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EVOLVE ELSEVIER HESI MED-SURG TEST EXAM||
ACCURATE AND FREQUENTLY TESTED QUESTIONS
AND 100% CORRECT ANSWERS WITH RATIONALES||
LATEST AND COMPLETE UPDATE WITH EXPERT
VERIFIED SOLUTIONS|| SURE PASS!!
A nurse is assisting an 82-year-old client with ambulation and is concerned that the
client may fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - ANSWER: Correct Answer: B
Rationale: Stooped posture results in the upper torso becoming the center of
gravity for older persons. The center of gravity for adults is the hips. However, as a
person grows older, a stooped posture is common because of changes caused by
osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and
elbows flex. The head and neck and feet and legs are not the center of gravity in
the older adult. Although the arms comprise a part of the upper torso, they do not
reflect the best and most complete answer.
A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks
and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is
120/70 mm Hg. Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
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D. Check the health care provider's prescription to clarify the dose. - ✔✔✔ -
ANSWER: Correct Answer: A
Rationale: The client's blood pressure is within normal limits, indicating that the
ramipril, an antihypertensive, is having the desired effect and should be
administered. Options B and C would be appropriate if the client's blood
pressure was excessively low (<100 mm Hg systolic) or if the client were
exhibiting signs of hypotension such as dizziness. This prescribed dose is within
the normal dosage range, as defined by the manufacturer; therefore, option D is not
necessary
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused
assessment related to this condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing E.Tinnitus
F.Hearing difficulties - ANSWER: Correct Answer: A,B
Rationale: Trigeminal neuralgia is characterized by paroxysms of pain, similar to
an electric shock, in the area innervated by one or more branches of the trigeminal
nerve (cranial V). The remaining symptoms are not related to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data warrants an
immediate nursing action?
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A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C.The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. -
✔✔✔ - ANSWER: Correct Answer: A
Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis,
which is a medical emergency and should be reported to the health care provider
immediately. Options B and C are expected clinical manifestations of diverticulitis.
Option D does not warrant immediate intervention.
The nurse is caring for a client with a fractured right elbow. Which assessment
finding has the highest priority and requires immediate intervention?
A. Ecchymosis over the right elbow area
B. Deep unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - ANSWER: Correct Answer: B
Rationale: Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing
pain uncontrolled by opioids and neurovascular compromise. Option A is an
expected finding. Option C related to compartment syndrome cannot be seen, and
any visible edema is an expected finding related to the injury. Option D is an
expected finding.
, 4|Page
The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent
dressing in place to the mid abdomen. The nurse notes a spot of red staining
centrally on the dressing. What is the nurse's next action? A. Note the size
of the stain in the chart.
B. Circle the stain with an ink pen.
C. Remove the dressing to assess the source of the bleeding.
D. Place a pressure dressing on the existing dressing. - ANSWER: Correct
Answer: B
Rationale:By circling the existing stain upon admission to the unit, the nurse can
then assess any increase, though subtle, in the amount of drainage over time. The
size of the stain will need to be noted in the chart, but it is not the first action. The
nurse removes the dressing under the prescription of the health care provider or in
an emergency. Neither of those conditions exist in the question. The dressing in
place is an absorbent dressing. There is no need for a further dressing until the
existing dressing becomes saturated.
While at a home game, the mother of a 6-year-old is heard screaming, "My child is
having an asthma attack! Can anyone help?" The nurse arrives and finds the child
gasping for breath with circumoral cyanosis. What are the nurse's next actions?
(Select all that apply.)
A. Yell, "Call 911."
EVOLVE ELSEVIER HESI MED-SURG TEST EXAM||
ACCURATE AND FREQUENTLY TESTED QUESTIONS
AND 100% CORRECT ANSWERS WITH RATIONALES||
LATEST AND COMPLETE UPDATE WITH EXPERT
VERIFIED SOLUTIONS|| SURE PASS!!
A nurse is assisting an 82-year-old client with ambulation and is concerned that the
client may fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - ANSWER: Correct Answer: B
Rationale: Stooped posture results in the upper torso becoming the center of
gravity for older persons. The center of gravity for adults is the hips. However, as a
person grows older, a stooped posture is common because of changes caused by
osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and
elbows flex. The head and neck and feet and legs are not the center of gravity in
the older adult. Although the arms comprise a part of the upper torso, they do not
reflect the best and most complete answer.
A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks
and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is
120/70 mm Hg. Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
,2|Page
D. Check the health care provider's prescription to clarify the dose. - ✔✔✔ -
ANSWER: Correct Answer: A
Rationale: The client's blood pressure is within normal limits, indicating that the
ramipril, an antihypertensive, is having the desired effect and should be
administered. Options B and C would be appropriate if the client's blood
pressure was excessively low (<100 mm Hg systolic) or if the client were
exhibiting signs of hypotension such as dizziness. This prescribed dose is within
the normal dosage range, as defined by the manufacturer; therefore, option D is not
necessary
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused
assessment related to this condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing E.Tinnitus
F.Hearing difficulties - ANSWER: Correct Answer: A,B
Rationale: Trigeminal neuralgia is characterized by paroxysms of pain, similar to
an electric shock, in the area innervated by one or more branches of the trigeminal
nerve (cranial V). The remaining symptoms are not related to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data warrants an
immediate nursing action?
,3|Page
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C.The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. -
✔✔✔ - ANSWER: Correct Answer: A
Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis,
which is a medical emergency and should be reported to the health care provider
immediately. Options B and C are expected clinical manifestations of diverticulitis.
Option D does not warrant immediate intervention.
The nurse is caring for a client with a fractured right elbow. Which assessment
finding has the highest priority and requires immediate intervention?
A. Ecchymosis over the right elbow area
B. Deep unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - ANSWER: Correct Answer: B
Rationale: Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing
pain uncontrolled by opioids and neurovascular compromise. Option A is an
expected finding. Option C related to compartment syndrome cannot be seen, and
any visible edema is an expected finding related to the injury. Option D is an
expected finding.
, 4|Page
The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent
dressing in place to the mid abdomen. The nurse notes a spot of red staining
centrally on the dressing. What is the nurse's next action? A. Note the size
of the stain in the chart.
B. Circle the stain with an ink pen.
C. Remove the dressing to assess the source of the bleeding.
D. Place a pressure dressing on the existing dressing. - ANSWER: Correct
Answer: B
Rationale:By circling the existing stain upon admission to the unit, the nurse can
then assess any increase, though subtle, in the amount of drainage over time. The
size of the stain will need to be noted in the chart, but it is not the first action. The
nurse removes the dressing under the prescription of the health care provider or in
an emergency. Neither of those conditions exist in the question. The dressing in
place is an absorbent dressing. There is no need for a further dressing until the
existing dressing becomes saturated.
While at a home game, the mother of a 6-year-old is heard screaming, "My child is
having an asthma attack! Can anyone help?" The nurse arrives and finds the child
gasping for breath with circumoral cyanosis. What are the nurse's next actions?
(Select all that apply.)
A. Yell, "Call 911."
