdominoperineal resection, the nurse anticipates that a client's colostomy stoma will have which appearance? a. dry, pale pink, flush with the skin b. moist, red, and raised above the skin surface c. dry, purple, and depressed below skin surface d. moist, pink, flush with the skin, and painful when touched

b Purines are precursors of uric acid, which crystallizes. Cystine stones are caused by a rare hereditary defect resulting in defective absorption of cysteine in the gastrointestinal tract and kidneys (inborn error of cystine metabolism). Serum purine will not be elevated if the stone is composed of calcium oxalate. A struvite stone sometimes is called a magnesium ammonium phosphate stone and is precipitated by recurrent urinary tract infections

The laboratory values of a client with renal calculi reveal a serum calcium within expected limits and an elevated serum purine. Which type of stone composition is consistent with these laboratory values? a. cystine b. uric acid c. calcium oxalate d. magnesium ammonium phosphate

B Mongolian spots are a medical condition characterized by the appearance of irregular, deep-blue pigmented spots on the gluteal regions. This skin abnormality is a common finding in newborns of Asian descent. Milia are distended sebaceous glands, which manifest as tiny white papules on cheeks, chin, and nose. Erythema toxicum manifests as a pink papular rash on the thorax, back, and buttocks. Harlequin color change is a clear line through the body caused by lying on one side. The side on which the baby sleeps turns pink.

The nurse is assessing a newborn whose parents are Asian. The nurse finds that the child has irregular, deep-blue pigmentation on the gluteal regions. How would the nurse interpret the examination findings? a. the skin has milia b. this is consistent with mongolian spots c. the child has erythema toxicum d. there is harlequin color change

d. Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.

The nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? a. Inclusion of transmural involvement of the small bowel wall b. Higher occurrence of fistulas and abscesses from changes in the bowel wall c. Pathology beginning proximally with intermittent plaques found along the colon d. Involvement starting distally with rectal bleeding that spreads continuously up the colon

b The orthopneic position is a sitting position that permits maximum lung expansion for gaseous exchange; it also enables the client to press the lower chest or abdomen against the overbed table, which increases pressure on the diaphragm to help with exhalation, reducing residual volume.

The nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? a. supine b. orthopneic c. low fowler d. semi fowler

d A black-tagged client in a mass casualty triage situation is a critically ill client who is expected and allowed to die or is not treated until others have received care. This is done so that limited resources can be dedicated to saving the most lives, and not expended to save one life at the possible expense of many others. The client with extensive full-thickness body burns falls in this category. A client with a contusion would be green-tagged because a contusion is a minor injury that can be managed in a delayed fashion. A client with airway obstruction would be red-tagged. This client has an immediate threat to life and requires immediate attention. A client with open fractures with a distal pulse would be yellow-tagged. This is major injury that requires treatment within 30 minutes to 2 hours.

When helping a triage officer evaluate the victims of a large-scale disaster, which client would the nurse anticipate will be given a black tag? a. pt with confusion b. pt with airway obstruction c. pt with open fractures and a distal pulse d. pt with extensive full-thickness body burns

b Pulmonary edema is associated with severe preeclampsia; as vasospasms worsen, capillary endothelial damage results in capillary leakage into the alveoli. Crackles are not an indication of an impending seizure; signs of an impending seizure include hyperreflexia, developing or worsening clonus, severe headache, visual disturbances, and epigastric pain. Pregnancy does not precipitate bronchial constriction, although the hormones associated with pregnancy can cause nasal congestion. Impaired diaphragmatic function is a discomfort associated with pregnancy that may result in shortness of breath or dyspnea, not crackles.

Which inference would the nurse draw when crackles are heard while auscultating the lungs of a client admitted with severe preeclampsia? a. seizure activity is imminent b. pulmonary edema may have developed c. diaphragmatic function is being impaired by the enlarged uterus d. bronchial constriction was precipitated by the stress of pregnancy

a, d Passive or spontaneous rewarming involves using radiant lights and moving the client to a warm and dry place. Active internal or core rewarming involves application of heat directly to the core. This includes administering humidified oxygen heated up to 111.2°F (44°C), administering intravenous fluids warmed to 98.6°F (37°C), and performing peritoneal lavage with fluids warmed to 113°F (45°C).

