HESI Review: Concepts 2

A nurse is assessing a 15-month old girl at the well-child clinic. The nurse determines that further education about toddler development is necessary when the mother says what? 1. She's always trying to get out of her car seat 2. she cries when i leave her at the daycare center 3. she gets into everything and scatters toys everywhere 4. she has a temper tantum every time i put her on the potty chair

4 Rationale: Most 15-month-old toddlers are not ready for toilet training.

How many hours of sleep should the nurse recommend for the 1--year-old client? 1. 9 2. 8 3. 11 4. 12

9

A child is being treated with oral ampicillin for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client? 1. Complete the entire course of antibiotic therapy 2. Herbal fever remedies are highly discouraged 3. Administered the medication with meals 4. Stop the antibiotic therapy when the child no longer has a fever.

1

A nurse notices that a client is in spiritual distress. Which nursing action establishes the nurse as a caregiver? 1. The nurse provides therapeutic treatment to the client 2. The nurse teaches the client about signs of spiritual distress. 3. The nurse communicates the wishes to the client to family members 4. The nurse collaborates with the agency chaplain to pursue the best treatment plan

1

During follow-up visits, the client's child reports to the nurse, "I tell my parent every day about what may happen if medications aren't taken as prescribed. Despite that, my parent does not take the medication regularly and is depressed." What can be inferred about the client's motivational level? 1. Not 2. Intrinsically 3. Extrinsically with self-determination 4. Extrinsically without self-determination

1

On a routine visit to the well-child clinic, the parents of a 3-year-old child tell the nurse that their child is a picky eater and express concern about their child's nutritional status. What should the nurse suggest to help the parents meet the child's nutritional requirements? 1. Including some of the foods the child prefers in every meal 2. Cooking nutritious meals and staying with the child until the food is eaten 3. Severing a regular diet to the family and a special meal that the child will eat 4. Explaining that there will be no dessert until the child eats the food on the plate.

1

The parent of a 7-year-old child wants to improve the child's performance on schoolwork. What advice should then school nurse provide? 1. Praise your child's accomplishments 2. Compare your child's work to that of more successful children 3. Allow your child to paly more and don't focus too much on academies 4. Complete some of the harder tasks until your child gains comprehension.

1

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client? 1. Control of pain 2. Immobilization of joints 3. Motivation and teaching 4. Bladder training and control

1 Rationale: After the need to survive (air, food, water), the need for comfort and freedom from pain closely follow; care should be given in order of the client's basic needs.

The nurse provides a list of appropriate food choices to a client with newly diagnosed diabetes. The client reviews the list and says," I do not like and refuse to eat asparagus, broccoli, and mushrooms." In response, the nurse teaches the client about the food exchange list. The nurse evaluates that teaching was effective when the client states, "Instead of asparagus, broccoli, and mushrooms, I will eat which foods"? 1. string beans, beets, or carrots 2. corn, lima beans, or dried peas 3. baked beans, potatoes, or parsnips 4. corn muffins, corn chips, or pretzels.

1 Rationale: Same nutrients.

A nurse is teaching a class of nursing assistants about the differences in care among various age groups. Care of which age group of children does the nurse describe as the most challenging? 1. 1-4 years 2. 6-8 years 3. 6-12 months 4. birth-6 months

1 Rationale: The 1-4 child is learning to use the body and manipulate and experiment with all aspects of the environment; these abilities may challenge the nurse assistant. School-aged children are able to cooperate and understand when receiving care.

Which joint in the human body is an example of a condyloid joint? 1. Wrist 2. Elbow 3. Shoulder 4. Sacroiliac

1 Rationale: The eblow is a hinge joint, shoulder is a ball and socket, sacroiliac is a gliding joint.

At which stage of Kohlberg's theory does an individual want to fulfill the expectations of one's immediate group? 1. Good boy-nice girl orientation 2. Society-maintaining orientation 3. Instrumental relativist orientation 4. Universal ethical principle orientation.

