Evolve Comprehensive Exam (Hesi) 1
A 16-year-old male client is admitted to the hospital after falling off a bike and
sustaining a fractured bone. The healthcare provider explains the surgery needed to
immobilize the fracture. Which action should be implemented to obtain a valid
informed consent? - ANS-Obtain the permission of the custodial parent for the
surgery.
The client is a minor and cannot legally sign his own consent unless he is an
emancipated minor, so the consent should be obtained from the guardian for this
client, which is the custodial parent (B). (A) is not a legal option. A stepparent is not a
legal guardian for a minor unless the child has been adopted by the stepparent (C).
The non-custodial parent does not need to co-sign this form (D).
\A 56 year old female client is receiving intracavitary radiation via a radium implant.
Which nurse should be assigned to care for this client? - ANS-A nurse with marfran's
syndrome who is postmenopausal.
A client receiving intracavity radiation poses a radiation hazard as long as the
intracavity radiation source is in place. A nurse's ability to care of this client is not
affected by Marfan's syndrome (B), which is a hereditary disorder of connective
tissues, bones, muscles, ligaments and skeletal structures. The goal is to limit any
one staff member's exposure to the calculated time span based on the half-life of
radium, such as the number of minutes at the bedside per day, so (A) should not be
assigned. (C) should not be exposed to the radiation due to the possible effect on
the fetus. A radiation exposure decreases the immune response in the client who
should not be exposed to the potential inadvertent transmission of an infectious
organism (D).
\A 6 year old child is alert but quiet when brought to the emergency center with
periobital ecchymosis and ecchymosis behind the ears. The nurse suspects potential
child abuse and continues to assess the child for additional manifestations of a
basilar skull fracture. What assessment finding would be consistent with the basilar
skull fracture? - ANS-Rhinorrhoea or otorrhoea with halo sign
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear
over the mastoid process) are both signs of a basilar skull fracture, so the nurse
should assess for possible meningeal tears that manifest as a Halo sign with CSF
leakage from the ears or nose (D). (A) is consistent with orbital fractures. (B) occurs
with wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt
abdominal injuries.
\A 63-year-old female client whose husband died one month ago is seen in the
psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps
very little at night, and continues to set the table for her deceased husband. What
,nursing problem best describes this problem? - ANS-Denial related to the loss of a
loved one.
Based on the data provided, (C) is the best nursing diagnosis. This client is
exhibiting symptoms of anxiety and the pain is too great for her to acknowledge, so
she is denying the situation. Although she may seem confused (A), she is actually
trying to deal with the pain through the defense mechanism of denial. (B) occurs
after one year or longer following the loss. The client's husband died one month ago.
(D) and depression are often related, and depression is sometimes described as
unexpressed anger. However, this client has not acknowledged her loss (denial) and
the anger is not yet realized.
\A 9 year old is hospitalized for the neutropenia and is placed in reverse isolation.
The child asks the nurse " why do you have to wear a gown and mask when you are
in my room?" How should the nurse respond? - ANS-" To protect you because you
can get an infection very easily
Reverse isolation precaution implement measures to protect the client from exposure
to microorganisms from others (B). Although microbes are prevalent in all
environments, (A) does not adequately answer the child's question. Reverse
isolation should be implemented until the client's white blood cell increases (C).
Neutropenia in this child does not place others (D) at risk for infection.
\A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for
the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10
and 20. How many milliliters per hour should the nurse program the infusion pump
for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required,
round to the nearest whole number.) - ANS-61
The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day;
or 10 to 20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for
each kilogram between 10 and 20. To determine an hourly rate, divide the total
milliliters per day by 24. 19.5 kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24
hours = 61 mL/hour
\A child with bacterial conjunctivitis receives a prescription for erythromycin eye
drops. Which information is most important for the nurse to include in the teaching
plan? - ANS-Avoid sharing towels and washcloths with siblings
All of the information is important to include in the teaching plan, but it is most
important to avoid spreading the bacterial infection. The child should avoid sharing
towels and washcloths (D) and should stay home from school for the first 24 hours
after antibiotics are started, to prevent contamination of others. (A, B, and C) are
important measures to reduce the child's discomfort, but inhibiting the spread of the
infection is the priority intervention.
\A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate
action by the nurse can lessen the symptoms of this " TET" spell? - ANS-Place child
, in knee-chest positionThis pressure reduces the rush of blood flow through the
septal hole and improves blood circulation.
