PEDS HESI PRACTICE TEST QUESTIONS
AND CORRECT VERIFIED ANSWERS
TheA2nurseA2isA2assessingA2aA22-year-
old.A2WhatA2behaviorA2indicatesA2thatA2theA2child'sA2languageA2developmentA2isA2withinA2
normalA2limits?A2-A2Ans--HalfA2ofA2child'sA2speechA2isA2understandable.
Rationale:
BetweenA2approximatelyA215A2andA224A2monthsA2ofA2age,A2aA2child'sA2speechA2isA2onlyA2h
alfA2understandable.A2AA2childA2canA2beginA2countingA2andA2nameA2colorsA2usuallyA2betw
eenA23A2andA25A2yearsA2ofA2age.A2AndA2aA2childA2isA2capableA2ofA2twoA2-
A2fourA2wordA2sentencesA2betweenA218A2monthsA2toA224A2monthsA2ofA2age.
AsA2partA2ofA2theA2physicalA2assessmentA2ofA2children,A2theA2nurseA2observesA2andA2palp
atesA2theA2fontanels.A2WhichA2child'sA2fontanelA2findingA2shouldA2beA2reportedA2toA2theA2h
ealthcareA2provider?A2-A2Ans--AA26-month-
oldA2withA2failureA2toA2thriveA2thatA2hasA2aA2closedA2anteriorA2fontanel.
Rationale:
AtA2sixA2monthsA2ofA2ageA2theA2anteriorA2fontanelA2shouldA2beA2open,A2andA2itA2shouldA2n
otA2beA2closedA2untilA2approximatelyA218A2monthsA2ofA2age.A2PrematureA2closureA2ofA2the
A2fontanelsA2isA2aA2conditionA2calledA2"craniosynostosis".A2TheA2onlyA2treatmentA2forA2this
A2conditionA2isA2surgeryA2toA2reopenA2theA2fontanels,A2toA2allowA2andA2accommodateA2the
A2infant'sA2growingA2brain,A2otherwiseA2ifA2notA2surgicalA2corrected,A2theA2infantA2willA2suff
erA2severeA2neurologicalA2damage.
TheA2nurseA2mustA2preventA2aA22-year-
oldA2withA2severeA2eczemaA2onA2theA2face,A2neck,A2andA2scalpA2fromA2scratchingA2theA2af
fectedA2areas.A2WhichA2nursingA2interventionA2isA2mostA2effectiveA2inA2preventingA2further
A2excoriationA2dueA2toA2theA2pruritis?A2-A2Ans--
PlaceA2elbowA2restraintsA2onA2theA2child'sA2arms.
Rationale:
ElbowA2restraintsA2preventA2armA2flexionA2andA2theA2abilityA2toA2reachA2toA2scratchA2theA2i
nvolvedA2areas,A2butA2doA2notA2inhibitA2useA2ofA2theA2handsA2forA2playA2activities.
TheA2nurseA2observesA2aA24-year-
oldA2boyA2inA2aA2daycareA2setting.A2WhichA2behaviorA2shouldA2theA2nurseA2considerA2nor
malA2forA2thisA2child?A2-A2Ans--
DemonstratesA2aggressivenessA2byA2boastingA2whenA2tellingA2aA2story.
Rationale:
Four-year-oldA2childrenA2areA2aggressiveA2inA2theirA2behaviorA2andA2enjoyA2"taleA2telling"
,TheA2clinicA2nurseA2isA2takingA2theA2historyA2forA2aA2newA26-month-
oldA2client.A2TheA2motherA2reportsA2thatA2sheA2tookA2aA2greatA2dealA2ofA2aspirinA2whileA2pr
egnant.A2WhichA2assessmentA2shouldA2theA2nurseA2obtain?A2-A2Ans--
TypeA2ofA2reactionA2toA2loudA2noises.
Rationale:
OtotoxicityA2diminishesA2hearingA2acuityA2andA2causesA2symptomsA2ofA2tinnitusA2andA2ver
tigoA2inA2olderA2childrenA2whoA2canA2expressA2subjectiveA2symptoms,A2soA2assessingA2an
A2infant'sA2reactionA2toA2loudA2noisesA2helpsA2toA2determineA2anA2infant'sA2riskA2forA2aA2he
aringA2deficitA2relatedA2toA2aA2historyA2ofA2theA2motherA2takingA2anA2ototoxicA2drug,A2suchA
2asA2aspirin,A2whileA2pregnant.
WhenA2evaluatingA2theA2effectivenessA2ofA2interventionsA2toA2improveA2theA2nutritionalA2st
atusA2ofA2anA2infantA2withA2gastro-
esophagealA2reflux,A2whichA2interventionA2isA2mostA2importantA2forA2theA2nurseA2toA2imple
ment?A2-A2Ans--RecordA2weightA2daily.
