SAUNDERS ONLINE REVIEW- MODULE 10-
PHYSIOLOGICAL HEALTH PROBLEMS HESI-
EXAM 2024/2025
A nurse is reading the medical record of a pregnant client in the second trimester with a
diagnosis of abruption placentae. Which clinical manifestation of the disorder does the
nurse expect to see documented? - CORRECT ANSWERA. Uterine tenderness.
Rationale: In abruption placentae, abdominal pain and uterine tenderness are present.
Uterine tenderness accompanies placental abruption, especially with a central abruption
in which blood becomes trapped behind the placenta. The abdomen will feel hard and
board like on palpation because the blood penetrates the myometrium, resulting in
uterine irritability. Excessive uterine activity with poor relaxation between contractions is
present. Fetal monitoring often reveals increased uterine resting tone, caused by failure
of the uterus to relax in an attempt to constrict blood vessels and control bleeding.
Painless bright-red vaginal bleeding in the second or third trimester of pregnancy is a
sign of placenta Previa. Constipation is not associated with this disorder.
A nurse is monitoring a client who is in the active phase of labor and has been
experiencing contractions that are coordinated but weak. Which of the following
assessment findings indicates to the nurse that the client may be experiencing
hypotonic contractions? - CORRECT ANSWER D. Contractions that can be indented
easily with fingertip pressure at their peak.
Rationale: Hypotonic contractions, coordinated but too weak to be effective, usually
occur during the active phase of labor, when progress normally quickens. Contractions
are infrequent and brief and can easily be indented on the abdomen with fingertip
pressure at their peak. These contractions cause minimal discomfort because the
contractions are weak. Fetal hypoxia is not usually seen with hypotonic contractions.
A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets
this as an expected finding in the client with: - CORRECT ANSWERC. Addison disease.
Rationale: A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and
the nurse would report the finding to the physician. Adrenal insufficiency (Addison
disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include
tissue damage, such as that in burn injuries, renal failure, and the use of potassium-
sparing diuretics. The client with diarrhea or wound drainage or the client being treated
with diuretics is at risk for hypokalemia.
A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mg/dL.
Which assessment findings does the nurse expect to note? Select all that apply. -
CORRECT ANSWERB. Abdominal distention
,C. Trousseau sign.
Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0
mg/dL reflects hypomagnesemia. Assessment signs include hypertension;
gastrointestinal manifestations such as anorexia, nausea, abdominal distention, and
decreased bowel sounds; shallow respirations; neuromuscular manifestations such as
twitches, paresthesias, hyperreflexia, and the Trousseau and Chvostek signs; and
irritability and confusion.
A client with a leg fracture who has been placed in skeletal traction is transported to the
orthopedic unit after surgery. Which finding would indicate the need to contact the
orthopedic specialist? - CORRECT ANSWER D. The traction ropes are unable to move
over the pulleys.
Rationale: After skeletal traction pins are inserted and traction is applied, all ropes,
knots, and pulleys are inspected to ensure that they are positioned properly. Traction
knots and ropes must be intact and secure. Ropes should move easily over pulleys and
weights, and the weights should hang freely at all times. The clamps on the traction
frame should be tight.
A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to
the client's room and quickly assesses the client. The client appears to be having
respiratory difficulty. The nurse should first: - CORRECT ANSWER D. Manually
ventilate the client, using a resuscitation bag.
Rationale: Because the client is experiencing respiratory distress, the client should be
manually ventilated with the use of a resuscitation bag until the problem can be
determined. Mechanical ventilators have alarm systems that warn the nurse of a
problem with either the client or the ventilator. Such alarms must be activated and
functional at all times. The low exhaled volume alarm sounds when there is a
disconnection or leak in the ventilator circuit or a leak in the client's artificial airway cuff.
A code is called when the client requires resuscitation. An anesthesiologist may be
needed to insert an endotracheal tube or to assist with a code. Accumulation of
secretions in the respiratory system and the need for suctioning would trigger the high-
pressure alarm.
A client is transported to the recovery area of the ambulatory care unit after cataract
surgery. In which position does the nurse place the client? - CORRECT ANSWER B.
Semi-Fowler.
Rationale: After cataract extraction surgery, the client should be placed in the semi-
Fowler position or on the unaffected side to prevent edema at the surgical site. Supine,
on the affected side, and prone are all incorrect because they will result in increased
edema at the site.