1 Rationale: The good boy-good girl orientation stage involves an individual who wants to win the approval and maintain the expectations of one's immediate group. During the society-maintaining orientation stage, an individual expands focus from a relationship with others to societal concerns. The instrumental relativist orientation stage involves a child who wants to follow his or her parent's rules. The universal ethical principle orientation stage defines "right" by the decision of conscience according to self-chosen ethical principles.

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action? 1. Data collection 2. Data validation 3. Data clustering 4. Data interpretation

1 Rationale: The nursing is gathering objective data to support the subjective data.

A 2-year-old toddler requires close supervision to protect against potential accidents. The nurse teaches a class for parents about the learning style of toddlers. How do toddlers learn self-protection? 1. Through trial-and-error strategies 2. By imitating playmates and siblings 3. By obeying orders from other and father 4. By playing with age-appropriate toys and puzzles

1 Rationale: The toddler is developing autonomy is curious, and learns self-protection from experience.

A healthcare provider diagnoses attention deficit hyperactivity disider (ADHD) in a 7-year-old child and prescribes methylphenidate. The nurse discusses the child's treatment with the parents. What does the nurse emphasize as important for the parents to do? 1. Monitor the effect of the medication on their child's behavior 2. Increase or decrease the dosage, depending on the child's behavior 3. Avoid imposing too many rules, because this will frustrate the child. 4. Point out to their child that behavior can be controlled.

1 Rationale: this helps determine the effectiveness of the medication.

Tests reveal that a client has phosphatic renal calculi. The nurse teaches the client that the diet may include which food item? 1. apples 2. chocolate 3. rye bread 4. cheddar cheese

1 Rationale; Apples are low in phosphate; fresh fruit is low in phosphorus. Chocolate contains more phosphate than apples. Rye bread contains more phosphate than apples. Cheese is made with milk, which contains phosphate and should be avoided. Dairy products are high in phosphorus.

Which nursing interventions are examples of the nurse as a caregiver? Select all that apply 1. Encouraging the client to exercise daily 2. setting goals for the client to reduce weight 3. arranging for the client to meet a spiritual advisor 4. evaluating the client's understanding of prescribed diet 5. demonstrating the procedure to self-administer insulin injection

1, 2, 3 Rationale: The nurse's duty is a caregiver and these are interventions for giving care.

A mother and her 5-year-old daughter have been referred to a child advocacy center for a forensic pediatric sexual examination. Before the child is examined or interview, the mother gives a detailed history, relaying her suspicion that the child's maternal grandfather sexually assaulted her. As the interview progresses, the mother suddenly says, "My father sexually molested me when I was a child, but I try not to think about it." What defense mechanism does the nurse recognize that the mother's statement demonstrates. 1. Intojection 2. Suppression 3. Reaction formation 4. Passive aggression

2

The nurse is assessing an elderly male. Which finding is seen with aging? 1. Symmetrical tests 2. Reduced size of testes 3. presence of pubic hear 4. presence of foreskin on the penis

2

The parents of an infant ask a nurse why their baby is not receiving the measles, mumps, and rubella (MMR) vaccine at the same time that other immunizations are being given. What explanation should the nurse give about why the MMR vaccine is administered at 12-15 months of age? 1. There is an increased risk of side-effects in infants 2. Maternal antibodies provide immunity for about 1 year 3. It interferes with the effectiveness of vaccines given during infancy 4. There are rare instances of these infections occurring during the first year of life.

2

Which structure protects a client's internal organs, supports blood cell production, and stores minerals? 1. Joints 2. Bones 3. Muscles 4. Cartilages

2

Which of these stages is followed by the "society-maintaining orientation," according to Kohlberg's theory 1. Social contact orientation 2. Good boy-nice girl orientation 3. Instrumental relativist orientation 4. Punishment and obedience orientation

2 Rationale: According to Kohlberg's theory, the "good boy-nice girl orientation" phase (stage 3) occurs before the "society-maintaining orientation" phase (stage 4). "Social contract orientation" is the fifth stage. "Instrumental relativist orientation" is the second stage.