Rationale:
TheA2mostA2definitiveA2measureA2ofA2improvedA2nutritionA2inA2anA2infantA2isA2obtainingA2th
eA2infant'sA2dailyA2weightA2atA2theA2sameA2timeA2andA2ideallyA2usingA2theA2sameA2scaleA2a
ndA2theA2infantA2fullyA2naked.
WhenA2takingA2theA2healthA2historyA2ofA2aA2child,A2theA2nurseA2knowsA2thatA2whichA2findin
gA2isA2anA2earlyA2indicationA2ofA2hypothyroidismA2inA2children?A2-A2Ans--
CessationA2ofA2growthA2inA2aA2childA2thatA2hadA2beenA2normal.
Rationale:
SinceA2theA2thyroidA2glandA2isA2responsibleA2forA2metabolism,A2cessationA2ofA2growthA2wh
ichA2wasA2previouslyA2withinA2normalA2range,A2isA2theA2mostA2commonA2signA2forA2hypoth
yroidismA2inA2children.
WhichA2measurementsA2shouldA2beA2usedA2toA2accuratelyA2calculateA2aA2pediatricA2medi
cationA2dosage?A2(SelectA2allA2thatA2apply.)A2-A2Ans--1.A2Child'sA2heightA2andA2weight.
2.A2NomogramA2determinedA2mathematicalA2constant.
Rationale:
TheA2mostA2accurateA2calculationsA2ofA2pediatricA2dosagesA2useA2theA2child'sA2heightA2an
dA2weight.A2TheA2child'sA2BSAA2isA2calculatedA2usingA2theA2squareA2rootA2ofA2weightA2inA2k
gA2timesA2heightA2inA2cmA2dividedA2byA23600A2orA2theA2squareA2rootA2ofA2weightA2inA2poun
dsA2timesA2heightA2inA2inchesA2dividedA2byA23131,A2thenA2theA2child'sA2BSAA2isA2multiplied
A2byA2theA2recommendedA2publishedA2doseA2perA2BSA.A2TheA2nomogramA2isA2usedA2toA2
plotA2theA2child'sA2heightA2andA2weight,A2andA2theA2pointA2atA2whichA2theyA2intersectA2isA2t
heA2BSAA2mathematicalA2constantA2usedA2toA2calculateA2theA2child'sA2dose.
TheA2motherA2ofA2aA2preschool-
agedA2childA2asksA2theA2nurseA2ifA2itA2isA2allA2rightA2toA2administerA2bismuthA2subsalicylate
,A2(PeptoA2Bismol,A2Bismylate)A2toA2herA2sonA2whenA2heA2"hasA2aA2tummyA2ache."A2AfterA2
remindingA2theA2motherA2toA2checkA2theA2labelA2ofA2allA2over-the-
counterA2drugsA2forA2theA2presenceA2ofA2aspirin,A2whichA2instructionA2shouldA2theA2nurseA
2includeA2whenA2replyingA2toA2thisA2mother'sA2question?A2-A2Ans--
DoA2notA2giveA2ifA2theA2childA2hasA2chickenpox,A2theA2flu,A2orA2anyA2otherA2viralA2illness.
Rationale:
PeptoA2Bismol,A2BismylateA2containsA2subsalicylateA2andA2ifA2usedA2inA2theA2presenceA2of
A2aA2viralA2illness,A2thereA2isA2theA2potentialA2ofA2developingA2Reye'sA2syndrome,A2aA2som
etimesA2fatalA2conditionA2forA2children.
AtA28A2a.m.A2theA2unlicensedA2assistiveA2personnelA2(UAP)A2informsA2theA2chargeA2nurse
A2thatA2aA2femaleA2adolescentA2clientA2withA2acuteA2glomerulonephritisA2hasA2aA2bloodA2pr
essureA2ofA2210/110.A2TheA24A2a.m.A2bloodA2pressureA2readingA2wasA2170/88.A2TheA2clie
ntA2reportsA2toA2theA2UAPA2thatA2sheA2isA2upsetA2becauseA2herA2boyfriendA2didA2notA2visitA
2lastA2night.A2WhatA2actionA2shouldA2theA2nurseA2takeA2first?A2-A2Ans--
AdministerA2PRNA2prescriptionA2ofA2nifedipineA2(Procardia)A2sublingually.
Rationale:
AfterA2theA2nurseA2hasA2verifiedA2theA2client'sA2elevatedA2bloodA2pressure,A2theA2sublingu
alA2ProcardiaA2shouldA2beA2administeredA2firstA2becauseA2itA2lowersA2theA2bloodA2pressur
eA2veryA2quickly,A2beforeA2implementingA2anyA2ofA2theA2otherA2interventions.
