HESI CRITICAL CARE RN NEWEST 2024 ACTUAL
EXAM TEST BANK 200+ QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) ALREADY GRADED A+ UPDATED MAY
2024!
A client is receiving atenolol (Tenormin) 25 mg PO after a
myocardial infarction. The nurse
determines the client's apical pulse is 65 beats per minute.
What action should the nurse
implement
next?
A. Measure the blood pressure.
B. Reassess the apical pulse.
C. Notify the healthcare provider.
D. Administer the medication. - ANSWER >>>>D. Administer
the medication.
Atenolol, a beta-blocker, blocks the beta receptors of the
sinoatrial node to reduce the heart rate,
so the medication should be administered because the client's
apical pulse is greater than 60.
The nurse is assessing a client and identifies a bruit over the
thyroid. This finding is consistent
with which interpretation?
A. Hypothyroidism.
B. Thyroid cyst.
C. Thyroid cancer.
,D. Hyperthyroidism. - ANSWER >>>>D. Hyperthyroidism.
Hyperthyroidism (D) is an enlargement of the thyroid gland,
often referred to as a goiter, and a
bruit may be auscultated over the goiter due to an increase in
glandular vascularity which
increases as the thyroid gland becomes hyperactive. A bruit is
not common with (A, B, and C).
A 6-year-old child is alert but quiet when brought to the
emergency center with periorbital
ecchymosis and ecchymosis behind the ears. The nurse
suspects potential child abuse and
continues to assess the child for additional manifestations of a
basilar skull fracture. What
assessment finding would be consistent with a basilar skull
fracture?
A. Hematemesis and abdominal distention.
B. Asymmetry of the face and eye movements.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and movement of the arm. - ANSWER
>>>>C. Rhinorrhoea or otorrhoea with Halo sign.
Raccoon eyes (periorbital ecchymosis) and Battle's sign
(ecchymosis behind the ear over the
mastoid process) are both signs of a basilar skull fracture, so
the nurse should assess for possible
meningeal tears that manifest as a Halo sign with CSF
leakage from the ears or nose (C). (B) is
consistent with orbital fractures. (D) occurs with wrenching
traumas of the shoulder or arm
fractures. (A) occurs with blunt abdominal injuries.
,The nurse is assessing a client who complains of weight loss,
racing heart rate, and difficulty
sleeping. The nurse determines the client has moist skin with
fine hair, prominent eyes, lid
retraction, and a staring expression. These findings are
consistent with which disorder?
A. Grave's disease.
B. Multiple sclerosis.
C. Addison's disease.
D. Cushing syndrome. - ANSWER >>>>A. Grave's disease.
This client is exhibiting symptoms associated with
hyperthyroidism or Grave's disease (A),
which is an autoimmune condition affecting the thyroid. (B, C,
and D) are not associated with
these symptoms.
The nurse is assessing an older client and determines that the
client's left upper eyelid droops,
covering more of the iris than the right eyelid. Which
description should the nurse use to
document this finding?
A. A nystagmus on the left.
B. Exophthalmos on the right.
C. Ptosis on the left eyelid.
D. Astigmatism on the right. - ANSWER >>>>C. Ptosis on the
left eyelid.
Ptosis is the term to describe an eyelid droop that covers a
large portion of the iris (C), which
, may result from oculomotor nerve or eyelid muscle disorder.
(A) is characterized by rapid,
rhythmic movement of both eyes. (D) is a distortion of the lens
of the eye, causing decreased
visual acuity. (B) is a term used to describe a protrusion of the
eyeballs that occurs with
hyperthyroidism.
The nurse is assessing a child's weight and height during a
clinic visit prior to starting school.
The nurse plots the child's weight on the growth chart and
notes that the child's weight is in the
95th percentile for the child's height. What action should the
nurse take?
A. Question the type and quantity of foods eaten in a typical
day.
B. Encourage giving two additional snacks each day to the
child.
C. Recommend a daily intake of at least four glasses of whole
milk.
D. Assess for signs of poor nutrition, such as a pale
appearance. - ANSWER >>>>A. Question the type and
quantity of foods eaten in a typical day.
The child is overweight for height, so assessment of the
child's daily diet (A) should be
determined. The child does not need (C or B), both of which
will increase the child's weight.
