HESI EXIT EXAM 2022/STUDY GUIDE
A client is admitted to the intensive care unit with diabetes insipidus due to a
pituitary gland tumor. Which potential complication should the nurse monitor
closely?
A. Hypokalemia
B. Ketonuria.
C. Peripheral edema
D. Elevated blood pressure
Ans ~ A. Hypokalemia
Pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes
insipidus, which causes massive polyuria and serum electrolyte imbalances,
including hypokalemia, which can lead to lethal arrhythmias.
A 3-year-old boy was successfully toilet trained prior to his admission to the
hospital for injuries sustained from a fall. His parents are very concerned
about this regression in toileting. Which information should the nurse provide
the parents?
A. A retraining program will need to be initiated when the child returns
home.
B. Diapering will be provided since hospitalization is stressful to
preschoolers.
C. Children usually resume their toileting behaviors when they leave the
hospital.
D. A potty chair will be brought from home so he can maintain his toileting
skills.
Ans ~ C. Children usually resume their toileting behaviors when they leave
the hospital.
The parents should be reassured that once the child is back in his familiar
environment, he is likely to resume using the toileting behaviors (C).
Retraining (A) is unlikely to be needed and such information might be
distressing to the parents. (B) does not address the parents' concern.
Bringing a potty chair from home (B) is likely to increase the child's stress
because he is being encouraged to perform toileting skills while he remains
in unfamiliar surroundings.
The family of an older woman reports that they are no longer capable of
caring for her at home. While performing the admission assessment at a
long-term care facility, the nurse determines that the client is in continent of
urine, has dry mucous membranes, and has a large bruise on the coccyx.
What interventions should the nurse include in the plan of care? (Select all
that apply.)
A. Thicken liquids and provide pureed foods.
B. Apply a barrier cream to perianal areas.
C. Report suspicion of elder abuse.
, D. Implement toilet training program.
E. Offer beverages at frequent intervals.
Ans ~ B. Apply a barrier cream to perianal areas.
D. Implement toilet training program.
E. Offer beverages at frequent intervals.
The plan of care should include measures to prevent skin breakdown due to
the incontinence using a barrier cream (B) and a toileting program (D) to
help reduce the incidence of incontinence. Dry mucous membranes indicate
the need for increased fluids (E). Further assessment is needed before the
other interventions are indicated.
Sleep apnea - obesity
Ans ~ Obesity is a risk factor for OSAS, and calculation of BMI provides data
related to obesity. A BMI of 30.00 and above is considered obese.
pyloric stenosis- preop Ans ~ Hydrating an infant prior to surgery with
prescribed IV fluids is the highest priority bc vomiting associated with pyloric
stenosis often contributes to dehydration.
diabetes insipidus
Ans ~ Pituitary tumors that suppress ADH result in DI, which can cause
massive polyuria and serum electrolytes imbalances, including hypokalemia
which can lead to lethal arrythmias.
acute pancreatitis - care
Ans ~ The pathophysiologic processes in AP result form oral fluid and food
ingestion that causes secretion of pancreatic enzymes, which destroy ductal
tissue and pancreatic cells, resulting in autodigestion and fibrosis of the
pancreas. The main focus of nursing care is reducing pain caused by
pancreatic destruction through interventions that decrease GI activity such
as keeping the pt NPO.
Sex in a hospital room
Ans ~ Coming upon a client and visitor engaged in sexual activity requires
the nurse to use clinical judgement and sensitivity. The nurse should leave
and provide privacy.
Eczema pruritis
Ans ~ Antiinflammatory actions of topical corticosteroids and oral
antihistamines provide relief from severe itching. (pruritis)
Paralytic ileus- volvulus
Ans ~ A paralytic ileus develops due to local inflammatory reactions of the
bowel and its innervation that cause the failure of normal peristalsis action
A client is admitted to the intensive care unit with diabetes insipidus due to a
pituitary gland tumor. Which potential complication should the nurse monitor
closely?
A. Hypokalemia
B. Ketonuria.
C. Peripheral edema
D. Elevated blood pressure
Ans ~ A. Hypokalemia
Pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes
insipidus, which causes massive polyuria and serum electrolyte imbalances,
including hypokalemia, which can lead to lethal arrhythmias.
A 3-year-old boy was successfully toilet trained prior to his admission to the
hospital for injuries sustained from a fall. His parents are very concerned
about this regression in toileting. Which information should the nurse provide
the parents?
A. A retraining program will need to be initiated when the child returns
home.
B. Diapering will be provided since hospitalization is stressful to
preschoolers.
C. Children usually resume their toileting behaviors when they leave the
hospital.
D. A potty chair will be brought from home so he can maintain his toileting
skills.
Ans ~ C. Children usually resume their toileting behaviors when they leave
the hospital.
The parents should be reassured that once the child is back in his familiar
environment, he is likely to resume using the toileting behaviors (C).
Retraining (A) is unlikely to be needed and such information might be
distressing to the parents. (B) does not address the parents' concern.
Bringing a potty chair from home (B) is likely to increase the child's stress
because he is being encouraged to perform toileting skills while he remains
in unfamiliar surroundings.
The family of an older woman reports that they are no longer capable of
caring for her at home. While performing the admission assessment at a
long-term care facility, the nurse determines that the client is in continent of
urine, has dry mucous membranes, and has a large bruise on the coccyx.
What interventions should the nurse include in the plan of care? (Select all
that apply.)
A. Thicken liquids and provide pureed foods.
B. Apply a barrier cream to perianal areas.
C. Report suspicion of elder abuse.
, D. Implement toilet training program.
E. Offer beverages at frequent intervals.
Ans ~ B. Apply a barrier cream to perianal areas.
D. Implement toilet training program.
E. Offer beverages at frequent intervals.
The plan of care should include measures to prevent skin breakdown due to
the incontinence using a barrier cream (B) and a toileting program (D) to
help reduce the incidence of incontinence. Dry mucous membranes indicate
the need for increased fluids (E). Further assessment is needed before the
other interventions are indicated.
Sleep apnea - obesity
Ans ~ Obesity is a risk factor for OSAS, and calculation of BMI provides data
related to obesity. A BMI of 30.00 and above is considered obese.
pyloric stenosis- preop Ans ~ Hydrating an infant prior to surgery with
prescribed IV fluids is the highest priority bc vomiting associated with pyloric
stenosis often contributes to dehydration.
diabetes insipidus
Ans ~ Pituitary tumors that suppress ADH result in DI, which can cause
massive polyuria and serum electrolytes imbalances, including hypokalemia
which can lead to lethal arrythmias.
acute pancreatitis - care
Ans ~ The pathophysiologic processes in AP result form oral fluid and food
ingestion that causes secretion of pancreatic enzymes, which destroy ductal
tissue and pancreatic cells, resulting in autodigestion and fibrosis of the
pancreas. The main focus of nursing care is reducing pain caused by
pancreatic destruction through interventions that decrease GI activity such
as keeping the pt NPO.
Sex in a hospital room
Ans ~ Coming upon a client and visitor engaged in sexual activity requires
the nurse to use clinical judgement and sensitivity. The nurse should leave
and provide privacy.
Eczema pruritis
Ans ~ Antiinflammatory actions of topical corticosteroids and oral
antihistamines provide relief from severe itching. (pruritis)
Paralytic ileus- volvulus
Ans ~ A paralytic ileus develops due to local inflammatory reactions of the
bowel and its innervation that cause the failure of normal peristalsis action