A client at a fertility clinic is being treated for hypertension and obesity with a regimen of diet and exercise. During the past month, she has lost 8 lb (3.6) and her blood pressure has decreased to 154/98 mm Hg. The client states that she is using self-control strategies to reduce her blood pressure and weight. What is the nurse's most therapeutic response? 1. Explaining to the client that her current program needs revision to improve results 2. acknowledging the client's achievement while encouraging the continuation of her current program. 3. Emphasizing to the client the importance of exercise in addition to the reduction of sodium and caloric intake 4. recommending that the client ask her practitioner about a prescription for an antihypertensive or diuretic

2 Rationale: Acknowledging the client's achievement while encouraging the continuation of her current program recognizes achievement and reinforces the client's behavior.

A 13-year-old is found to have idiopathic scoliosis. She is upset about the treatment regimen and is worried about being different from her friends. What should the nurse do to help the child maintain a positive self-image during treatment? 1. Remind her how crooked her back will be if she refuses treatment 2. Help her investigate appropriate clothing to enhance her appearance 3. disregard her negative characteristic and focus on her positive attributes 4. refer her for psychological counseling until the treatment program is completed

2 Rationale: Clothes can be selected to minimize the appearance of a brace.

A client has an order for a sublingual nitroglycerin tablet. The nurse should teach the client to use what technique when self-administering this medication? 1. Place the pill inside the cheek and let it dissolve 2. Place the pill under the tongue and let it dissolve 3. Chew the pill and then swallow it 4. Swallow the pill with a full glass of water.

2 Rationale: Sublingual medication is placed under the tongue. The buccal route requires placing medication between the cheek and gums. Water is for PO route, chewing for large tablets

A client with a terminal illness is grateful for the care received in the hospital and has slowly started to come to terms with imminent death. The nurse recognizes that the client's behavior and attitude is most consistent with which cultural group? 1. German 2. Somalian 3. Ukrainian 4. More secular

2 Rationale: Terminally ill clients who belong to the Somalian culture may slowly accept their imminent death and have faith in God. Somalian clients will generally express their gratitude to the care received in the hospital. Clients who belong to the German and Ukrainian cultures may not accept their illness and may fight against the illness in them. Clients who belong to a more secular culture or are less identified by religious institutions may not accept their imminent death.

The parent of a 2-year-old calls a nurse who is a neighbor and reports that the child just ate several multivitamins with iron. What should the nurse say to the parent? 1. Give your child orange juice 2. Call the poison control center 3. Iron-fortified multivitamins are safe for your child 4. Administer an emetic-syrup of ipecac, if you have it.

2. Rationale: The Poison folk will provide the best guidance for treatment of excess ingestion of a substance.

During a home visit, the nurse finds that a healthy elderly person is actively practicing laughing therapy to maintain good health without pressure or insistence from the family. What does the nurse infer? 1. Not 2. Intrinsically 3. Extrinsically with self-determination 4. Extrinsically without self-determination

2. Rationale: An intrinsically motivated individual participates in an activity because it is inherently interesting or enjoyable rather than because of obligations or outside pressure from family members. If the person is not motivated, he or she would be unlikely to participate in the activity. An extrinsically motivated individual with or without self-determination may practice laughing therapy upon suggestion or pressure created by other individuals.

