Hesi Practice Exam
What should the nurse assess last when examining a 5-year-old child?
Heart.
Lungs.
Throat.
Abdomen. - ANS>Throat; most invasive
The nurse is assessing the parents of a nuclear family who are attending
a support group for parents of adolescents. According to Erikson, these
parents who are adapting to middle adulthood should exhibit which
characteristic?
Loss of independence.
Increased self-understanding.
Isolation from society.
Development of intimate relationships. - ANS>Increased self-
understanding.
Middle adulthood is characterized by self-reflection, understanding,
acceptance, and generativity or guidance of children. The other
developmental tasks are not specific to middle adulthood.
,During the well-child assessment, the parents of a 4-year-old express
concern that their child often chatters while playing alone. What
information should the nurse provide the parents?
The child is attempting to formulate a secondary language.
This is an attempt by the child to form an imaginary social base.
"Private speech" is normal at this age and serves as a problem-solving
tool.
Concern for psychological development is warranted so further testing
is required. - ANS>"Private speech" is normal at this age and serves as a
problem-solving tool.
Children chatter to themselves between the ages of 4 and 6 years, and
this "private speech" serves as a problem-solving tool for the
preschoolers as they try new tasks or work through unfamiliar
situations.
An older client with a decreased percentage of lean body mass is likely
to receive a prescription that is adjusted based on which
pharmacokinetic process?
Absorption.
Metabolism.
Elimination.
Distribution. - ANS>Distribution.
Rationale
,A decreased lean body mass in an older adult affects the distribution of
drugs which affects the pharmacokinetics of drugs. In contrast,
decreased gastric pH, delayed gastric emptying, decreased splanchnic
blood flow, decreased gastrointestinal absorption surface areas and
motility affect absorption in the older adult population. Decreased
hepatic blood flow, decreased hepatic mass, and decreased activity of
hepatic enzymes affect metabolism in older adults. Decreased renal
blood flow, decreased glomerular filtration rate, decreased tubular
secretion, and decreased number of nephrons affects elimination in an
older adult.
When assessing a client with an indwelling urinary catheter, which
observation requires the most immediate intervention by the nurse?
The drainage tubing is secured over the siderail.
The clamp on the urinary drainage bag is open.
There are no dependent loops in the drainage tubing.
The urinary drainage bag is attached to the bed frame. - ANS>The clamp
on the urinary drainage bag is open.
Maintaining a closed urinary drainage system is important to prevent
infection, so the most immediate priority is to close the clamp (B) to
reduce the risk for ascending microorganisms. If the drainage tubing is
secured over the siderail (A), urine will not be able to flow out of the
bladder, so the nurse should next reposition the tubing. (C and D)
indicate correct care of the urinary drainage system, so documentation
of an intact system is the last intervention needed.
, How should the nurse handle linens that are soiled with incontinent
feces?
Put the soiled linens in an isolation bag, then place it in the dirty linen
hamper.
Place an isolation hamper in the client's room and discard the linens in
it.
Place the soiled linens in a pillow case and deposit them in the dirty
linen hamper.
Ask the housekeeping staff to pick up the soiled linen from the dirty
utility room. - ANS>Place the soiled linens in a pillow case and deposit
them in the dirty linen hamper.
The nurse should be careful to keep the soiled linens from
contaminating the fresh linens, and should handle the soiled linens like
any other dirty linen (C). (A, B, and D) are not indicated.
Which family-centered care concept(s) should the nurse encourage
family members to use to promote child growth, development, and
independence?
Tough love.
Therapeutic care.
Enabling and empowerment.
Teaching and care provision. - ANS>Enabling and empowerment.
What should the nurse assess last when examining a 5-year-old child?
Heart.
Lungs.
Throat.
Abdomen. - ANS>Throat; most invasive
The nurse is assessing the parents of a nuclear family who are attending
a support group for parents of adolescents. According to Erikson, these
parents who are adapting to middle adulthood should exhibit which
characteristic?
Loss of independence.
Increased self-understanding.
Isolation from society.
Development of intimate relationships. - ANS>Increased self-
understanding.
Middle adulthood is characterized by self-reflection, understanding,
acceptance, and generativity or guidance of children. The other
developmental tasks are not specific to middle adulthood.
,During the well-child assessment, the parents of a 4-year-old express
concern that their child often chatters while playing alone. What
information should the nurse provide the parents?
The child is attempting to formulate a secondary language.
This is an attempt by the child to form an imaginary social base.
"Private speech" is normal at this age and serves as a problem-solving
tool.
Concern for psychological development is warranted so further testing
is required. - ANS>"Private speech" is normal at this age and serves as a
problem-solving tool.
Children chatter to themselves between the ages of 4 and 6 years, and
this "private speech" serves as a problem-solving tool for the
preschoolers as they try new tasks or work through unfamiliar
situations.
An older client with a decreased percentage of lean body mass is likely
to receive a prescription that is adjusted based on which
pharmacokinetic process?
Absorption.
Metabolism.
Elimination.
Distribution. - ANS>Distribution.
Rationale
,A decreased lean body mass in an older adult affects the distribution of
drugs which affects the pharmacokinetics of drugs. In contrast,
decreased gastric pH, delayed gastric emptying, decreased splanchnic
blood flow, decreased gastrointestinal absorption surface areas and
motility affect absorption in the older adult population. Decreased
hepatic blood flow, decreased hepatic mass, and decreased activity of
hepatic enzymes affect metabolism in older adults. Decreased renal
blood flow, decreased glomerular filtration rate, decreased tubular
secretion, and decreased number of nephrons affects elimination in an
older adult.
When assessing a client with an indwelling urinary catheter, which
observation requires the most immediate intervention by the nurse?
The drainage tubing is secured over the siderail.
The clamp on the urinary drainage bag is open.
There are no dependent loops in the drainage tubing.
The urinary drainage bag is attached to the bed frame. - ANS>The clamp
on the urinary drainage bag is open.
Maintaining a closed urinary drainage system is important to prevent
infection, so the most immediate priority is to close the clamp (B) to
reduce the risk for ascending microorganisms. If the drainage tubing is
secured over the siderail (A), urine will not be able to flow out of the
bladder, so the nurse should next reposition the tubing. (C and D)
indicate correct care of the urinary drainage system, so documentation
of an intact system is the last intervention needed.
, How should the nurse handle linens that are soiled with incontinent
feces?
Put the soiled linens in an isolation bag, then place it in the dirty linen
hamper.
Place an isolation hamper in the client's room and discard the linens in
it.
Place the soiled linens in a pillow case and deposit them in the dirty
linen hamper.
Ask the housekeeping staff to pick up the soiled linen from the dirty
utility room. - ANS>Place the soiled linens in a pillow case and deposit
them in the dirty linen hamper.
The nurse should be careful to keep the soiled linens from
contaminating the fresh linens, and should handle the soiled linens like
any other dirty linen (C). (A, B, and D) are not indicated.
Which family-centered care concept(s) should the nurse encourage
family members to use to promote child growth, development, and
independence?
Tough love.
Therapeutic care.
Enabling and empowerment.
Teaching and care provision. - ANS>Enabling and empowerment.