, A client arrives at the emergency department with complaints of a headache, hives,
itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour
earlier and believes that he is experiencing an allergic reaction to this medication. After
ensuring that the client has a patent airway, which intervention does the nurse prepare
the client for first? - CORRECT ANSWER D. Administration of a subcutaneous injection
of epinephrine (Adrenalin).
Rationale: Once airway has been established, the client would be given subcutaneous
epinephrine. IV corticosteroids and IV fluids may also be prescribed. Pain medication
may or may not be prescribed.
A nurse is obtaining subjective data from the mother of a child admitted to the hospital
with a diagnosis of intussusception. Which of the following occurrences does the nurse
expect the mother to report? - CORRECT ANSWER D. Bloody mucus stools and
diarrhea.
Rationale: In the child with intussusception, bloody mucus stools, commonly described
as "currant jelly" stools, and diarrhea may occur. The child classically presents with
severe abdominal pain that is crampy and intermittent, causing the child to draw the
knees to the chest. This pain progresses to a more severe constant pain. Vomiting may
be present, but it is not projectile in nature. Pale, hard stools and scleral jaundice are
not manifestations of this disorder.
A nurse is caring for a client experiencing hyponatremia who was admitted to the
medical-surgical unit with fluid-volume overload. For which clinical manifestations of this
electrolyte imbalance does the nurse monitor this client? Select all that apply. -
CORRECT ANSWER C. Skeletal muscle weakness
D. Hyperactive bowel sounds.
Rationale: Signs of hyponatremia include a rapid, thready pulse; skeletal muscle
weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive
bowel sounds; increased urine output; headache; and personality changes. The nurse
must assess these changes from baseline. If muscle weakness is detected, the nurse
should immediately check respiratory effectiveness, because ventilation depends on
strength of the respiratory muscles.
An emergency department (ED) nurse receives a telephone call from emergency
medical services and is told that a client who has sustained severe burns of the face
and upper arms is being transported to the ED. Which action does the nurse, preparing
for the arrival of the client, plan to implement first? - CORRECT ANSWER D.
Administering 100% humidified oxygen.
Rationale: When a victim who sustains a burn injury arrives at the ED, breathing is
assessed, a patent airway is established, and the client is given 100% humidified
oxygen. Inserting a Foley catheter, initiating an IV line, and cleansing the burn wound
PHYSIOLOGICAL HEALTH PROBLEMS HESI-
EXAM 2024/2025
A nurse is reading the medical record of a pregnant client in the second trimester with a
diagnosis of abruption placentae. Which clinical manifestation of the disorder does the
nurse expect to see documented? - CORRECT ANSWERA. Uterine tenderness.
Rationale: In abruption placentae, abdominal pain and uterine tenderness are present.
Uterine tenderness accompanies placental abruption, especially with a central abruption
in which blood becomes trapped behind the placenta. The abdomen will feel hard and
board like on palpation because the blood penetrates the myometrium, resulting in
uterine irritability. Excessive uterine activity with poor relaxation between contractions is
present. Fetal monitoring often reveals increased uterine resting tone, caused by failure
of the uterus to relax in an attempt to constrict blood vessels and control bleeding.
Painless bright-red vaginal bleeding in the second or third trimester of pregnancy is a
sign of placenta Previa. Constipation is not associated with this disorder.
A nurse is monitoring a client who is in the active phase of labor and has been
experiencing contractions that are coordinated but weak. Which of the following
assessment findings indicates to the nurse that the client may be experiencing
hypotonic contractions? - CORRECT ANSWER D. Contractions that can be indented
easily with fingertip pressure at their peak.
Rationale: Hypotonic contractions, coordinated but too weak to be effective, usually
occur during the active phase of labor, when progress normally quickens. Contractions
are infrequent and brief and can easily be indented on the abdomen with fingertip
pressure at their peak. These contractions cause minimal discomfort because the
contractions are weak. Fetal hypoxia is not usually seen with hypotonic contractions.
A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets
this as an expected finding in the client with: - CORRECT ANSWERC. Addison disease.
Rationale: A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and
the nurse would report the finding to the physician. Adrenal insufficiency (Addison
disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include
tissue damage, such as that in burn injuries, renal failure, and the use of potassium-
sparing diuretics. The client with diarrhea or wound drainage or the client being treated
with diuretics is at risk for hypokalemia.
A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mg/dL.
Which assessment findings does the nurse expect to note? Select all that apply. -
CORRECT ANSWERB. Abdominal distention
,C. Trousseau sign.
Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0
mg/dL reflects hypomagnesemia. Assessment signs include hypertension;
gastrointestinal manifestations such as anorexia, nausea, abdominal distention, and
decreased bowel sounds; shallow respirations; neuromuscular manifestations such as
twitches, paresthesias, hyperreflexia, and the Trousseau and Chvostek signs; and
irritability and confusion.
A client with a leg fracture who has been placed in skeletal traction is transported to the
orthopedic unit after surgery. Which finding would indicate the need to contact the
orthopedic specialist? - CORRECT ANSWER D. The traction ropes are unable to move
over the pulleys.
Rationale: After skeletal traction pins are inserted and traction is applied, all ropes,
knots, and pulleys are inspected to ensure that they are positioned properly. Traction
knots and ropes must be intact and secure. Ropes should move easily over pulleys and
weights, and the weights should hang freely at all times. The clamps on the traction
frame should be tight.
A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to
the client's room and quickly assesses the client. The client appears to be having
respiratory difficulty. The nurse should first: - CORRECT ANSWER D. Manually
ventilate the client, using a resuscitation bag.
Rationale: Because the client is experiencing respiratory distress, the client should be
manually ventilated with the use of a resuscitation bag until the problem can be
determined. Mechanical ventilators have alarm systems that warn the nurse of a
problem with either the client or the ventilator. Such alarms must be activated and
functional at all times. The low exhaled volume alarm sounds when there is a
disconnection or leak in the ventilator circuit or a leak in the client's artificial airway cuff.
A code is called when the client requires resuscitation. An anesthesiologist may be
needed to insert an endotracheal tube or to assist with a code. Accumulation of
secretions in the respiratory system and the need for suctioning would trigger the high-
pressure alarm.
A client is transported to the recovery area of the ambulatory care unit after cataract
surgery. In which position does the nurse place the client? - CORRECT ANSWER B.
Semi-Fowler.
Rationale: After cataract extraction surgery, the client should be placed in the semi-
Fowler position or on the unaffected side to prevent edema at the surgical site. Supine,
on the affected side, and prone are all incorrect because they will result in increased
edema at the site.
, A client arrives at the emergency department with complaints of a headache, hives,
itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour
earlier and believes that he is experiencing an allergic reaction to this medication. After
ensuring that the client has a patent airway, which intervention does the nurse prepare
the client for first? - CORRECT ANSWER D. Administration of a subcutaneous injection
of epinephrine (Adrenalin).
Rationale: Once airway has been established, the client would be given subcutaneous
epinephrine. IV corticosteroids and IV fluids may also be prescribed. Pain medication
may or may not be prescribed.
A nurse is obtaining subjective data from the mother of a child admitted to the hospital
with a diagnosis of intussusception. Which of the following occurrences does the nurse
expect the mother to report? - CORRECT ANSWER D. Bloody mucus stools and
diarrhea.
Rationale: In the child with intussusception, bloody mucus stools, commonly described
as "currant jelly" stools, and diarrhea may occur. The child classically presents with
severe abdominal pain that is crampy and intermittent, causing the child to draw the
knees to the chest. This pain progresses to a more severe constant pain. Vomiting may
be present, but it is not projectile in nature. Pale, hard stools and scleral jaundice are
not manifestations of this disorder.
A nurse is caring for a client experiencing hyponatremia who was admitted to the
medical-surgical unit with fluid-volume overload. For which clinical manifestations of this
electrolyte imbalance does the nurse monitor this client? Select all that apply. -
CORRECT ANSWER C. Skeletal muscle weakness
D. Hyperactive bowel sounds.
Rationale: Signs of hyponatremia include a rapid, thready pulse; skeletal muscle
weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive
bowel sounds; increased urine output; headache; and personality changes. The nurse
must assess these changes from baseline. If muscle weakness is detected, the nurse
should immediately check respiratory effectiveness, because ventilation depends on
strength of the respiratory muscles.
An emergency department (ED) nurse receives a telephone call from emergency
medical services and is told that a client who has sustained severe burns of the face
and upper arms is being transported to the ED. Which action does the nurse, preparing
for the arrival of the client, plan to implement first? - CORRECT ANSWER D.
Administering 100% humidified oxygen.
Rationale: When a victim who sustains a burn injury arrives at the ED, breathing is
assessed, a patent airway is established, and the client is given 100% humidified
oxygen. Inserting a Foley catheter, initiating an IV line, and cleansing the burn wound
