NUR 131 HESI EAQ Practice Exam 3 Questions
with Answers
1.Which early sign of impending hydrocephalus would the nurse monitor
for in an infant who has had surgery for repair of a myelomeningocele?
(1) Frequent crying
(2) Bulging fontanels
(3) Change in vital signs
(4) Difficulty with feeding: (2) Bulging fontanels
RATIONALE:
(1)after closure spinal fluid can buildup and reach the brain causing an
increase in ICP and thus bulging fontanels
2.would the nurse document on the child's clinical record? Select all
that apply. One, some, or all responses may be correct.
(1) Intake and output
(2) Measurement of pain
(3) Tolerance of low-residue diet
(4) Frequency of dressing changes
(5) Presence or absence of bowel sounds: (1) Intake and output
(2)Measurement of pain
(5)Presence or absence of bowel sounds
RATIONALE:
(1)pain is assessed because a laparoscopic surgery involves
insufflating the ab- domen with air which will cause pain until it's
reabsorbed
(2)checking for bowel sounds with help determine how the child is
adapting to the intestinal trauma caused by the surgery
3.Which is the most important safety measure for the nurse to
institute immediately when a 2-year-old child has a seizure?
(1) Monitoring the child's vital signs
(2) Padding the side rails of the toddler's crib
(3) Placing the child in the side-lying position
(4) Bringing suction equipment to the bedside: (3) Placing the child in
the side-lying position
,RATIONALE:
(1)maintaining a patent airway is the priority and the side-lying position
helps promote that by keeping the tongue away from the back of the
pharynx and allowing saliva to flow out by gravity
4.When assessing a toddler with autism spectrum disorder (ASD), which
characteristic findings or behaviors would the nurse expect? Select all
that apply. One, some, or all responses may be correct.
(1) The desire to hug the nurse
(2) Flat, blank facial expression
(3) Laughing when pulse is taken
(4) Inability to maintain eye contact
(5) Enjoys climbing on stairs and furniture: (2) Flat, blank facial expression
(3)Laughing when pulse is taken
(4)Inability to maintain eye contact
RATIONALE:
(1)characteristics expected from a toddler with ASD would be a flat
effect, inappro- priate laughing while measuring pulse, lack of eye
contact, and humming/grunting
(2)tend to over-respond to environmental stimuli
(3)will rarely hug anyone and would not enjoy climbing on furniture
5.While assessing a client's hair, the nurse notices the client has head lice.
The nurse teaches the client about hair hygiene and lice control. Which
client statement indicates an understanding of the teaching? Select all that
apply. One, some, or all responses may be correct.
(1) "I will clean my comb in ammonia water."
(2) "I should use lindane-containing shampoo."
(3) "I should shampoo my hair in a tub or shower."
(4) "I should use a dilute vinegar solution to loosen the nits."
(5) "I should use a shampoo treatment once every 24 hours.": (1) "I will
clean my comb in ammonia water."
(4)"I should use a dilute vinegar solution to loosen the nits."
(5)"I should use a shampoo treatment once every 24 hours."
6.recommendations for lice treatment: (1) lindane can be used but could
have serious side effects
(2)should not wash hair in tub or shower because this could cause the
lice to be able to migrate to other spots
(3)soaking combs in ammonia water can help enhance lice control
,(4)nits can be loosened with dilute vinegar solution
(5)shampooing should be done at least once every 24-48 hours
7.Which pathophysiological rationale explains why a client who is 4
days postabdominal surgery has not passed flatus and has hypoactive
bowel sounds and why a paralytic ileus is suspected of developing?
(1) Decreased blood supply
(2) Impaired neural functioning
(3) Perforation of the bowel wall
(4) Obstruction of the bowel lumen: (2) Impaired neural functioning
RATIONALE:
(1)paralytic ileus occurs when neurological impulses diminish result
from anesthe- sia, infection, or surgery
8.necrosis results when..?: there is an interference in blood supply
9.s/s of perforation of the bowel include: (1) pain
(2)peritonitis
10.initial s/s of bowel obstruction: (1) increased peristalsis and bowel
sounds
11.Which topical medication is typically used to treat a client with acne
vulgaris? Select all that apply. One, some, or all responses may be
correct.
