NURS 21000 HESI MED-SURG EXAM
QUESTIONS AND ANSWERS GRADED A+
LATEST UPDATE 2023-2024
Which assessment is most important for the nurse to perform on a patient who
is hospitalized for Guillain-Barre syndrome that is rapidly progressing?
• Respiratory effort.
• Unsteady gait.
• Intensity of pain.
• Ability to eat.
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 patient is able to breathe effectively.
Heuther, Understanding Pathophysiology, 6th ed. p. 412
A male patient comes into the clinic with a history of penile discharge with
painful, burning urination. Which action should the nurse implement?
• Collect a culture of the penile discharge.
• Palpate the inguinal lymph nodes gently.
,• Observe for scrotal swelling and redness.
• Express the discharge to determine color.
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.
Jarvis Physical Examination and Health Assessment, 6th edition 3
A patient 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?
• Check for a pulse deficit.
• Palpate the apical impulse.
• Inspect jugular vein pulse.
• Examine for a carotid bruit.
A patient 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 patient for a pulse deficit
because this condition occurs with atrial fibrillation.
,Jarvis. (2016); Physical Examination and Health Assessment, (Chap 19) 7th ed.,
p. 481
4.
Which patient should be further assessed for an ectopic pregnancy?
• A 24-year-old with shoulder and lower abdominal quadrant pain.
• A 33-year-old with intermittent lower abdominal cramping.
• A 20-year-old with fever and right lower abdominal colic.
• A 40-year-old with jaundice and right lower abdominal 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. Health Assessment for Nursing
Practice, Wilson and
Giddens. p.269 5.
Which dietary assessment finding is most important for the nurse to address
when
caring for a patient with diabetic nephropathy?
• Drinks a six pack of beer every day.
• Enjoys a hamburger once a month.
• Eats fortified breakfast cereal daily.
• Consumes beans and rice every day.
, Drinking six beers every day is the dietary assessment finding most important
for the nurse to address when caring for a patient with diabetic nephropathy.
The usual can of beer is 12 ounces (355 mL). patients 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 poor glucose control.
Nephropathy is exacerbated by poor blood glucose control. 6.
Which assessment finding is of greatest concern to the nurse who is caring for a
patient with stomatitis?
• Cough brought on by swallowing.
• Sore throat caused by speaking.
• Painful and dry oral cavity.
• Unintended weight loss.
A cough brought on by swallowing is a sign of dysphagia, which is a finding of
particular concern in a patient with stomatitis. Dysphagia can cause numerous
problems, including airway obstruction, and should be reported to the
healthcare provider immediately.
Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative
care, eight edition., Ch. 53, p. 1100.
7.
QUESTIONS AND ANSWERS GRADED A+
LATEST UPDATE 2023-2024
Which assessment is most important for the nurse to perform on a patient who
is hospitalized for Guillain-Barre syndrome that is rapidly progressing?
• Respiratory effort.
• Unsteady gait.
• Intensity of pain.
• Ability to eat.
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 patient is able to breathe effectively.
Heuther, Understanding Pathophysiology, 6th ed. p. 412
A male patient comes into the clinic with a history of penile discharge with
painful, burning urination. Which action should the nurse implement?
• Collect a culture of the penile discharge.
• Palpate the inguinal lymph nodes gently.
,• Observe for scrotal swelling and redness.
• Express the discharge to determine color.
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.
Jarvis Physical Examination and Health Assessment, 6th edition 3
A patient 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?
• Check for a pulse deficit.
• Palpate the apical impulse.
• Inspect jugular vein pulse.
• Examine for a carotid bruit.
A patient 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 patient for a pulse deficit
because this condition occurs with atrial fibrillation.
,Jarvis. (2016); Physical Examination and Health Assessment, (Chap 19) 7th ed.,
p. 481
4.
Which patient should be further assessed for an ectopic pregnancy?
• A 24-year-old with shoulder and lower abdominal quadrant pain.
• A 33-year-old with intermittent lower abdominal cramping.
• A 20-year-old with fever and right lower abdominal colic.
• A 40-year-old with jaundice and right lower abdominal 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. Health Assessment for Nursing
Practice, Wilson and
Giddens. p.269 5.
Which dietary assessment finding is most important for the nurse to address
when
caring for a patient with diabetic nephropathy?
• Drinks a six pack of beer every day.
• Enjoys a hamburger once a month.
• Eats fortified breakfast cereal daily.
• Consumes beans and rice every day.
, Drinking six beers every day is the dietary assessment finding most important
for the nurse to address when caring for a patient with diabetic nephropathy.
The usual can of beer is 12 ounces (355 mL). patients 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 poor glucose control.
Nephropathy is exacerbated by poor blood glucose control. 6.
Which assessment finding is of greatest concern to the nurse who is caring for a
patient with stomatitis?
• Cough brought on by swallowing.
• Sore throat caused by speaking.
• Painful and dry oral cavity.
• Unintended weight loss.
A cough brought on by swallowing is a sign of dysphagia, which is a finding of
particular concern in a patient with stomatitis. Dysphagia can cause numerous
problems, including airway obstruction, and should be reported to the
healthcare provider immediately.
Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative
care, eight edition., Ch. 53, p. 1100.
7.
