HESI RN EVOLVE
Medical-Surgical
Assignment Exam
2023 Version
Rationale
Which assessment is most important for the nurse to perform on a client who is hospitalized for
Guillain-Barre syndrome that is rapidly progressing?
A: Respiratory effort.
B: Unsteady gait.
C: Intensity of pain. D: Ability to eat.
A: Respiratory Effort
(Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses
upwards. As the condition progresses, the nurse must ensure that the client is able to breathe
effectively.)
A male client comes into the clinic with a history of penile discharge with painful, burning urination.
Which action should the nurse implement?
,A: Collect a culture of the penile discharge.
B: Palpate the inguinal lymph nodes gently.
C: Observe for scrotal swelling and redness.
D: Express the discharge to determine color.
A: Collect a culture of the penile discharge.
(Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should
collect a culture of the penile discharge to determine the cause of these symptoms. The cause must
be determined or confirmed through culture to identify the organism and ensure effective
treatment.)
A client with history of atrial fibrillation is admitted to the telemetry unit with sudden onset of
shortness of breath. The nurse observes a new irregular heart rhythm and should perform which
assessment at this time?
A: Check for a pulse deficit
B: Palpate the apical impulse
C: Inspect jugular vein pulse.
D: Examine for a carotid bruit.
A: Check for a pulse deficit.
(A client with a past history of atrial fibrillation may return to that rhythm. Any signs of atrial
fibrillation, such as sudden onset shortness of breath, requires further investigation. The nurse
should assess this client for a pulse deficit because this condition occurs with atrial fibrillation.)
Which client should be further assessed for an ectopic pregnancy?
A: A 24-year-old with shoulder and lower abdominal quadrant pain.
B: A 33-year-old with intermittent lower abdominal cramping.
C: A 20-year-old with fever and right lower abdominal colic.
D: A 40-year-old with jaundice and right lower abdominal pain.
A: A 24-year-old with shoulder and lower abdominal quadrant pain.
,(A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for an
ectopic pregnancy. The pain can also be referred to the shoulder and may be associated with vaginal
bleeding.)
Which dietary assessment finding is most important for the nurse to address when caring for a client
with diabetic nephropathy?
A: Drinks a six pack of beer every day.
B: Enjoys a hamburger once a month.
C: Eats fortified breakfast cereal daily.
D: Consumes beans and rice every day.
A: Drinks a six pack of beer every day.
(Drinking six beers every day is the dietary assessment finding most important for the nurse to
address when caring for a client with diabetic nephropathy. The usual can of beer is 12 ounces (355
mL). Clients with diabetes are recommended to drink no more than 12 ounces of beer per day
because beer contains carbohydrates that can create unhealthy fluctuations in blood glucose and
promote poorglucose control. Nephropathy is exacerbated by poor blood glucose control.)
Which assessment finding is of greatest concern to the nurse who is caring for a client with
stomatitis?
A: Cough brought on by swallowing.
B: Sore throat caused by speaking
C: Painful and dry oral cavity.
D: Unintended weight loss.
A: Cough brought on by swallowing.
, A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular concern in a
client with stomatitis. Dysphagia can cause numerous problems, including airway obstruction, and
should be reported to the healthcare provider immediately.
The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system
complication should the nurse include in the teaching?
A: Altered sexual response. B: Sterility.
C: Urinary incontinence.
D: Decreased pelvic muscle tone.
A: Altered sexual response.
Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing of the
arteries and reduced blood flow to the extremities. PAD is known to alter the blood flow to the
male's penis and is associated with erectile dysfunction in men.
A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk
factor for myocardia infarction?
A: Oral contraceptives.
B: Senile osteopenia.
C: Levothyroxine therapy.
D: Pernicious anemia.
A: Oral contraceptives.
Women older than 35 years old who smoke and take oral contraceptives have an increased risk of
myocardial infarction or stroke.
A client has been told that there is cataract formation over both eyes. Which finding should the
nurse expect when assessing the client?
A: Decreased color perception. B: Presence of floaters.
C: Loss of central vision.
D: Reduced peripheral vision.