The child should be placed on his or her back in the knee-to-chest position (B) to
increase blood vessel resistance. The increased pressure reduces the rush of blood
through the septal hole and improves blood circulation. (A) has nominal effects in
hypercyanosis. (C) is self-regulating. (D) is not indicated for immediate relief of tet
spells. It is used to improve cardiac output.
\A client assigned to a female practical nurse (PN) needs total morning care and
sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has
never performed a wound packing. Which intervention should the charge nurse
implement? - ANS-Demonstrate the wound care procedure to the PN while the PN
assists
It is within the PN's scope of practice to perform sterile wound care. The best
learning of skills is through demonstration and return demonstration, therefore (D)
promotes safe practice while allowing the PN the best opportunity to learn. (A) does
not allow the PN to gain the experience needed to perform her role. (B) does not
provide the best learning opportunity for the PN, or ensure safe practice. While (C)
would provide a safe method for learning the wet-to-dry procedure, it doesn't address
the problem immediately and is a more costly way for the PN to learn.
\A client is admitted to the hospital for alcohol dependency. What is the priority
nursing intervention during the first 48 hours following admission? - ANS-Monitor for
increased blood pressure and pulse
Clients with alcohol dependency experience withdrawal symptoms, which include
elevated blood pressure, pulse, and temperature, so (B) has the highest priority. (A)
will prevent Korsakoff's syndrome (secondary dementia caused by thiamine
deficiency, associated with malnutrition secondary to excessive alcohol intake), but
this intervention does not have the priority of (B). (C and D) are important for alcohol
detoxification, but do not have the priority of (B).
\A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and
influenza. Which categories of illness should the nurse develop goals for the client's
plan of care? - ANS-One chronic and one acute illness
The plan of care should include goals that are specific for chronic and acute
illnesses. Adult-onset diabetes is a life-long chronic disease, whereas influenza is an
acute illness with a short term duration (C). (A, B, and D) do not include the correct
duration categories for this situation.
\A client is admitted with a medical diagnosis of addisonian crisis. When completing
the admission assessment, the nurse expects this client to exhibit which clinical
manifestations? - ANS-Hypotension, rapid weak pulse, and rapid respiratory rate
A 16-year-old male client is admitted to the hospital after falling off a bike and
sustaining a fractured bone. The healthcare provider explains the surgery needed to
immobilize the fracture. Which action should be implemented to obtain a valid
informed consent? - ANS-Obtain the permission of the custodial parent for the
surgery.
The client is a minor and cannot legally sign his own consent unless he is an
emancipated minor, so the consent should be obtained from the guardian for this
client, which is the custodial parent (B). (A) is not a legal option. A stepparent is not a
legal guardian for a minor unless the child has been adopted by the stepparent (C).
The non-custodial parent does not need to co-sign this form (D).
\A 56 year old female client is receiving intracavitary radiation via a radium implant.
Which nurse should be assigned to care for this client? - ANS-A nurse with marfran's
syndrome who is postmenopausal.
A client receiving intracavity radiation poses a radiation hazard as long as the
intracavity radiation source is in place. A nurse's ability to care of this client is not
affected by Marfan's syndrome (B), which is a hereditary disorder of connective
tissues, bones, muscles, ligaments and skeletal structures. The goal is to limit any
one staff member's exposure to the calculated time span based on the half-life of
radium, such as the number of minutes at the bedside per day, so (A) should not be
assigned. (C) should not be exposed to the radiation due to the possible effect on
the fetus. A radiation exposure decreases the immune response in the client who
should not be exposed to the potential inadvertent transmission of an infectious
organism (D).
\A 6 year old child is alert but quiet when brought to the emergency center with
periobital ecchymosis and ecchymosis behind the ears. The nurse suspects potential
child abuse and continues to assess the child for additional manifestations of a
basilar skull fracture. What assessment finding would be consistent with the basilar
skull fracture? - ANS-Rhinorrhoea or otorrhoea with halo sign
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear
over the mastoid process) are both signs of a basilar skull fracture, so the nurse
should assess for possible meningeal tears that manifest as a Halo sign with CSF
leakage from the ears or nose (D). (A) is consistent with orbital fractures. (B) occurs
with wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt
abdominal injuries.
\A 63-year-old female client whose husband died one month ago is seen in the
psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps
very little at night, and continues to set the table for her deceased husband. What
,nursing problem best describes this problem? - ANS-Denial related to the loss of a
loved one.
