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HESI MED SURG EXAM REAL EXAM 160 QUESTIONS AND DETAILED ANSWERS WITH RATIONALES(AGRADE)
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HESI MED SURG EXAM REAL EXAM 160 QUESTIONS AND DETAILED ANSWERS WITH RATIONALES(AGRADE)
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HESI MedSurg ExamStudy online at https://quizlet.com/_8xnbkd
· Respiratory effort.
Guillain-Barre syndrome causes paraly-
sis or weakness that typically starts at
the feet and progresses upwards. As the
Which assessment is most important for condition progresses, the nurse must en-
the nurse to perform on a client who is sure that the client is able to breathe
hospitalized for Guillain-Barre syndrome effectively.
that is rapidly progressing?
· Respiratory effort. Heuther, Understanding Pathophysiolo-
· Unsteady gait. gy, 6th ed. p. 412
· Intensity of pain.
· Ability to eat.
· Collect a culture of the penile discharge.
A male client comes into the clinic with a
Penile discharge with painful urination
history of penile discharge with painful,
is commonly associated with gonorrhea.
burning urination. Which action should
The nurse should collect a culture of the
the nurse implement?
penile discharge to determine the cause
· Collect a culture of the penile discharge.
of these symptoms. The cause must be
· Palpate the inguinal lymph nodes gen-
determined or confirmed through culture
tly.
to identify the organism and ensure ef-
· Observe for scrotal swelling and red-
fective treatment.
ness.
· Express the discharge to determine col-
Jarvis Physical Examination and Health
or.
Assessment, 6th edition
· Check for a pulse deficit.
A client with history of atrial fibrillation is
A client with a past history of atrial fibrilla-
admitted to the telemetry unit with sud-
tion may return to that rhythm. Any signs
den onset of shortness of breath. The
of atrial fibrillation, such as sudden on-
nurse observes a new irregular heart
set shortness of breath, requires further
rhythm and should perform which as-
investigation. The nurse should assess
sessment at this time?
this client for a pulse deficit because this
· Check for a pulse deficit.
condition occurs with atrial fibrillation.
· Palpate the apical impulse.
, HESI MedSurg Exam
Study online at https://quizlet.com/_8xnbkd
Jarvis. (2016); Physical Examination and
· Inspect jugular vein pulse.
Health Assessment, (Chap 19) 7th ed.,
· Examine for a carotid bruit.
p. 481
· A 24-year-old with shoulder and lower
Which client should be further assessed
abdominal quadrant pain.
for an ectopic pregnancy?
A 24-year-old with sudden onset of low-
· A 24-year-old with shoulder and lower
er abdominal quadrant pain should be
abdominal quadrant pain.
assessed for an ectopic pregnancy. The
· A 33-year-old with intermittent lower
pain can also be referred to the shoul-
abdominal cramping.
der and may be associated with vaginal
· A 20-year-old with fever and right lower
bleeding.
abdominal colic.
· A 40-year-old with jaundice and right
Health Assessment for Nursing Practice,
lower abdominal pain.
Wilson and Giddens. p.269
· Drinks a six pack of beer every day.
Drinking six beers every day is the di-
etary assessment finding most important
Which dietary assessment finding is
for the nurse to address when caring for
most important for the nurse to address
a client with diabetic nephropathy. The
when caring for a client with diabetic
usual can of beer is 12 ounces (355 mL).
nephropathy?
Clients with diabetes are recommended
· Drinks a six pack of beer every day.
to drink no more than 12 ounces of beer
· Enjoys a hamburger once a month.
per day because beer contains carbohy-
· Eats fortified breakfast cereal daily.
drates that can create unhealthy fluctua-
· Consumes beans and rice every day.
tions in blood glucose and promote poor
glucose control. Nephropathy is exacer-
bated by poor blood glucose control.
· Cough brought on by swallowing.
A cough brought on by swallowing is a
Which assessment finding is of greatest
sign of dysphagia, which is a finding of
concern to the nurse who is caring for a
particular concern in a client with stom-
client with stomatitis?
atitis. Dysphagia can cause numerous
· Cough brought on by swallowing.
problems, including airway obstruction,
· Sore throat caused by speaking.
and should be reported to the healthcare
· Painful and dry oral cavity.
provider immediately.
· Unintended weight loss.
Ignatavicius, (2016). Medical-surgical
, HESI MedSurg Exam
Study online at https://quizlet.com/_8xnbkd
nursing: Patient-centered collaborative
care, eight edition., Ch. 53, p. 1100.
· Altered sexual response.
Peripheral arterial disease (PAD) is a
The nurse is teaching a client diag-
cardiovascular condition characterized
nosed with peripheral arterial disease.
by narrowing of the arteries and re-
Which genitourinary system complica-
duced blood flow to the extremities. PAD
tion should the nurse include in the
is known to alter the blood flow to the
teaching?
male's penis and is associated with erec-
· Altered sexual response.
tile dysfunction in men.
· Sterility.
· Urinary incontinence.
Ignatavicius,. (2016). Medical-surgical
· Decreased pelvic muscle tone.
nursing: Patient-centered collaborative
care, eight edition., Ch. 69, p. 1452.
· Oral contraceptives.
A 40-year-old female client has a histo-
Women older than 35 years old who
ry of smoking. Which finding should the
smoke and take oral contraceptives have
nurse identify as a risk factor for myocar-
an increased risk of myocardial infarction
dia infarction?
or stroke.
· Oral contraceptives.
· Senile osteopenia.
Ignatavicius, (2013). Medical-surgical
· Levothyroxine therapy.
nursing: Patient-centered collaborative
· Pernicious anemia.
care, 7th ed.., Ch. 35, p. 694.
· Decreased color perception.
A client has been told that there is Decreased color perception occurs with
cataract formation over both eyes. Which cataract formation. Cataract formation is
finding should the nurse expect when also associated with blurred vision and a
assessing the client? global loss of vision so gradual that the
· Decreased color perception. client may not be aware of it.
· Presence of floaters.
· Loss of central vision. Ignatavicius, (2016). Medical-surgical
· Reduced peripheral vision. nursing: Patient-centered collaborative
care, eight edition., Ch. 47,
· New onset of coughing.
Which assessment finding should most A pneumothorax (partial or complete
concern the nurse who is monitoring a lung collapse) is the potential complica-
client two hours after a thoracentesis? tion of a thoracentesis. Manifestations of
a pneumothorax include new onset of a
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