NIGHTINGALE -HESI CAT EXAM QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS
A 1-month-old infant with a ventricular septal defect (VSD) is
examined in the cardiology clinic. What sign related to this
disorder does the nurse expect to find when assessing this
infant?
1
Bradycardia at rest
2
Activity-related cyanosis
3
Bounding peripheral pulses
4
Murmur at the left sternal border Correct Answers 4
A murmur at the left sternal border is the most characteristic
finding in infants and children with a VSD. A left-to-right shunt
is caused by the flow of blood from the higher pressure left
ventricle to the lower pressure right ventricle. Children with
VSDs generally have tachycardia and are often acyanotic. A
bounding peripheral pulse is not a common finding in children
with a VSD.
A 15-year-old client tearfully states that her father has been
sexually abusing her for the past 8 years. What statement should
the nurse initially respond with?
1
"Which type of incidents preceded the abuse?"
2
"Sharing this information is a positive step in getting help."
3
,"I have to report this to child protective services right now."
4
"What kinds of things does he do to you when he abuses you?"
Correct Answers 2
"Sharing this information is a positive step in getting help" is an
emotionally supportive response; it demonstrates that sharing
this information is acceptable and provides hope that the client
will get help. The client needs support, and asking what
incidents preceded the abuse may precipitate or increase feelings
of guilt. Telling the client that the abuse must be reported
immediately to child protective services is not a priority at this
time and may interfere with future sharing; the client needs
immediate emotional support. Asking what the father did as part
of the abuse implies that the client does not know what she is
talking about; the client needs support, whether the abuse is real
or imagined.
A 16-year-old boy with a diagnosis of adolescent adjustment
disorder and his family are beginning family therapy. What is
the best initial nursing approach?
1
Setting long-term goals for the family
2
Letting the client express his feelings first
3
Having the parents explain their rationale for setting firm limits
4
Encouraging each family member to share how the problem is
perceived Correct Answers 4
Family therapy must include the whole family. Each member
must be considered not just individually from his or her
,perspective but also as a member of the whole. Identification of
the problem by the people involved is the priority. The family,
not the nurse, sets goals. The nurse assists the family in setting
goals by acting as a facilitator. Feelings should be shared
eventually, but this is not the initial focus. Setting limits may or
may not be a problem within the family.
A 16-year-old client has a blood pressure reading of 119/75.
What is the approximate pulse pressure? Record your answer
using a whole number. __________ mm Hg Correct Answers
The difference between the systolic and diastolic pressure is
called the pulse pressure. The given blood pressure is 119/75.
The difference between 119 and 75 is 44.
A 2-month-old infant with the diagnosis of heart failure is
discharged with a prescription for oral digoxin 0.05 mg every 12
hours. The bottle of digoxin is labeled "0.05 mg/mL." Which
item should the nurse teach the mother to use when
administering the medication?
1
Nipple
2
Calibrated syringe
3
Plastic measuring spoon
4
Bottle containing an ounce of water Correct Answers 2
A calibrated syringe or dropper provides the most accurate
measurement of the medication. Using a nipple or spoon is not
an accurate way to measure medication. If the dose of
, medication is diluted and the infant does not drink the entire
ounce, the resulting dose will be insufficient.
A 2-year-old child is admitted to the pediatric unit with a
diagnosis of thalassemia major (Cooley anemia). The parents are
told that there is no cure, but the anemia can be treated with
frequent blood transfusions. The father tells the nurse he is glad
that there is a treatment that "fixes" his child's problem. Before
responding, the nurse should recall that blood transfusions do
what?
1
Correct the anemia, but may cause other problems
2
Reverse the anemia, but also present a risk of hepatitis
3
Are a supportive treatment; fewer will be needed as the child
grows older
4
Are a replacement for defective red blood cells; they are like
giving insulin to a person with diabetes Correct Answers 1
Excess iron from hemolysis of the replaced red blood cells is
deposited in the organs and body tissue, causing hemosiderosis.
Chelation therapy is then required. With the practice of aseptic
technique and screening of donated blood, hepatitis should not
occur. Red blood cell replacement depends on the child's
hematologic picture; the number of transfusions is not related to
age. Although red blood cells are replaced, it is erroneous to
compare this treatment with insulin therapy.
