HESI CAT EXAM VERSION 3
The nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone
(SIADH). Which finding in the client is consistent with the diagnosis?
1
Preservation of salt
2
Retention of water
3
Decrease of vasopressin
4
Presence of pedal edema -ANSWER-2
SIADH is manifested in the form of retention of free water. This is because of excessive
secretion of vasopressin causing reabsorption of water in renal tubules. There is hyponatremia
and dilution of serum sodium in SIADH. Decreased vasopressin is seen in diabetes insipidus.
Generally pedal (dependent) edema is not seen in SIADH despite the water retention.
A client has returned from surgery with a nephrostomy tube. Which is the most essential
nursing intervention for this client?
1
Ensure free drainage of urine.
2
Milk the tube every 2 hours.
3
Keep an accurate record of intake and output.
4
Instill 12 mL of normal saline every 8 hours. -ANSWER-1
,The tube must be kept patent to prevent urine backup, hydronephrosis, and kidney damage.
Milking the tube every 2 hours is unnecessary. Instill no more than 5 mL of normal saline only if
prescribed. Although keeping an accurate record of intake and output is important, it will not
ensure free drainage of urine, which is the priority.
The primary healthcare provider diagnoses placenta previa in a primiparous client. What does
this indicate to the nurse regarding the condition of the placenta?
1
Infarcted
2
Low-lying
3
Immaturely developed
4
Separating prematurely -ANSWER-2
Implantation should occur in the upper third of the uterus; a low-lying placenta is termed
placenta previa. Infarctions may appear on a placenta because of some interference with the
blood supply; this is not related to its location within the uterus. Placenta previa indicates
where the placenta is implanted and has no relationship to placental aging. Abruptio placentae,
not placenta previa, is the premature separation of a normally implanted placenta.
What should the nurse include in the plan of care for a client who just had a total
laryngectomy?
1
Instructing the client to whisper
2
Removing the outer tracheostomy tube as needed
3
Placing the client in the orthopneic position
4
,Suctioning the tracheostomy tube whenever necessary -ANSWER-4
Secretions are increased because of alterations in structure and function. A patent airway must
be maintained. Whispering can put tension on the suture line; initially nonverbal and written
forms of communication should be encouraged. The outer tube is not removed because the
stoma may close. The orthopneic position may cause neck flexion and block the airway.
The parents of a 12-year-old boy with cystic fibrosis (CF) ask the nurse why he needs a glucose
tolerance test. What information should the nurse consider before replying?
1
Pancreatic scarring predisposes the child to diabetes.
2
The thickened mucus blocks the insulin-secreting glands.
3
The test reveals the degree to which the child adheres to the diet.
4
Adjustments of the dosage of pancreatic enzymes are based on the results of the test. -
ANSWER-1
Pancreatic scarring affects the ability of the islets of Langerhans to produce insulin; about half
of all children with CF have altered glucose tolerance. The endocrine glands, which produce
insulin, are ductless and are not affected by the thickened mucus in the ducts. However, the
general scarring throughout the pancreas does affect the insulin-producing glands. The glucose
tolerance test is a measure of the body's ability to produce and metabolize carbohydrates, not
a measure of the child's adherence to the diet. The dosage of pancreatic enzymes is based on
food consumption, not the blood glucose level.
A 1-month-old infant with a ventricular septal defect (VSD) is examined in the cardiology clinic.
What sign related to this disorder does the nurse expect to find when assessing this infant?
1
Bradycardia at rest
2
Activity-related cyanosis
, 3
Bounding peripheral pulses
4
Murmur at the left sternal border -ANSWER-4
A murmur at the left sternal border is the most characteristic finding in infants and children
with a VSD. A left-to-right shunt is caused by the flow of blood from the higher pressure left
ventricle to the lower pressure right ventricle. Children with VSDs generally have tachycardia
and are often acyanotic. A bounding peripheral pulse is not a common finding in children with a
VSD.
An adolescent who works out 6 hours a day reports not eating well, weight loss, and an absence
of menses for the past few months. Which nursing intervention is most appropriate?
1
Ask the adolescent to stop exercising for a few days.
2
Talk to the client to find out any reasons for stress.
3
Perform a β-human chorionic gonadotropin pregnancy test.
4
Modify the adolescent's diet to incorporate more nutrients. -ANSWER-4
If an athletic adolescent experiences symptoms of eating disorders, weight loss, and an absence
of menses indicating female athlete triad, then her diet should be modified incorporate more
nutrients. Asking the adolescent to stop exercising for a few days would not solve the problem.
Stress does not cause amenorrhea. Being an athlete and having eating disorders rules out the
chances for becoming pregnant.
An obese smoker complains of feeling sleepy during the daytime, waking up tired in the
morning, and snoring heavily while sleeping. The client is found to have enlarged tonsils. Which
condition may the client have?
1
Laryngeal trauma
The nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone
(SIADH). Which finding in the client is consistent with the diagnosis?
1
Preservation of salt
2
Retention of water
3
Decrease of vasopressin
4
Presence of pedal edema -ANSWER-2
SIADH is manifested in the form of retention of free water. This is because of excessive
secretion of vasopressin causing reabsorption of water in renal tubules. There is hyponatremia
and dilution of serum sodium in SIADH. Decreased vasopressin is seen in diabetes insipidus.
Generally pedal (dependent) edema is not seen in SIADH despite the water retention.
A client has returned from surgery with a nephrostomy tube. Which is the most essential
nursing intervention for this client?
1
Ensure free drainage of urine.
2
Milk the tube every 2 hours.
3
Keep an accurate record of intake and output.
4
Instill 12 mL of normal saline every 8 hours. -ANSWER-1
,The tube must be kept patent to prevent urine backup, hydronephrosis, and kidney damage.
Milking the tube every 2 hours is unnecessary. Instill no more than 5 mL of normal saline only if
prescribed. Although keeping an accurate record of intake and output is important, it will not
ensure free drainage of urine, which is the priority.
The primary healthcare provider diagnoses placenta previa in a primiparous client. What does
this indicate to the nurse regarding the condition of the placenta?
1
Infarcted
2
Low-lying
3
Immaturely developed
4
Separating prematurely -ANSWER-2
Implantation should occur in the upper third of the uterus; a low-lying placenta is termed
placenta previa. Infarctions may appear on a placenta because of some interference with the
blood supply; this is not related to its location within the uterus. Placenta previa indicates
where the placenta is implanted and has no relationship to placental aging. Abruptio placentae,
not placenta previa, is the premature separation of a normally implanted placenta.
What should the nurse include in the plan of care for a client who just had a total
laryngectomy?
1
Instructing the client to whisper
2
Removing the outer tracheostomy tube as needed
3
Placing the client in the orthopneic position
4
,Suctioning the tracheostomy tube whenever necessary -ANSWER-4
Secretions are increased because of alterations in structure and function. A patent airway must
be maintained. Whispering can put tension on the suture line; initially nonverbal and written
forms of communication should be encouraged. The outer tube is not removed because the
stoma may close. The orthopneic position may cause neck flexion and block the airway.
The parents of a 12-year-old boy with cystic fibrosis (CF) ask the nurse why he needs a glucose
tolerance test. What information should the nurse consider before replying?
1
Pancreatic scarring predisposes the child to diabetes.
2
The thickened mucus blocks the insulin-secreting glands.
3
The test reveals the degree to which the child adheres to the diet.
4
Adjustments of the dosage of pancreatic enzymes are based on the results of the test. -
ANSWER-1
Pancreatic scarring affects the ability of the islets of Langerhans to produce insulin; about half
of all children with CF have altered glucose tolerance. The endocrine glands, which produce
insulin, are ductless and are not affected by the thickened mucus in the ducts. However, the
general scarring throughout the pancreas does affect the insulin-producing glands. The glucose
tolerance test is a measure of the body's ability to produce and metabolize carbohydrates, not
a measure of the child's adherence to the diet. The dosage of pancreatic enzymes is based on
food consumption, not the blood glucose level.
A 1-month-old infant with a ventricular septal defect (VSD) is examined in the cardiology clinic.
What sign related to this disorder does the nurse expect to find when assessing this infant?
1
Bradycardia at rest
2
Activity-related cyanosis
, 3
Bounding peripheral pulses
4
Murmur at the left sternal border -ANSWER-4
A murmur at the left sternal border is the most characteristic finding in infants and children
with a VSD. A left-to-right shunt is caused by the flow of blood from the higher pressure left
ventricle to the lower pressure right ventricle. Children with VSDs generally have tachycardia
and are often acyanotic. A bounding peripheral pulse is not a common finding in children with a
VSD.
An adolescent who works out 6 hours a day reports not eating well, weight loss, and an absence
of menses for the past few months. Which nursing intervention is most appropriate?
1
Ask the adolescent to stop exercising for a few days.
2
Talk to the client to find out any reasons for stress.
3
Perform a β-human chorionic gonadotropin pregnancy test.
4
Modify the adolescent's diet to incorporate more nutrients. -ANSWER-4
If an athletic adolescent experiences symptoms of eating disorders, weight loss, and an absence
of menses indicating female athlete triad, then her diet should be modified incorporate more
nutrients. Asking the adolescent to stop exercising for a few days would not solve the problem.
Stress does not cause amenorrhea. Being an athlete and having eating disorders rules out the
chances for becoming pregnant.
An obese smoker complains of feeling sleepy during the daytime, waking up tired in the
morning, and snoring heavily while sleeping. The client is found to have enlarged tonsils. Which
condition may the client have?
1
Laryngeal trauma