Medical-Surgical
Assignment Exam
2023 Version
Rationale
Which assessment is most important for the nurse to perform on a client who is hospitalized for
Guillain-Barre syndrome that is rapidly progressing?
A: Respiratory effort.
B: Unsteady gait.
C: Intensity of pain. D: Ability to eat.
A: Respiratory Effort
(Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses
upwards. As the condition progresses, the nurse must ensure that the client is able to breathe
effectively.)
A male client comes into the clinic with a history of penile discharge with painful, burning urination.
Which action should the nurse implement?
,A: Collect a culture of the penile discharge.
B: Palpate the inguinal lymph nodes gently.
C: Observe for scrotal swelling and redness.
D: Express the discharge to determine color.
A: Collect a culture of the penile discharge.
(Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should
collect a culture of the penile discharge to determine the cause of these symptoms. The cause must
be determined or confirmed through culture to identify the organism and ensure effective
treatment.)
A client with history of atrial fibrillation is admitted to the telemetry unit with sudden onset of
shortness of breath. The nurse observes a new irregular heart rhythm and should perform which
assessment at this time?
A: Check for a pulse deficit
B: Palpate the apical impulse
C: Inspect jugular vein pulse.
D: Examine for a carotid bruit.
A: Check for a pulse deficit.
(A client with a past history of atrial fibrillation may return to that rhythm. Any signs of atrial
fibrillation, such as sudden onset shortness of breath, requires further investigation. The nurse
should assess this client for a pulse deficit because this condition occurs with atrial fibrillation.)
Which client should be further assessed for an ectopic pregnancy?
A: A 24-year-old with shoulder and lower abdominal quadrant pain.
B: A 33-year-old with intermittent lower abdominal cramping.
C: A 20-year-old with fever and right lower abdominal colic.
D: A 40-year-old with jaundice and right lower abdominal pain.
A: A 24-year-old with shoulder and lower abdominal quadrant pain.
,(A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for an
ectopic pregnancy. The pain can also be referred to the shoulder and may be associated with vaginal
bleeding.)
Which dietary assessment finding is most important for the nurse to address when caring for a client
with diabetic nephropathy?
A: Drinks a six pack of beer every day.
B: Enjoys a hamburger once a month.
C: Eats fortified breakfast cereal daily.
D: Consumes beans and rice every day.
A: Drinks a six pack of beer every day.
(Drinking six beers every day is the dietary assessment finding most important for the nurse to
address when caring for a client with diabetic nephropathy. The usual can of beer is 12 ounces (355
mL). Clients with diabetes are recommended to drink no more than 12 ounces of beer per day
because beer contains carbohydrates that can create unhealthy fluctuations in blood glucose and
promote poorglucose control. Nephropathy is exacerbated by poor blood glucose control.)
Which assessment finding is of greatest concern to the nurse who is caring for a client with
stomatitis?
A: Cough brought on by swallowing.
B: Sore throat caused by speaking
C: Painful and dry oral cavity.
D: Unintended weight loss.
A: Cough brought on by swallowing.
, A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular concern in a
client with stomatitis. Dysphagia can cause numerous problems, including airway obstruction, and
should be reported to the healthcare provider immediately.
The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system
complication should the nurse include in the teaching?
A: Altered sexual response. B: Sterility.
C: Urinary incontinence.
D: Decreased pelvic muscle tone.
A: Altered sexual response.
Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing of the
arteries and reduced blood flow to the extremities. PAD is known to alter the blood flow to the
male's penis and is associated with erectile dysfunction in men.
A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk
factor for myocardia infarction?
A: Oral contraceptives.
B: Senile osteopenia.
C: Levothyroxine therapy.
D: Pernicious anemia.
A: Oral contraceptives.
Women older than 35 years old who smoke and take oral contraceptives have an increased risk of
myocardial infarction or stroke.
A client has been told that there is cataract formation over both eyes. Which finding should the
nurse expect when assessing the client?
A: Decreased color perception. B: Presence of floaters.
C: Loss of central vision.
D: Reduced peripheral vision.
