HESI Comprehensive Exam A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen. What statement by the nurse indicates a need for further information? "We need to administer the antidote N -acetyl cysteine and dilute it in juice or soda." "A loading dose of N -acetyl cysteine has to be followed by maintenance doses." Incorrect "We need to give N -acetyl cysteine before we do gastric lavage with activated charcoal." "If the child is unconscious, we must do gastric lavage with activated charcoal to decrease the absorption of acetaminophen." - "We need to give N -acetyl cysteine before we do gastric lavage with activated charcoal." Rationale: There is a need for further information if the nurse states, "We need to give N-acetyl cysteine before we do gastric lavage with activated charcoal." Activated charcoal with lavage is done if the child is unconscious, but N -acetyl cysteine cannot be used because activated charcoal inactivates t he antidote. If given orally, it can be diluted in juice or soda, and a loading dose of N -acetyl cysteine must be followed by maintenance doses. A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace , and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? "My child will need to do exercises." "My child needs to wear the brace 18 to 23 hours per day." "Wearing the brace is really important in curing the scoliosis." "I need to check my child's skin under the brace to be sure it doesn't break down." - "Wearing the brace is really important in curing the scoliosis." Rationale: Scoliosis is a lateral curvature of the spin e. There is a need for further information when the mother says, "Wearing the brace is really important in curing the scoliosis." Bracing is not curative of scoliosis but may slow the progression of the curvature to allow skeletal growth and maturation. A brace needs to be worn 18 to 23 hours a day, but it may be removed at night for sleep if this is prescribed. To be more cosmetically acceptable, a brace is usually worn under loose -fitting clothing. Back exercises are important in maintaining and strengthe ning the abdominal and spinal muscles. The child's skin must be meticulously monitored for signs of breakdown. A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse prepares the room for the child and places a sign at the child's bedside. What does this sign tell staff to avoid? Palpating the abdomen Taking temperatures recta lly Turning the child to the right side Measuring blood pressure in the right arm - Palpating the abdomen Rationale: The nurse would place a sign at the child's bedside warning against palpation of the child's abdomen. Wilms' tumor, or nephroblastoma, is the most common renal tumor in children. Arising from the renal parenchyma of the kidney, this tumor grows very rapidly. It may be unilateral and localized or bilateral and sometimes involves metastasis to other organs. The tumor mass should not be palpat ed because of the risk that the protective capsule will rupture. Excessive manipulation can result in seeding of the tumor and the spread of cancerous cells. Taking temperatures rectally, turning the child to the right side, and measuring blood pressure in the right arm are interventions that do not need to be avoided. A child with growth hormone deficiency will be receiving somatropin. The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurs e tell the mother will require monitoring? Creatinine Hemoglobin Blood urea nitrogen (BUN) Thyroid -stimulating hormone (TSH) - Thyroid -stimulating hormone (TSH) Rationale: TSH is the laboratory value the nurse tells the mother to monitor. Somatropin is a growth hormone. One adverse reaction to somatropin is hypothyroidism. Thyroid function is assessed before treatment and periodically thereafter. Creatinine and BUN are used to evaluate renal function, and hemoglobin reflects hematologic activity. A clien t arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2017. Using Nagele's rule, what item of client information is needed for the nurse to accurately determine estimated date of delivery (EDD)? Client has never had an abortion Client has regular 28 -day menstrual cycle Client was 14 years old when menses first started Client's menstrual periods never last longer than 3 days - Client has regular 28 -day menstrual cycle Rationale: Accurate use of Nagele's rule is used to calculate the EDD. It requires that the woman have a regular 28 -day menstrual cycle. A client arrives in the emergency department and tells the nurse that he/she is experiencing tingling in both hands and is unable to move his/her fingers. The client states that he/she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier his/her partner said he/she wanted a separation a nd that he/she would have to support self financially. What problem does the nurse conclude that this client is exhibiting signs/symptoms compatible with? Severe anxiety Conversion disorder Posttraumatic stress disorder (PTSD) Obsessive -compulsive disorder - Conversion disorder Rationale: Conversion disorder is characterized by the presence of one or more signs/symptoms suggesting a neurological problem that cannot be attributed to a medica l disorder. Psychological factors such as stress and conflict are associated with the onset or exacerbation of the sign/symptom. A person with severe anxiety may focus on a particular detail or many scattered details. The person may have difficulty noticin g what is going on in the environment, even when it is pointed out by another. Learning and problem -solving are not possible at this level of anxiety, and the client may be dazed and confused. PTSD