A client has a prayer cloth pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client's gown? 1. Make a new prayer cloth 2. Discard the soiled prayer cloth 3. Pin the prayer cloth to the clean gown 4. Wash the prayer cloth with a mild detergent

3

A client is admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? 1. Your primary healthcare provider must have forgotten to prescribe it 2. Your condition is not severe enough to have physical therapy approved 3. Your joints are still inflamed, and physical therapy can be harmful 4. Physical therapy is not helpful for persons who suffer from RA

3

A client with obsessive-compulsive disorder performs a specific ritual. Why should the nurse give the client time to perform the ritual? 1. It demonstrates respect for the client's autonomy 2. This behavior is viewed as result of anger turned inward. 3. Denying this activity may precipitate an increased level of anxiety 4. Successful performance of independent activates enhances self-esteem.

3

An older client who has had multiple hospital admissions for recurring heart failure is returned to the hospital by an adult child. The client is admitted for observation to the coronary care unit and calmly states," I know I'm sick, but I can really take care of myself at hoe." What should the nurse conclude that the client most likely is attempting to do? 1. Suppress fears 2. Deny the illness 3. Maintain independence 4. Reassure the adult child

3

The nurse anticipates that the family of a child with cerebral palsy is at risk for difficult parenting issues. What does the nurse conclude is the probably basis for this difficulty 1. Lack of social support 2. Unrealistic expectations 3. Loss of the expected healthy child 4. Having a child with cognitive impairment

3 Rationale: All parents initially grieve over the loss of a health child, what could have been, and what may never be.

According to the student nurse, in which stage of Erikson's theory does the child initiate self-care activities? 1. Initiative versus guilt 2. Integrity versus despair 3. Autonomy versus sense of shame and doubt 4. Generativity versus self-absorption and stagnation.

3 Rationale: Initiative versus guilt stage is the 3rd stage, and during this stage children like to pretend and try out new roles. Integrity versus despair is the 8th stage, and during this stage many older adults' view their lives with a sense of satisfaction.

A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. What does the nurse identify as the drug's mechanism of action? 1. Blocks the effects of acetylcholine 2. Increases the production of dopamine 3. Restores the dopamine levels in the brain 4. Promotes the production of acetylcholine

3 Rationale: Levodopa is a precursor of dopamine, a catecholamine neurotransmitter; it increases dopamine levels in the brain that are depleted in Parkinson disease.

A nurse is caring for a 13-year-old child who has an external fixation device on the leg. What is the nurse's priority goal when providing pin care? 1. Easing pain 2. Minimizing scarring 3. Preventing infection 4. Preventing skin breakdown

3 Rationale: Pin sites provide a direct avenue for organism into the bode.

A nurse is advising a client about the risk associated with failing to seek treatment for acute phyngitits caused by beta-hemolytic streptococcus. For what health problem is the client at risk? 1. Asthma 2. anemia 3. endocarditis 4. reye syndrome

3 Rationale: Streptococcal infections can spread via circulation to the heart; endocarditis results and affects the valves of heart.

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? 1. Perform the procedure once in the morning and at night 2. Move the trunk to an upright position and then exhale while bending over. 3. Inhale completely and then blow out as hard and as fast as possible through the mouthpiece 4. Place the mouthpiece between the lips and in front of the teeth before starting the procedure.

3 Rationale: The meter measures the peak expiratory flow rate, the max flow of air that can be forcefully exhaled in one second; this monitors the pulmonary status of a client with asthma.

A nurse is considering Erikson's stages of psychosocial development while caring for a client. Which behavior is consistent with a problem involving trust versus mistrust? 1. Woman in an abusive relationship who refuses to leave the abuser 2. Man with paranoid schizophrenia who demands placement in a private room. 3. Woman whose parents were chronic alcoholics and who has problems making friends 4. Man with borderline personality disorder who has been caught steeling from other clients.

3 Rationale: Trust is learned in infancy. Being parented by individuals who were not able to consistently meet the client's basic physiologic and safety needs is likely to result in an inability to engage in healthy interpersonal relationships as an adult. The response of the client in an abusive relationship is based not on events that occurred during infancy but rather on events in adulthood. The responses of the clients with paranoid schizophrenia and borderline personality disorder are symptoms of a psychiatric disorder rather than of an event that occurred during infancy.