A 28-year-old woman comes into the clinic and tells the nurse
that she fears that she is infertile, because she has been trying to
ANSWERS WITH COMPLETE SOLUTIONS
A 1-month-old infant with a ventricular septal defect (VSD) is
examined in the cardiology clinic. What sign related to this
disorder does the nurse expect to find when assessing this
infant?
1
Bradycardia at rest
2
Activity-related cyanosis
3
Bounding peripheral pulses
4
Murmur at the left sternal border Correct Answers 4
A murmur at the left sternal border is the most characteristic
finding in infants and children with a VSD. A left-to-right shunt
is caused by the flow of blood from the higher pressure left
ventricle to the lower pressure right ventricle. Children with
VSDs generally have tachycardia and are often acyanotic. A
bounding peripheral pulse is not a common finding in children
with a VSD.
A 15-year-old client tearfully states that her father has been
sexually abusing her for the past 8 years. What statement should
the nurse initially respond with?
1
"Which type of incidents preceded the abuse?"
2
"Sharing this information is a positive step in getting help."
3
,"I have to report this to child protective services right now."
4
"What kinds of things does he do to you when he abuses you?"
Correct Answers 2
"Sharing this information is a positive step in getting help" is an
emotionally supportive response; it demonstrates that sharing
this information is acceptable and provides hope that the client
will get help. The client needs support, and asking what
incidents preceded the abuse may precipitate or increase feelings
of guilt. Telling the client that the abuse must be reported
immediately to child protective services is not a priority at this
time and may interfere with future sharing; the client needs
immediate emotional support. Asking what the father did as part
of the abuse implies that the client does not know what she is
talking about; the client needs support, whether the abuse is real
or imagined.
A 16-year-old boy with a diagnosis of adolescent adjustment
disorder and his family are beginning family therapy. What is
the best initial nursing approach?
1
Setting long-term goals for the family
2
Letting the client express his feelings first
3
Having the parents explain their rationale for setting firm limits
4
Encouraging each family member to share how the problem is
perceived Correct Answers 4
Family therapy must include the whole family. Each member
must be considered not just individually from his or her
,perspective but also as a member of the whole. Identification of
the problem by the people involved is the priority. The family,
not the nurse, sets goals. The nurse assists the family in setting
goals by acting as a facilitator. Feelings should be shared
eventually, but this is not the initial focus. Setting limits may or
may not be a problem within the family.
A 16-year-old client has a blood pressure reading of 119/75.
What is the approximate pulse pressure? Record your answer
using a whole number. __________ mm Hg Correct Answers
The difference between the systolic and diastolic pressure is
called the pulse pressure. The given blood pressure is 119/75.
The difference between 119 and 75 is 44.
A 2-month-old infant with the diagnosis of heart failure is
discharged with a prescription for oral digoxin 0.05 mg every 12
hours. The bottle of digoxin is labeled "0.05 mg/mL." Which
item should the nurse teach the mother to use when
administering the medication?
1
Nipple
2
Calibrated syringe
3
Plastic measuring spoon
4
Bottle containing an ounce of water Correct Answers 2
A calibrated syringe or dropper provides the most accurate
measurement of the medication. Using a nipple or spoon is not
an accurate way to measure medication. If the dose of
, medication is diluted and the infant does not drink the entire
ounce, the resulting dose will be insufficient.
A 2-year-old child is admitted to the pediatric unit with a
diagnosis of thalassemia major (Cooley anemia). The parents are
told that there is no cure, but the anemia can be treated with
frequent blood transfusions. The father tells the nurse he is glad
that there is a treatment that "fixes" his child's problem. Before
responding, the nurse should recall that blood transfusions do
what?
1
Correct the anemia, but may cause other problems
2
Reverse the anemia, but also present a risk of hepatitis
3
Are a supportive treatment; fewer will be needed as the child
grows older
4
Are a replacement for defective red blood cells; they are like
giving insulin to a person with diabetes Correct Answers 1
Excess iron from hemolysis of the replaced red blood cells is
deposited in the organs and body tissue, causing hemosiderosis.
Chelation therapy is then required. With the practice of aseptic
technique and screening of donated blood, hepatitis should not
occur. Red blood cell replacement depends on the child's
hematologic picture; the number of transfusions is not related to
age. Although red blood cells are replaced, it is erroneous to
compare this treatment with insulin therapy.
A 28-year-old woman comes into the clinic and tells the nurse
that she fears that she is infertile, because she has been trying to