is characterized by repeated re -experiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others to which the individual responded with intense fear, helplessness, or horror. Obsessions are thoughts, impulses, or images that persist and recur so that they canno t be dismissed from the mind. Compulsions are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed because t he primary health care provider suspects iron -deficiency anemia. After reviewing the laboratory results, which finding indicative of this type of anemia does the nurse expect to note?. An increased RBC count An increased hematocrit level An increased hemo globin level Microcytic red blood cells (RBCs) - Microcytic red blood cells (RBCs) Rationale: The nurse expects to note a low RBC count and microcytic (small) RBCs. In iron-deficiency anemia, laboratory testing will reveal low hemoglobin and hematocrit levels. In iron -deficiency anemia, iron stores are depleted first, followed by hemoglobin stores. A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. What does the n urse tell the client to immediately do? Contact the primary health care provider Report to the emergency department for treatment Get into the shower and rinse the skin for at least 15 minutes Go to the drugstore, purchase an over -the-counter topical cor ticosteroid, and rub it into the exposed skin - Get into the shower and rinse the skin for at least 15 minutes Rationale: If contact with poison ivy is suspected, signs/symptoms may be averted by immediately rinsing the skin for 15 minutes with running w ater to remove the resin before skin penetration occurs. Persons walking or working in areas where poison ivy grows should protect the skin by wearing appropriate clothing. The client is also instructed to remove clothing carefully to avoid skin contact. A lthough a topical over -the-
counter corticosteroid may relieve some of the discomfort of the poison ivy rash, this is not the action that needs to be taken immediately. Contacting the primary health care provider and coming to the emergency department for t reatment are unnecessary. A client diagnosed with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo -oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. Eat foods that are low in fat and protein Obtain pneumococcal and influenza vaccines Drink copious amounts of fluid and void frequently Avoid contact with any individual who has signs/symptoms of a cold Avoid contact with all individuals other than immediate family members - Drink copious amounts of fluid and void frequently Avoid contact with any individual who has signs/symptoms of a c old Rationale: Hemorrhagic cystitis is an adverse effect of this medication. The client is encouraged to drink copious amounts of fluid at least 24 hours before, during, and after chemotherapy, and avoid contact with individuals who are ill, have a cold, or have recently received a live -virus vaccine. The client is also encouraged to void frequently to prevent cystitis. The client is not to receive immunizations without the primary health care provider's approval, because they could diminish the body's re sistance, putting the client at increased risk for infection. It is not necessary for the client to avoid contact with all individuals other than immediate family members. The client should, however, avoid contact with individuals who are ill, have a cold, or have recently received a live -
virus vaccine. Encouraging adequate dietary intake is appropriate, but a low -protein or low-fat diet is not necessary. A client diagnosed with advanced chronic kidney disease (CKD) and oliguria has been taught about sodiu m and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that what is acceptable to use?
counter corticosteroid may relieve some of the discomfort of the poison ivy rash, this is not the action that needs to be taken immediately. Contacting the primary health care provider and coming to the emergency department for t reatment are unnecessary. A client diagnosed with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo -oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. Eat foods that are low in fat and protein Obtain pneumococcal and influenza vaccines Drink copious amounts of fluid and void frequently Avoid contact with any individual who has signs/symptoms of a cold Avoid contact with all individuals other than immediate family members - Drink copious amounts of fluid and void frequently Avoid contact with any individual who has signs/symptoms of a c old Rationale: Hemorrhagic cystitis is an adverse effect of this medication. The client is encouraged to drink copious amounts of fluid at least 24 hours before, during, and after chemotherapy, and avoid contact with individuals who are ill, have a cold, or have recently received a live -virus vaccine. The client is also encouraged to void frequently to prevent cystitis. The client is not to receive immunizations without the primary health care provider's approval, because they could diminish the body's re sistance, putting the client at increased risk for infection. It is not necessary for the client to avoid contact with all individuals other than immediate family members. The client should, however, avoid contact with individuals who are ill, have a cold, or have recently received a live -
virus vaccine. Encouraging adequate dietary intake is appropriate, but a low -protein or low-fat diet is not necessary. A client diagnosed with advanced chronic kidney disease (CKD) and oliguria has been taught about sodiu m and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that what is acceptable to use?
