HESI RN EVOLVE Medical-Surgical Assignment Exam with
100% Verified Solutions 2024/2025 (CUNY College)
1.
Which assessment is most important for the nurse to perform on a client 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 client is able to breathe effectively.
Heuther, Understanding Pathophysiology, 6th ed. p. 412
2.
A male client 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 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?
• Check for a pulse deficit.
1|Page
, HESI RN EVOLVE Medical-Surgical Assignment Exam with
100% Verified Solutions 2024/2025 (CUNY College)
• Palpate the apical impulse.
• Inspect jugular vein pulse.
• Examine for a carotid bruit.
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.
2|Page
, HESI RN EVOLVE Medical-Surgical Assignment Exam with
100% Verified Solutions 2024/2025 (CUNY College)
Jarvis. (2016); Physical Examination and Health Assessment, (Chap 19) 7th ed., p. 481
4.
Which client 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 client 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
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 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 client 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 client with stomatitis.
Dysphagia can cause numerous problems, including airway obstruction, and should be reported to the healthcare provider
immediately.
3|Page
, HESI RN EVOLVE Medical-Surgical Assignment Exam with
100% Verified Solutions 2024/2025 (CUNY College)
Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative care, eight edition., Ch. 53, p. 1100.
7.
The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system complication should
the nurse include in the teaching?
• Altered sexual response.
• Sterility.
• Urinary incontinence.
• Decreased pelvic muscle tone.
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.
Ignatavicius,. (2016). Medical-surgical nursing: Patient-centered collaborative care, eight edition., Ch. 69, p. 1452.
8.
A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk factor for myocardia
infarction?
• Oral contraceptives.
• Senile osteopenia.
• Levothyroxine therapy.
• Pernicious anemia.
Women older than 35 years old who smoke and take oral contraceptives have an increased risk of myocardial infarction or
stroke.
Ignatavicius, (2013). Medical-surgical nursing: Patient-centered collaborative care, 7th ed.., Ch. 35, p. 694.
9.
A client has been told that there is cataract formation over both eyes. Which finding should the nurse expect when assessing
the client?
• Decreased color perception.
• Presence of floaters.
• Loss of central vision.
• Reduced peripheral vision.
Decreased color perception occurs with cataract formation. Cataract formation is also associated with blurred vision and a
global loss of vision so gradual that the client may not be aware of it.
4|Page
100% Verified Solutions 2024/2025 (CUNY College)
1.
Which assessment is most important for the nurse to perform on a client 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 client is able to breathe effectively.
Heuther, Understanding Pathophysiology, 6th ed. p. 412
2.
A male client 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 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?
• Check for a pulse deficit.
1|Page
, HESI RN EVOLVE Medical-Surgical Assignment Exam with
100% Verified Solutions 2024/2025 (CUNY College)
• Palpate the apical impulse.
• Inspect jugular vein pulse.
• Examine for a carotid bruit.
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.
2|Page
, HESI RN EVOLVE Medical-Surgical Assignment Exam with
100% Verified Solutions 2024/2025 (CUNY College)
Jarvis. (2016); Physical Examination and Health Assessment, (Chap 19) 7th ed., p. 481
4.
Which client 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 client 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
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 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 client 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 client with stomatitis.
Dysphagia can cause numerous problems, including airway obstruction, and should be reported to the healthcare provider
immediately.
3|Page
, HESI RN EVOLVE Medical-Surgical Assignment Exam with
100% Verified Solutions 2024/2025 (CUNY College)
Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative care, eight edition., Ch. 53, p. 1100.
7.
The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system complication should
the nurse include in the teaching?
• Altered sexual response.
• Sterility.
• Urinary incontinence.
• Decreased pelvic muscle tone.
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.
Ignatavicius,. (2016). Medical-surgical nursing: Patient-centered collaborative care, eight edition., Ch. 69, p. 1452.
8.
A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk factor for myocardia
infarction?
• Oral contraceptives.
• Senile osteopenia.
• Levothyroxine therapy.
• Pernicious anemia.
Women older than 35 years old who smoke and take oral contraceptives have an increased risk of myocardial infarction or
stroke.
Ignatavicius, (2013). Medical-surgical nursing: Patient-centered collaborative care, 7th ed.., Ch. 35, p. 694.
9.
A client has been told that there is cataract formation over both eyes. Which finding should the nurse expect when assessing
the client?
• Decreased color perception.
• Presence of floaters.
• Loss of central vision.
• Reduced peripheral vision.
Decreased color perception occurs with cataract formation. Cataract formation is also associated with blurred vision and a
global loss of vision so gradual that the client may not be aware of it.
4|Page