(1) Mupirocin
(2) Gentamicin
(3) Clindamycin
(4) Erythromycin
(5) Metronidazole: (3) Clindamycin
(4) Erythromycin
RATIONALE:
12.medicines for impetigo: (1) mupirocin
13.medicine for gram (-) organisms: (1) gentamicin
14.medicine for rosacea and bacterial vaginosis: (1) metronidazole
15.Which factor increases the risk for testicular cancer in adolescent
clients? Select all that apply. One, some, or all responses may be correct.
(1) Infertility
(2) Hemophilia
(3) Liver disease
(4) Cryptorchidism
(5) Klinefelter syndrome: (1) Infertility
(4)Cryptorchidism
, (5)Klinefelter syndrome
16.what is the client with liver disease at risk for?: (1) gynecomastia
17.Which condition in the gynecological history of the client scheduled
for hysterectomy causes the nurse to anticipate an abdominal, rather than
a vaginal, hysterectomy?
(1) Prolapsed uterus
(2) Large uterine fibroids
(3) Mild dysplasia of the cervical os
(4) Urinary incontinence when coughing: (2) Large uterine fibroids
RATIONALE:
(1)removing a uterus with large fibroids vaginally could cause trauma
resulting in hemorrhage
(2)vaginal hysterectomy is indicated for a prolapsed uterus (uterus is
collapsed inside the vagina)
(3)hysterectomy is not the treatment of choice for mild cervical dysplasi
(4)when a hysterectomy is performed the vaginal route is preferred
18.Which parental statement would the nurse recognize as signs that an
infant may need to be evaluated for cerebral palsy? Select all that apply.
One, some, or all responses may be correct.
(1) "My baby doesn't make eye contact."
(2) "My baby seems to have a voracious appetite."
(3) "My baby was able to turn from front to back by 2 months of age."
(4) "I've noticed that this baby clings to me more than other children of
the same age."
(5) "All of my other children were sitting alone by this age. This baby
doesn't seem to be anywhere near sitting alone.": (3) "My baby was able
to turn from front to back by 2 months of age."
(5)"All of my other children were sitting alone by this age. This baby
doesn't seem to be anywhere near sitting alone."
RATIONALE:
(1)usually able to turn from front to back at an early age due to
spastic cerebral palsy - spasticity is what causes unintentional turn
from front to back
(2)is also considered a neurologic problem and is common associated
with failure to meet developmental normals
(3)anorexia or voracious appetite are not associated
(4)personality traits are not related to the diagnosis of cerebral palsy
with Answers
1.Which early sign of impending hydrocephalus would the nurse monitor
for in an infant who has had surgery for repair of a myelomeningocele?
(1) Frequent crying
(2) Bulging fontanels
(3) Change in vital signs
(4) Difficulty with feeding: (2) Bulging fontanels
RATIONALE:
(1)after closure spinal fluid can buildup and reach the brain causing an
increase in ICP and thus bulging fontanels
2.would the nurse document on the child's clinical record? Select all
that apply. One, some, or all responses may be correct.
(1) Intake and output
(2) Measurement of pain
(3) Tolerance of low-residue diet
(4) Frequency of dressing changes
(5) Presence or absence of bowel sounds: (1) Intake and output
(2)Measurement of pain
(5)Presence or absence of bowel sounds
RATIONALE:
(1)pain is assessed because a laparoscopic surgery involves
insufflating the ab- domen with air which will cause pain until it's
reabsorbed
(2)checking for bowel sounds with help determine how the child is
adapting to the intestinal trauma caused by the surgery
3.Which is the most important safety measure for the nurse to
institute immediately when a 2-year-old child has a seizure?
(1) Monitoring the child's vital signs
(2) Padding the side rails of the toddler's crib
(3) Placing the child in the side-lying position
(4) Bringing suction equipment to the bedside: (3) Placing the child in
the side-lying position
,RATIONALE:
(1)maintaining a patent airway is the priority and the side-lying position
helps promote that by keeping the tongue away from the back of the
pharynx and allowing saliva to flow out by gravity
4.When assessing a toddler with autism spectrum disorder (ASD), which
characteristic findings or behaviors would the nurse expect? Select all
that apply. One, some, or all responses may be correct.
(1) The desire to hug the nurse
(2) Flat, blank facial expression
(3) Laughing when pulse is taken
(4) Inability to maintain eye contact
(5) Enjoys climbing on stairs and furniture: (2) Flat, blank facial expression
(3)Laughing when pulse is taken
(4)Inability to maintain eye contact
RATIONALE:
(1)characteristics expected from a toddler with ASD would be a flat
effect, inappro- priate laughing while measuring pulse, lack of eye
contact, and humming/grunting
(2)tend to over-respond to environmental stimuli
(3)will rarely hug anyone and would not enjoy climbing on furniture
5.While assessing a client's hair, the nurse notices the client has head lice.