Based on the data provided, (C) is the best nursing diagnosis. This client is
exhibiting symptoms of anxiety and the pain is too great for her to acknowledge, so
she is denying the situation. Although she may seem confused (A), she is actually
trying to deal with the pain through the defense mechanism of denial. (B) occurs
after one year or longer following the loss. The client's husband died one month ago.
(D) and depression are often related, and depression is sometimes described as
unexpressed anger. However, this client has not acknowledged her loss (denial) and
the anger is not yet realized.
\A 9 year old is hospitalized for the neutropenia and is placed in reverse isolation.
The child asks the nurse " why do you have to wear a gown and mask when you are
in my room?" How should the nurse respond? - ANS-" To protect you because you
can get an infection very easily
Reverse isolation precaution implement measures to protect the client from exposure
to microorganisms from others (B). Although microbes are prevalent in all
environments, (A) does not adequately answer the child's question. Reverse
isolation should be implemented until the client's white blood cell increases (C).
Neutropenia in this child does not place others (D) at risk for infection.
\A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for
the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10
and 20. How many milliliters per hour should the nurse program the infusion pump
for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required,
round to the nearest whole number.) - ANS-61
The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day;
or 10 to 20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for
each kilogram between 10 and 20. To determine an hourly rate, divide the total
milliliters per day by 24. 19.5 kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24
hours = 61 mL/hour
\A child with bacterial conjunctivitis receives a prescription for erythromycin eye
drops. Which information is most important for the nurse to include in the teaching
plan? - ANS-Avoid sharing towels and washcloths with siblings
All of the information is important to include in the teaching plan, but it is most
important to avoid spreading the bacterial infection. The child should avoid sharing
towels and washcloths (D) and should stay home from school for the first 24 hours
after antibiotics are started, to prevent contamination of others. (A, B, and C) are
important measures to reduce the child's discomfort, but inhibiting the spread of the
infection is the priority intervention.
\A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate
action by the nurse can lessen the symptoms of this " TET" spell? - ANS-Place child
, in knee-chest positionThis pressure reduces the rush of blood flow through the
septal hole and improves blood circulation.
The child should be placed on his or her back in the knee-to-chest position (B) to
increase blood vessel resistance. The increased pressure reduces the rush of blood
through the septal hole and improves blood circulation. (A) has nominal effects in
hypercyanosis. (C) is self-regulating. (D) is not indicated for immediate relief of tet
spells. It is used to improve cardiac output.
\A client assigned to a female practical nurse (PN) needs total morning care and
sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has
never performed a wound packing. Which intervention should the charge nurse
implement? - ANS-Demonstrate the wound care procedure to the PN while the PN
assists
It is within the PN's scope of practice to perform sterile wound care. The best
learning of skills is through demonstration and return demonstration, therefore (D)
promotes safe practice while allowing the PN the best opportunity to learn. (A) does
not allow the PN to gain the experience needed to perform her role. (B) does not
provide the best learning opportunity for the PN, or ensure safe practice. While (C)
would provide a safe method for learning the wet-to-dry procedure, it doesn't address
the problem immediately and is a more costly way for the PN to learn.
\A client is admitted to the hospital for alcohol dependency. What is the priority
nursing intervention during the first 48 hours following admission? - ANS-Monitor for
increased blood pressure and pulse
Clients with alcohol dependency experience withdrawal symptoms, which include
elevated blood pressure, pulse, and temperature, so (B) has the highest priority. (A)
will prevent Korsakoff's syndrome (secondary dementia caused by thiamine
deficiency, associated with malnutrition secondary to excessive alcohol intake), but
this intervention does not have the priority of (B). (C and D) are important for alcohol
detoxification, but do not have the priority of (B).
\A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and
influenza. Which categories of illness should the nurse develop goals for the client's
plan of care? - ANS-One chronic and one acute illness
The plan of care should include goals that are specific for chronic and acute
illnesses. Adult-onset diabetes is a life-long chronic disease, whereas influenza is an
acute illness with a short term duration (C). (A, B, and D) do not include the correct
duration categories for this situation.
\A client is admitted with a medical diagnosis of addisonian crisis. When completing
the admission assessment, the nurse expects this client to exhibit which clinical
manifestations? - ANS-Hypotension, rapid weak pulse, and rapid respiratory rate
