HESI

Electrocardiography (ECG) is scheduled for an infant who has tetralogy of Fallot. The parent asks the nurse what type of test this is and why it is done. Which response would the nurse provide?

"Electrical activity in the baby's heart is recorded, then printed on graph paper"

A child ingests a substance that may be poison, and the parent calls the nurse to ask what to do. Which response by the nurse is best?

"call the poison control center"

an auditory screening reveals that a child has mild hearing loss. Which statement would the nurse use to explain this degree of hearing loss?

"speech therapy and hearing aids may be required"

A child with type 1 diabetes is exhibiting deep, rapid respirations; flushed dry cheeks; abdominal pain with nausea; and increased thirst. Which blood pH and glucose level would the nurse expect the laboratory tests to reveal?

7.20 and 460 mg/dL (25.5 mmol/L)

Which vital sign findings would alert the nurse to a client's opioid overdose?

70/40 mmHg, weak pulse, and respiratory rate of 10 breaths per minute

Which assessment data would cause the nurse to suspect that a toddler-age child is experiencing physical neglect?

Abdominal distention

Which finding would the nurse expect when assessing a client with Addison disease?

Exophthalmos

Which finding would the nurse expect when taking a health history of a 15-month-old child with celiac disease?

Has bulky, foul, frothy stools

The nurse is performing an assessment and notes that the client has exophthalmos and complains of double vision. These assessment findings are consistent with which condition?

Hyperthyroidism

Which assessment finding would the nurse document in the client's health record as a positive Romberg test?

Inability to stand with feet together when eyes are closed

Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early?

Laryngeal edema

Which term is another name for rubeola?

Measles

While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. Which score on the Lovett scale would be given to this client?

Normal (N)

Which assessment finding is a late sign of heart failure?

Peripheral edema

When checking placement of a feeding tube, the nurse is unable to hear the air injected because of noisy breath sounds. Which action would the nurse take?

Try aspirating stomach contents

the nurse in the pediatric clinic is examining a toddler with a suspected pinworm infestation. For which first sing of an infestation would the nurse assess the child?

anal itching

Which action would be the priority for the nurse to take in preparation for a lumbar puncture for an infant with a tentative diagnosis of bacterial meningitis?

ask the parents what they were told about the test

Which positioning would be avoided while assessing a client with a history of asthma?

asthma

While obtaining a client's health history, which factor would the nurse identify as predisposing the client to type 2 diabetes?

being 20 pounds overweight

The client had a colon resection and formation of a colostomy 2 days ago. Which color indicates to the nurse that the stoma is viable?

brick red

Which assessment data would cause the nurse to suspect that a toddler is experiencing physical abuse?

bruises in various stages of healing

The nurse finds that an adolescent has episodes of binge eating followed by self-induced vomiting and strenuous exercise. Which condition is the adolescent likely to have?

bulimia

The nurse is performing a neurologic assessment of an adolescent with a seizure disorder. Which action would the nurse take to test cranial nerve XI?

by telling the adolescent to shrug the shoulders

A client arrives at a health clinic reporting a recent onset of hematuria, frequency, urgency, and pain on urination. Which diagnosis will the nurse observe in the client's medical record?

cystitis

a client's breath has a sweet, fruity odor. Which condition is affecting this client?

diabetic acidosis

Which clinical manifestation would the nurse expect when a client experiences fat embolism syndrome?

dyspnea

which symptom would the nurse identify when assessing a client with Graves disease?

exophthalmos

A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment findings observed by the nurse would relate to this diagnosis?

fainting, weakness, lightheadedness

When completing a health assessment, the nurse identifies tremors of the clients hands. When discussing the assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Which additional assessment finding would the nurse report immediately to the health care provider?

fluttering in the chest

Which manifestation is associated with hypoestrogenism?

hot flashes, amenorrhea, reduced bone density

An unconscious adolescent with type 1 diabetes is brought to the emergency department. The blood glucose level is 742 mg/dL (41.2 mmol/L). Which finding would the nurse expect during the initial assessment?

hyperpnea

While inspecting the external eye structure of a client, the nurse finds bulging of the eyes. Which condition would be suspected in the client?

hyperthyroidism

a client reports giddiness, excessive thirst, and nausea. which parameter assessed by the nurse confirms the diagnosis as a heat stroke?

increased heart rate

Which result would the nurse monitor in a client with acetaminophen overdose?

liver function tests

A child who has a history of a 5-Ib (2.3 kg) weight gain in 1 week and periorbital edema is admitted with a diagnosis of acute glomerulonephritis. How can the nurse obtain the most accurate information on the status of the childs edema?

observing body changes

The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis report. Which urinary finding indicates the need to notify the primary health care provider?

presence of large proteins

Which diagnostic tests are used to measure kidney size?

radiography, computed tomography (CT)

Which variations in nail color would indicate that a client has trauma to the nail beds?

red color

While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures. These episodes are longer than 24 hours. Which fever pattern would the nurse anticipate?

relapsing

The nurse notes large welts and scars on the back of a toddler who has been admitted for an asthma attack. Which information would the nurse assess further?

signs of child abuse

Which assessment finding for a client who is anxious indicates sympathetic nervous system stimulation?

skin pallor

the nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. Which parameter is the nurse assessing?

skin turgor

The registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns would be expected in this client?

softening of nail beds and flat nails

which method would the nurse use to best elicit the Moro reflex in a full-term newborn?

stroking the sole of the foot along the outer edge from the heel to the toe

Which action would the nurse take to determine a client's pulse pressure?

subtract the diastolic from the systolic reading

Which sign indicates a child is a victim of bullying and would be included in a teaching session for teachers?

the child asks to go to the nurse's office frequently with vague complaints

Which process would the nurse use to determine the length of tube needed to reach a client's stomach for nasogastric feeding?

the tube is advanced until resistance is met

Which condition is likely in a client who has an interruption of venous return?

varicosity

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?

yellow