Poor nutrition (D) is commonly seen in underweight children,
not overweight.
EXAM TEST BANK 200+ QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) ALREADY GRADED A+ UPDATED MAY
2024!
A client is receiving atenolol (Tenormin) 25 mg PO after a
myocardial infarction. The nurse
determines the client's apical pulse is 65 beats per minute.
What action should the nurse
implement
next?
A. Measure the blood pressure.
B. Reassess the apical pulse.
C. Notify the healthcare provider.
D. Administer the medication. - ANSWER >>>>D. Administer
the medication.
Atenolol, a beta-blocker, blocks the beta receptors of the
sinoatrial node to reduce the heart rate,
so the medication should be administered because the client's
apical pulse is greater than 60.
The nurse is assessing a client and identifies a bruit over the
thyroid. This finding is consistent
with which interpretation?
A. Hypothyroidism.
B. Thyroid cyst.
C. Thyroid cancer.
,D. Hyperthyroidism. - ANSWER >>>>D. Hyperthyroidism.
Hyperthyroidism (D) is an enlargement of the thyroid gland,
often referred to as a goiter, and a
bruit may be auscultated over the goiter due to an increase in
glandular vascularity which
increases as the thyroid gland becomes hyperactive. A bruit is
not common with (A, B, and C).
A 6-year-old child is alert but quiet when brought to the
emergency center with periorbital
ecchymosis and ecchymosis behind the ears. The nurse
suspects potential child abuse and
continues to assess the child for additional manifestations of a
basilar skull fracture. What
assessment finding would be consistent with a basilar skull
fracture?
A. Hematemesis and abdominal distention.
B. Asymmetry of the face and eye movements.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and movement of the arm. - ANSWER
>>>>C. Rhinorrhoea or otorrhoea with Halo sign.
Raccoon eyes (periorbital ecchymosis) and Battle's sign
(ecchymosis behind the ear over the
mastoid process) are both signs of a basilar skull fracture, so
the nurse should assess for possible
meningeal tears that manifest as a Halo sign with CSF
leakage from the ears or nose (C). (B) is
consistent with orbital fractures. (D) occurs with wrenching
traumas of the shoulder or arm
fractures. (A) occurs with blunt abdominal injuries.
,The nurse is assessing a client who complains of weight loss,
racing heart rate, and difficulty
sleeping. The nurse determines the client has moist skin with
fine hair, prominent eyes, lid
retraction, and a staring expression. These findings are
consistent with which disorder?
A. Grave's disease.
B. Multiple sclerosis.
C. Addison's disease.
D. Cushing syndrome. - ANSWER >>>>A. Grave's disease.
This client is exhibiting symptoms associated with
hyperthyroidism or Grave's disease (A),
which is an autoimmune condition affecting the thyroid. (B, C,
and D) are not associated with
these symptoms.
The nurse is assessing an older client and determines that the
client's left upper eyelid droops,
covering more of the iris than the right eyelid. Which
description should the nurse use to
document this finding?
A. A nystagmus on the left.
B. Exophthalmos on the right.
C. Ptosis on the left eyelid.
D. Astigmatism on the right. - ANSWER >>>>C. Ptosis on the
left eyelid.
Ptosis is the term to describe an eyelid droop that covers a
large portion of the iris (C), which
, may result from oculomotor nerve or eyelid muscle disorder.
(A) is characterized by rapid,
rhythmic movement of both eyes. (D) is a distortion of the lens
of the eye, causing decreased
visual acuity. (B) is a term used to describe a protrusion of the
eyeballs that occurs with
hyperthyroidism.
The nurse is assessing a child's weight and height during a
clinic visit prior to starting school.
The nurse plots the child's weight on the growth chart and
notes that the child's weight is in the
95th percentile for the child's height. What action should the
nurse take?
A. Question the type and quantity of foods eaten in a typical
day.
B. Encourage giving two additional snacks each day to the
child.
C. Recommend a daily intake of at least four glasses of whole
milk.
D. Assess for signs of poor nutrition, such as a pale
appearance. - ANSWER >>>>A. Question the type and
quantity of foods eaten in a typical day.
The child is overweight for height, so assessment of the
child's daily diet (A) should be
determined. The child does not need (C or B), both of which
will increase the child's weight.
Poor nutrition (D) is commonly seen in underweight children,
not overweight.
