COMPLETE SOLUTIONS FOR EXIT HESI EXAM

COMPLETE SOLUTIONS FOR EXIT HESI EXAM 101. A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell‟s palsy rather than a stroke? a- Slow onset of facial drooping associated with headache b- Inability to close the affected eye, raise brow, or smile c- A flat nasolabial fold on the right resulting in facial asymmetry. d- Drooling is present on right side of the mouth, but not on the left. - CORRECT ANSWER -b- Inability to close the affected eye, raise brow, or smile Rationale: Because the motor function controlling eye closure, brow movement and smiling are all carried on the 7th cranial (facial) nerve, the combination of symptoms directly relating to an impairment of all branches of the facial nerve indicate that Bell‟s palsy has occurred. 102. The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching? a- Turns to left the side to instill the irrigating solution into the stoma b- Keeps the irrigating container less than 18 inches above the stoma c- Instills 1,200 ml of irrigating solution to stimulate bowel evacuation d- Inserts irrigating catheter deeper into stoma when cramping occurs - CORRECT ANSWER -b- Keeps the irrigating container less than 18 inches above the stoma Rationale: Keeping the irrigating container less than 18 inches above the stoma permits the solution to flow slowly with little excessive peristalsis does not cause immediate release of stool. 103. The nurse should teach the client to observe which precaution while taking dronedarone? a- Stay out of direct sunlight b- Avoid grapefruits and its juice c- Reduce the use of herbal supplements d- Minimize sodium intake. - CORRECT ANSWER -b- Avoid grapefruits and its juice Rationale: Grapefruit increase the effect of dronedarone thereby increasing the possibility of serious side effects. A does not cause a serious effect. C may potentiate lethal arrhythmias and should be avoided. D does not directly affect those taking dronedarone. 104. A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse includes the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased?