HESI EXIT PACKAGED TEST BANK
COMPLETE QUESTIONS AND ANSWERS
COMPREHENSIVE STUDY GUIDE VERIFIED
ACCURACY
⩥ A school nurse observing a child diagnosed with Down syndrome is
participating in a physical education class and notes that the child is
experiencing a diminution in motor abilities. The nurse asks to see the
child and conducts an assessment, during which the child complains of
neck pain and loss of bladder control. What is the appropriate action by
the nurse?
Contacting the child's primary health care provider to report the findings
Administering acetaminophen to the child to relieve the pain
Asking that the child not attend the physical education class until the
neck pain has subsided
Teaching the child how to use peripads to prevent embarrassment
resulting from loss of bladder control.
Answer: Contacting the child's primary health care provider to report the
findings
Rationale: Children with Down syndrome who participate in sports that
may involve stress on the neck should be evaluated radiologically for
atlantoaxial instability. Signs/symptoms of the disorder include neck
,pain, weakness, and torticollis. Affected children are at risk for spinal
cord compression. Signs/symptoms of spinal cord compression include
persistent neck pain, loss of established motor skills and bladder or
bowel control, and changes in sensation. If any of these signs/symptoms
are noted, it must be reported immediately to the primary health care
provider. Administering acetaminophen to relieve the pain and not
allowing the child to attend physical education class until the pain has
subsided are inappropriate actions that will delay necessary
interventions. Teaching the child to use peripads to prevent
embarrassment resulting from loss of bladder control may be appropriate
in certain scenarios, but in this situation the child is exhibiting
signs/symptoms of spinal cord compression, requiring immediate
intervention.
⩥ A client is taking gentamicin sulfate for the treatment of pelvic
inflammatory disease. What does the nurse ask the client during
assessment for adverse effects of the medication?
"When was your last bowel movement?"
"When was your last menstrual period?"
"Are you having any difficulty hearing?"
"Are you having any difficulty breathing?".
Answer: "Are you having any difficulty hearing?"
Rationale: Serious adverse reactions to aminoglycosides include
ototoxicity and nephrotoxicity. Gentamicin sulfate is an aminoglycoside.
,It inhibits bacterial protein synthesis and has a bactericidal effect. The
nurse must assess the client for changes in hearing, balance, and urine
output. The remaining assessment questions are not associated with the
adverse effects of this medication.
⩥ A nurse is providing instruction about insulin therapy and its
administration to an adolescent client who has just been found to have
diabetes mellitus. Which statement by the client indicates a need for
further instruction?
"It's important to rotate injection sites."
"I need to store the insulin in a cool, dry place."
"I need to keep any unopened bottles of insulin in the freezer."
"I need to check the expiration date on the insulin before I use it.".
Answer: "I need to keep any unopened bottles of insulin in the freezer."
Rationale: There is a need for further instruction if the client states, "I
need to keep any unopened bottles of insulin in the freezer." Insulin is
stored in a cool, dry place. It should not be placed in the freezer or
exposed to excess heat or agitation. Injection sites should be rotated to
ensure adequate insulin absorption and to prevent complications of
insulin administration. Once a bottle of insulin has been opened, it is
dated and discarded as recommended. The client should check the
expiration date on the insulin vial before using it.
, ⩥ A nurse is providing information on the glycosylated hemoglobin
assay and its purpose to a client with diabetes mellitus. What does the
nurse tell the client about this blood test?
Is a measure of the client's hematocrit level
Is a measure of the client's hemoglobin level
Helps predict the risk for the development of chronic complications of
diabetes mellitus
Provides a determination of short-term glycemic control in the client
with diabetes mellitus.
Answer: Helps predict the risk for the development of chronic
complications of diabetes mellitus
Rationale: The nurse tells the client that the blood test is used to assess
long-term glycemic control, as well as to predict the risk for the
development of chronic complications. Glycosylated hemoglobin is the
best indicator of the average blood glucose level. Because glucose
attaches itself to the hemoglobin molecule, measurement of glycosylated
hemoglobin indicates the average blood glucose level during the
previous 120 days, the lifespan of the red blood cell.
⩥ A client living in a long-term care facility shouts at the nurse, "Get out
of my room! I don't need your help!" What is the most appropriate way
for the nurse to document this occurrence in the client's record?
