HESI Prep - Health Assessment NEWEST
COMPLETE VERSION QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+.
A 6-year-old boy says he does not like the food at the hospital. A review of the
child's intake reveals that he has eaten very little for the past 2 days. The nurse
formulates a nursing problem of, "Imbalanced nutrition, less than body
requirements." What action should the nurse implement?
Select nutritious foods on the menu for the child.
Provide the child with any snack foods between meals.
Encourage family members to bring foods from home.
Arrange the child's meal tray with generous portions of food. - answer-
Encourage family members to bring foods from home.
Encouraging the parents to bring familiar foods from home that the child likes
should increase the child's likelihood to eat. Although selecting nutritious food
from the menu gives a 6-year-old control in the selection of foods that are
preferred, an adult should provide direction to ensure nutritious variation,
instead of any snack or "junk" food that can curb the appetite. Children should
be served smaller portions to prevent feeling overwhelmed by large portions
that may be refused.
,A 60-year-old homeless man who complains of a cough, late-afternoon fever,
and night sweats has a 10 mm induration after receiving a purified protein
derivative (PPD) skin test. Which action should the nurse implement?
Refer for further diagnostic evaluation.
Determine exposure of others to the tuberculosis.
Begin anti-tubercular drug therapy.
Quarantine or isolate to control communicability. - answer-A) Refer for further
diagnostic evaluation
Disturbed Body Image. - answer-Risk for Infection.
Risk for Infection related to altered immune mechanisms caused by disease
and effects of steroids is the priority.
The other nursing diagnoses are not priority for a child with nephrotic
syndrome who is receiving prednisone.
A client at 13-weeks gestation is scheduled for an amniocentesis in one week.
The nurse knows that the primary reason for conducting this procedure is to
obtain what information?
Level of fetal lung maturity.
Presence of genetic disorders.
Quantification of alpha-fetoprotein levels.
Determination of gestational age. - answer-Presence of genetic disorders.
,Amniocentesis is done at 14 to 16 weeks gestation to determine chromosomal,
genetic, and metabolic disorders. Amniocentesis in the third trimester assesses
fetal lung maturity by evaluating the lecithin/sphingomyelin (L/S) ratio and the
presence of phosphatidylglycerol (PG). Amniocentesis is performed to quantify
alpha-fetoprotein levels after abnormal maternal serum alpha-fetoprotein
levels (done at 15 to 18 weeks ) are found.
A client at 26-weeks gestation comes to the labor and delivery unit and
complains, "Something is not right". Which finding should the nurse assess
further?
Estriol is absent from the maternal saliva.
The cervix is effacing and dilated to 2 cm.
Fetal fibronectin is absent in vaginal secretions.
Irregular mild uterine contractions occurring daily. - answer-B) The cervix is
effacing and dilated to 2cm.
The PPD skin test results is indicative of exposure or latent Mycobacterium
tuberculosis infection (LTBI), which this client is in a high-risk category for
exposure in a homeless environment. Although productive prolonged cough,
fever, and night sweats are common early symptoms, persons suspected of
LTBI should not begin treatment until active TB disease has been excluded.
Further diagnostic evaluation should be implemented. A dormant form that
neither causes disease nor is communicable.
A child weighing 44 pounds is receiving a bolus of Ringer's Lactate solution for
fluid replacement at 20 ml/kg. How many ml should the nurse administer?
(Enter numeric value only.) - answer-400
, Isotonic crystalloid solution (normal saline or lactated Ringer's solution) is
usually the first choice for fluid replacement in children and is given in IV
boluses of 10 to 20 ml/kg over 10 to 15 minutes and repeated as necessary.
First convert the pounds to kg, then multiply by 20 ml.
44 pounds 2.2 pounds/kg = 20 kg 20 ml = 400 ml.
A child with nephrotic syndrome is receiving prednisone (Deltasone). Which
priority nursing diagnosis should the nurse include in the plan of care?
Nausea.
Risk for Infection.
Risk for Bleeding.
Cervical changes, such as shortened endocervical length, effacement, and
dilation accompanied by regular contractions indicate labor at any gestation
period, so the client should be monitored for pre-term labor. Estriol is a form
of estrogen found in plasma at 9-weeks gestation, and increased levels of
salivary estriol have been shown to occur before preterm birth. The presence
of fetal fibronectin in vaginal secretions, between 24 and 36 weeks of gestation
has a 20% to 40% positive predictive value for preterm labor. Irregular mild
contractions that do not cause cervical change indicate Braxton Hicks
contractions or false labor.
A client has a living will and an advance directive specifying no intubation or
CPR. The client's spouse and children tell the nurse privately that they want the
client resuscitated, if the need arises. How should the nurse respond?