A nurse is planning to provide self-care health info to several clients. Which client should the nurse anticipate will be most motivated to learn 1. A 55-year-old client who had a mastectomy and is very anxious about her body. 2. An 18-year-old client who smokes cigarettes and is in denial about the dangers of smoking 3. A 56-year-old client who had a heart attack last week is requesting info about exercise 4. A 47-year-old client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain.

3 Rationale: the requesting indicates motivation

A 2-year-old toddler is to have intravenous antibiotic therapy. What will the nurse plan to do to prevent the child from pull out the IV line? 1. Keep the arms restrained 2. Tell the child to not touch the IV site 3. Cover the IV site with a protective device 4. Have the parent hold the child continuously.

3. Rationale: Restraints are a last resort, verbal instructions will not work, the family is not responsible for holding the child.

A 50-year-old male client has difficulty communication because of expressive aphasia after a cerebrovascular accident (CVA, "brain attack"). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior? 1. Ask the wife how she knows how the client feels 2. Instruct the wife to let the client answer for himself .3 When the life leaves return to speak with the client 4. Acknowledge the wife but look at the client for a response.

4

Which carative factor is involved in creating a healing environment at all levels, physical and non-physical, according to Watson's Transpersonal Caring? 1. Promoting transpersonal teaching-learning 2. Promoting and expressing positive and negative feelings 3. Developing a helpful, trusting, human caring relationship 4. Providing a supportive, protective, and/or spiritual environment

4

A 4-year-old child is being prepared for a myringotomy in the ambulatory care unit. What is most important for the nurse to do when the child is called to the operating room. 1. Removing the child's undergarments 2. Placing the child's toys on the bedside table 3. Allowing the child to climb onto the stretcher 4. Having the parents accompany the child to the operating suite.

4 Rationale: Current practice encourages parents to stay with the child as long as possible; this helps reduce stress related to a frightening experience. Removing undergarments is usually not necessary for a myringotomy procedure. Toys, especially a favorite one, should accompany the child until sedation is induced. The child is too young to climb onto a stretcher.

Which drug may cause gynecologic malignancies in females? 1. Oxytocin 2. Raloxifene 3. Thalidomide 4. Diethylstilbestrol

4 Rationale: Diethylstilbestrol may cause gynecologic malignancies such as endometrial, ovarian, and cervical cancers. Tamoxifen is used to treat breast cancer. Raloxifene is used to prevent postmenopausal osteoporosis. The use of thalidomide during pregnancy may cause birth defects in the newborn.

A nurse is assessing the grief response of a family member whose relative has died. What must the nurse consider first about the family to conduct an effective assessment? 1. Personality traits 2. Educational level 3. Socioeconomic class 4. Cultural background

4 Rationale: Grief is factored by cultural background

A client is diagnosed with pulmonary tuberculosis, and the healthcare provider prescribes a combination of rifampin and isoniazid. The nurse evaluates that the teaching regarding the drug is effective when the client reports which action as most important 1. Report any changes in vision 2. Take the medicine with my meals 3. Call my doctor if urine or tears turned red-orange 4. Continue taking the medication even after I feel better.

4 Rationale: Medication should be taken for the full course of therapy; most regimens last from 6-9 months.

A client expresses concern that because of supply and demand there is no vaccine available for the annual flu vaccine. What is the nurse's best reply? 1. It's unfortunate, but there was such a limited supply available 2. There are many others who also were unable to get a flu vaccine 3. It doesn't matter because the vaccine is for just one particular strain 4. There are other things you can do to prevent the flu, such as hand washing

4 Rationale: This still helps the client avoid the flu and is productive

What is the most common teratogenic effect associated with thalidomide? 1. Shortened limbs 2. Growth delay 3. Neural tube defects 4. Cleft lip with a cleft palate

Shortened limbs