COMPLETE QUESTIONS AND ANSWERS
COMPREHENSIVE STUDY GUIDE VERIFIED
ACCURACY
⩥ A school nurse observing a child diagnosed with Down syndrome is
participating in a physical education class and notes that the child is
experiencing a diminution in motor abilities. The nurse asks to see the
child and conducts an assessment, during which the child complains of
neck pain and loss of bladder control. What is the appropriate action by
the nurse?
Contacting the child's primary health care provider to report the findings
Administering acetaminophen to the child to relieve the pain
Asking that the child not attend the physical education class until the
neck pain has subsided
Teaching the child how to use peripads to prevent embarrassment
resulting from loss of bladder control.
Answer: Contacting the child's primary health care provider to report the
findings
Rationale: Children with Down syndrome who participate in sports that
may involve stress on the neck should be evaluated radiologically for
atlantoaxial instability. Signs/symptoms of the disorder include neck
,pain, weakness, and torticollis. Affected children are at risk for spinal
cord compression. Signs/symptoms of spinal cord compression include
persistent neck pain, loss of established motor skills and bladder or
bowel control, and changes in sensation. If any of these signs/symptoms
are noted, it must be reported immediately to the primary health care
provider. Administering acetaminophen to relieve the pain and not
allowing the child to attend physical education class until the pain has
subsided are inappropriate actions that will delay necessary
interventions. Teaching the child to use peripads to prevent
embarrassment resulting from loss of bladder control may be appropriate
in certain scenarios, but in this situation the child is exhibiting
signs/symptoms of spinal cord compression, requiring immediate
intervention.
⩥ A client is taking gentamicin sulfate for the treatment of pelvic
inflammatory disease. What does the nurse ask the client during
assessment for adverse effects of the medication?
"When was your last bowel movement?"
"When was your last menstrual period?"
"Are you having any difficulty hearing?"
"Are you having any difficulty breathing?".
Answer: "Are you having any difficulty hearing?"
Rationale: Serious adverse reactions to aminoglycosides include
ototoxicity and nephrotoxicity. Gentamicin sulfate is an aminoglycoside.
,It inhibits bacterial protein synthesis and has a bactericidal effect. The
nurse must assess the client for changes in hearing, balance, and urine
output. The remaining assessment questions are not associated with the
adverse effects of this medication.
⩥ A nurse is providing instruction about insulin therapy and its
administration to an adolescent client who has just been found to have
diabetes mellitus. Which statement by the client indicates a need for
further instruction?
"It's important to rotate injection sites."
"I need to store the insulin in a cool, dry place."
"I need to keep any unopened bottles of insulin in the freezer."
"I need to check the expiration date on the insulin before I use it.".
Answer: "I need to keep any unopened bottles of insulin in the freezer."
Rationale: There is a need for further instruction if the client states, "I
need to keep any unopened bottles of insulin in the freezer." Insulin is
stored in a cool, dry place. It should not be placed in the freezer or
exposed to excess heat or agitation. Injection sites should be rotated to
ensure adequate insulin absorption and to prevent complications of
insulin administration. Once a bottle of insulin has been opened, it is
dated and discarded as recommended. The client should check the
expiration date on the insulin vial before using it.
, ⩥ A nurse is providing information on the glycosylated hemoglobin
assay and its purpose to a client with diabetes mellitus. What does the
nurse tell the client about this blood test?
Is a measure of the client's hematocrit level
Is a measure of the client's hemoglobin level
Helps predict the risk for the development of chronic complications of
diabetes mellitus
Provides a determination of short-term glycemic control in the client
with diabetes mellitus.
Answer: Helps predict the risk for the development of chronic
complications of diabetes mellitus
Rationale: The nurse tells the client that the blood test is used to assess
long-term glycemic control, as well as to predict the risk for the
development of chronic complications. Glycosylated hemoglobin is the
best indicator of the average blood glucose level. Because glucose
attaches itself to the hemoglobin molecule, measurement of glycosylated
hemoglobin indicates the average blood glucose level during the
previous 120 days, the lifespan of the red blood cell.
⩥ A client living in a long-term care facility shouts at the nurse, "Get out
of my room! I don't need your help!" What is the most appropriate way
for the nurse to document this occurrence in the client's record?