COMPLETE VERSION QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+.
A 6-year-old boy says he does not like the food at the hospital. A review of the
child's intake reveals that he has eaten very little for the past 2 days. The nurse
formulates a nursing problem of, "Imbalanced nutrition, less than body
requirements." What action should the nurse implement?
Select nutritious foods on the menu for the child.
Provide the child with any snack foods between meals.
Encourage family members to bring foods from home.
Arrange the child's meal tray with generous portions of food. - answer-
Encourage family members to bring foods from home.
Encouraging the parents to bring familiar foods from home that the child likes
should increase the child's likelihood to eat. Although selecting nutritious food
from the menu gives a 6-year-old control in the selection of foods that are
preferred, an adult should provide direction to ensure nutritious variation,
instead of any snack or "junk" food that can curb the appetite. Children should
be served smaller portions to prevent feeling overwhelmed by large portions
that may be refused.
,A 60-year-old homeless man who complains of a cough, late-afternoon fever,
and night sweats has a 10 mm induration after receiving a purified protein
derivative (PPD) skin test. Which action should the nurse implement?
Refer for further diagnostic evaluation.
Determine exposure of others to the tuberculosis.
Begin anti-tubercular drug therapy.
Quarantine or isolate to control communicability. - answer-A) Refer for further
diagnostic evaluation
Disturbed Body Image. - answer-Risk for Infection.
Risk for Infection related to altered immune mechanisms caused by disease
and effects of steroids is the priority.
The other nursing diagnoses are not priority for a child with nephrotic
syndrome who is receiving prednisone.
A client at 13-weeks gestation is scheduled for an amniocentesis in one week.
The nurse knows that the primary reason for conducting this procedure is to
obtain what information?
Level of fetal lung maturity.
Presence of genetic disorders.
Quantification of alpha-fetoprotein levels.
Determination of gestational age. - answer-Presence of genetic disorders.
,Amniocentesis is done at 14 to 16 weeks gestation to determine chromosomal,
genetic, and metabolic disorders. Amniocentesis in the third trimester assesses
fetal lung maturity by evaluating the lecithin/sphingomyelin (L/S) ratio and the
presence of phosphatidylglycerol (PG). Amniocentesis is performed to quantify
alpha-fetoprotein levels after abnormal maternal serum alpha-fetoprotein
levels (done at 15 to 18 weeks ) are found.
A client at 26-weeks gestation comes to the labor and delivery unit and
complains, "Something is not right". Which finding should the nurse assess
further?
Estriol is absent from the maternal saliva.
The cervix is effacing and dilated to 2 cm.
Fetal fibronectin is absent in vaginal secretions.
Irregular mild uterine contractions occurring daily. - answer-B) The cervix is
effacing and dilated to 2cm.
The PPD skin test results is indicative of exposure or latent Mycobacterium
tuberculosis infection (LTBI), which this client is in a high-risk category for
exposure in a homeless environment. Although productive prolonged cough,
fever, and night sweats are common early symptoms, persons suspected of
LTBI should not begin treatment until active TB disease has been excluded.
Further diagnostic evaluation should be implemented. A dormant form that
neither causes disease nor is communicable.
A child weighing 44 pounds is receiving a bolus of Ringer's Lactate solution for
fluid replacement at 20 ml/kg. How many ml should the nurse administer?
(Enter numeric value only.) - answer-400
, Isotonic crystalloid solution (normal saline or lactated Ringer's solution) is
usually the first choice for fluid replacement in children and is given in IV
boluses of 10 to 20 ml/kg over 10 to 15 minutes and repeated as necessary.
First convert the pounds to kg, then multiply by 20 ml.
44 pounds 2.2 pounds/kg = 20 kg 20 ml = 400 ml.
A child with nephrotic syndrome is receiving prednisone (Deltasone). Which
priority nursing diagnosis should the nurse include in the plan of care?
Nausea.
Risk for Infection.
Risk for Bleeding.
Cervical changes, such as shortened endocervical length, effacement, and
dilation accompanied by regular contractions indicate labor at any gestation
period, so the client should be monitored for pre-term labor. Estriol is a form
of estrogen found in plasma at 9-weeks gestation, and increased levels of
salivary estriol have been shown to occur before preterm birth. The presence
of fetal fibronectin in vaginal secretions, between 24 and 36 weeks of gestation
has a 20% to 40% positive predictive value for preterm labor. Irregular mild
contractions that do not cause cervical change indicate Braxton Hicks
contractions or false labor.
A client has a living will and an advance directive specifying no intubation or
CPR. The client's spouse and children tell the nurse privately that they want the
client resuscitated, if the need arises. How should the nurse respond?