The nurse teaches the client about hair hygiene and lice control. Which
client statement indicates an understanding of the teaching? Select all that
apply. One, some, or all responses may be correct.
(1) "I will clean my comb in ammonia water."
(2) "I should use lindane-containing shampoo."
(3) "I should shampoo my hair in a tub or shower."
(4) "I should use a dilute vinegar solution to loosen the nits."
(5) "I should use a shampoo treatment once every 24 hours.": (1) "I will
clean my comb in ammonia water."
(4)"I should use a dilute vinegar solution to loosen the nits."
(5)"I should use a shampoo treatment once every 24 hours."
6.recommendations for lice treatment: (1) lindane can be used but could
have serious side effects
(2)should not wash hair in tub or shower because this could cause the
lice to be able to migrate to other spots
(3)soaking combs in ammonia water can help enhance lice control
,(4)nits can be loosened with dilute vinegar solution
(5)shampooing should be done at least once every 24-48 hours
7.Which pathophysiological rationale explains why a client who is 4
days postabdominal surgery has not passed flatus and has hypoactive
bowel sounds and why a paralytic ileus is suspected of developing?
(1) Decreased blood supply
(2) Impaired neural functioning
(3) Perforation of the bowel wall
(4) Obstruction of the bowel lumen: (2) Impaired neural functioning
RATIONALE:
(1)paralytic ileus occurs when neurological impulses diminish result
from anesthe- sia, infection, or surgery
8.necrosis results when..?: there is an interference in blood supply
9.s/s of perforation of the bowel include: (1) pain
(2)peritonitis
10.initial s/s of bowel obstruction: (1) increased peristalsis and bowel
sounds
11.Which topical medication is typically used to treat a client with acne
vulgaris? Select all that apply. One, some, or all responses may be
correct.
(1) Mupirocin
(2) Gentamicin
(3) Clindamycin
(4) Erythromycin
(5) Metronidazole: (3) Clindamycin
(4) Erythromycin
RATIONALE:
12.medicines for impetigo: (1) mupirocin
13.medicine for gram (-) organisms: (1) gentamicin
14.medicine for rosacea and bacterial vaginosis: (1) metronidazole
15.Which factor increases the risk for testicular cancer in adolescent
clients? Select all that apply. One, some, or all responses may be correct.
(1) Infertility
(2) Hemophilia
(3) Liver disease
(4) Cryptorchidism
(5) Klinefelter syndrome: (1) Infertility
(4)Cryptorchidism
, (5)Klinefelter syndrome
16.what is the client with liver disease at risk for?: (1) gynecomastia
17.Which condition in the gynecological history of the client scheduled
for hysterectomy causes the nurse to anticipate an abdominal, rather than
a vaginal, hysterectomy?
(1) Prolapsed uterus
(2) Large uterine fibroids
(3) Mild dysplasia of the cervical os
(4) Urinary incontinence when coughing: (2) Large uterine fibroids
RATIONALE:
(1)removing a uterus with large fibroids vaginally could cause trauma
resulting in hemorrhage
(2)vaginal hysterectomy is indicated for a prolapsed uterus (uterus is
collapsed inside the vagina)
(3)hysterectomy is not the treatment of choice for mild cervical dysplasi
(4)when a hysterectomy is performed the vaginal route is preferred
18.Which parental statement would the nurse recognize as signs that an
infant may need to be evaluated for cerebral palsy? Select all that apply.
One, some, or all responses may be correct.
(1) "My baby doesn't make eye contact."
(2) "My baby seems to have a voracious appetite."
(3) "My baby was able to turn from front to back by 2 months of age."
(4) "I've noticed that this baby clings to me more than other children of
the same age."
(5) "All of my other children were sitting alone by this age. This baby
doesn't seem to be anywhere near sitting alone.": (3) "My baby was able
to turn from front to back by 2 months of age."
(5)"All of my other children were sitting alone by this age. This baby
doesn't seem to be anywhere near sitting alone."
RATIONALE:
(1)usually able to turn from front to back at an early age due to
spastic cerebral palsy - spasticity is what causes unintentional turn
from front to back
(2)is also considered a neurologic problem and is common associated
with failure to meet developmental normals
(3)anorexia or voracious appetite are not associated
(4)personality traits are not related to the diagnosis of cerebral palsy