Which interventions would the nurse employ when using spontaneous rewarming for the victims of a natural disaster who are all hypothermic? Select all that apply. One, some, or all responses may be correct. a. using radiant lights b. admin heated humidified oxygen c. admin warmed IV fluids d. move pt. to warm, dry place e. perform peritoneal lavage with warmed fluids

B The rotavirus vaccine prevents rotavirus gastroenteritis and diarrhea-related problems. The vaccination requires two doses. The first dose of rotavirus should be given between 6 and 12 weeks followed by the second dose, which is given 4 or more weeks after the first dose. Administering the vaccine before the age of 5 weeks is too early, and administering it at 13 to 18 weeks or 19 to 24 weeks is too late.

Which statement by the nurse correctly identifies when the first dose of rotavirus vaccine is administered to infants? a. from birth-5 weeks b. from 6-12 weeks c. from 13-18 weeks d. from 19-24 weeks

c, e The 5-year-old preschool-aged client would be expected to participate in dress-up play because of preoccupation with magical thinking and the beginnings of cooperative play characterize this stage. Solitary play is expected for the infant and toddler. Parallel play is expected for the toddler and young preschool-aged client. Team sport play is expected for the school-aged client.

Which type of play would the nurse recognize as age-appropriate for a 5-year-old client? Select all that apply. One, some, or all responses may be correct. a. solitary play b. parallel play c. dress up play d. team sport play e. cooperative play

c Kussmaul breathing is an abnormally deep, very rapid, sighing type of respiratory pattern that develops as a compensatory response to metabolic acidosis and attempts to raise the pH of the blood by blowing off carbon dioxide

Which type of respiratory pattern would the nurse expect in a client with metabolic acidosis? a. ataxic b. cluster c. kussmaul d. cheyne-stokes

B Impetigo may develop as a secondary bacterial infection because of breaks in the skin caused by scratching. Eczema is an allergic response and not related to episodes of pediculosis. Cellulitis is an extended inflammation that is not commonly found in children with pediculosis. Folliculitis is a pimple or an infection of the hair follicle; it does not occur as a result of pediculosis.

. Which condition is commonly seen following infestation with pediculosis capitis (head lice)? a. eczema b. impetigo c. cellulitis d. folliculitis

d, b, a, c

According to priority, in which order would the nurse perform care activities for a client with complete partial seizures? a. assessing vital signs b. recording time and duration of seizure c. performing neuro checks d. maintaining airway

a After surgery for peripheral arterial disease, clients are instructed to start taking short walks and to gradually increase frequency and distance. Elevation of the legs would decrease arterial blood flow through the graft; leg elevation is recommended for venous disease. Clients with peripheral artery disease should avoid extremes of hot or cold, because these can injure extremities with poor perfusion. Continuing use of antiplatelet medications such as aspirin is needed to prevent arterial thrombus in blood vessels with poor perfusion.

After the nurse provides discharge teaching for a client who had a femoropopliteal bypass graft, which client action indicates that the teaching has been effective? a. walking 10 mins per day b. elevating the legs when sitting or lying c. taking a hot bath d. d/c prescribed aspirin

d If there is no subsequent infection of the burned areas, wound healing should be uneventful. Although partial-thickness burns are painful, they usually heal with little or no scarring. Regeneration will occur unless there is further insult to the burn injury, such as infection; grafting should not be necessary. Occlusive dressings may be applied to minimize the discomfort of frequent dressing changes; hydrotherapy is not required for partial-thickness burns.

An adolescent is admitted to the burn unit with partial-thickness burns of both arms and the chest. Which information about burns would guide the nurse's plan of care? a. burns are extremely painful and disfiguring b. some grafting of the burned area is necessary c. pressure dressings and prolonged hydrotherapy are required d. spontaneous epithelial regeneration occurs within several weeks

B A school-age client who is 11 years of age would require 9 hours of sleep each night. A 5-year-old school-age client requires 11.5 hours of sleep per night

How many hours of sleep would the nurse recommend for the 11-year-old client? a. 8 b. 9 c. 11 d. 12

A first generation antihistamines such as chlorpheniramine have side effects such as confusion, dry mouth, and constipation in older adults

Which medication taken by an older client who has been treated for rhinitis and pharyngitis may be causing the client's new onset confusion, dry mouth, and constipation? a. Chlorpheniramine b. Acetaminophen c. Ibuprofen d. Guaifenesin

a Epinephrine stimulates beta- and alpha-receptors; its actions include increasing heart rate and blood pressure and inducing bronchodilation. Increased blood pressure, not hypotension, is a potential side effect. Epinephrine relieves respiratory problems; it does not cause respiratory arrest. Epinephrine stimulates, not depresses, the central nervous system.

Which side effect would the nurse assess for after epinephrine is administered to an infant with severe bronchospasms? a. tachycardia b. hypotension c. respiratory arrest d. central venous system depression