WhatA2preoperativeA2nursingA2interventionA2shouldA2beA2includedA2inA2theA2planA2ofA2care
A2forA2anA2infantA2withA2pyloricA2stenosis?A2-A2Ans--ObserveA2forA2projectileA2vomiting.
Rationale:
InA2pyloricA2stenosis,A2theA2valveA2betweenA2stomachA2andA2smallA2intestineA2enlargesA2b
lockingA2theA2passageA2ofA2food.A2TheA2nurseA2needsA2toA2ensureA2suctioningA2equipmen
tA2isA2closedA2byA2toA2helpA2preventA2aspirationA2fromA2theA2projectileA2vomitingA2episode
sA2andA2monitorA2forA2theA2stateA2ofA2metabolicA2alkalosis,A2whichA2isA2aA2classicA2signA2of
A2pyloricA2stenosis.
TheA2nurseA2isA2teachingA2aA212-year-
oldA2maleA2adolescentA2andA2hisA2familyA2aboutA2takingA2injectionsA2ofA2growthA2hormone
A2forA2idiopathicA2hypopituitarism.A2WhichA2adverseA2symptoms,A2commonlyA2associatedA
2withA2growthA2hormoneA2therapy,A2shouldA2theA2nurseA2planA2toA2describeA2toA2theA2child
A2andA2hisA2family?A2-A2Ans--PolyuriaA2andA2polydipsia.
Rationale:
SignsA2andA2symptomsA2ofA2diabetesA2orA2hyperglycemiaA2needA2toA2beA2reported.A2Clien
tsA2whoA2areA2receivingA2growthA2hormonesA2shouldA2beA2monitoredA2toA2detectA2elevate
dA2bloodA2sugarsA2andA2glucoseA2intolerance.
, WhichA2findingA2inA2aA219-year-
oldA2femaleA2clientA2shouldA2triggerA2furtherA2assessmentA2byA2theA2nurse?A2-A2Ans--
MenstruationA2hasA2notA2occurred.
Rationale:
MenstruationA2isA2anA2expectedA2secondaryA2sexA2characteristicA2thatA2occursA2withA2pub
escenceA2andA2typicallyA2occursA2betweenA2theA2agesA2ofA210A2toA217,A2soA2theA2factA2the
A2clientA2isA218A2yearsA2oldA2andA2hasA2notA2experienceA2menarche,A2shouldA2promptA2fur
therA2investigationA2toA2determineA2theA2causeA2ofA2thisA2primaryA2amenorrhea.
DuringA2administrationA2ofA2aA2bloodA2transfusion,A2aA2childA2complainsA2ofA2chills,A2head
ache,A2andA2nausea.A2WhichA2actionA2shouldA2theA2nurseA2implement?A2-A2Ans--
StopA2theA2infusionA2immediatelyA2andA2notifyA2theA2healthcareA2provider.
Rationale:
TheA2childA2isA2exhibitingA2signsA2ofA2aA2reactionA2toA2theA2bloodA2transfusion.A2TheA2bloo
dA2transfusionA2shouldA2beA2stoppedA2immediatelyA2andA2theA2healthcareA2providerA2notifi
ed.
TheA2nurseA2isA2assessingA2aA213-year-
oldA2girlA2withA2suspectedA2hyperthyroidism.A2WhichA2questionA2isA2mostA2importantA2forA2
theA2nurseA2toA2askA2herA2duringA2theA2admissionA2interview?A2-
A2Ans--"AreA2youA2experiencingA2anyA2typeA2ofA2nervousness?"
Rationale:
AssessingA2theA2client'sA2psychophysiologicA2stateA2uponA2admissionA2isA2aA2priority,A2an
dA2nervousness,A2apprehension,A2hyperexcitability,A2andA2palpitationsA2areA2signsA2ofA2h
yperthyroidism.A2WeightA2lossA2(evenA2withA2aA2heartyA2appetite)A2occursA2inA2thoseA2with
A2hyperthyroidism,A2butA2assessingA2theA2client'sA2neurologicalA2stateA2hasA2aA2higherA2pr
iority.
AA2childA2isA2rescuedA2fromA2aA2burningA2houseA2andA2broughtA2toA2theA2emergencyA2roo
mA2withA2partial-
thicknessA2burnsA2onA2theA2faceA2andA2chest.A2WhichA2actionA2shouldA2theA2nurseA2imple
mentedA2first?A2-A2Ans--AssessA2theA2child'sA2respiratoryA2status.
Rationale:
AssessingA2theA2airwayA2andA2theA2respiratoryA2statusA2isA2theA2highestA2priorityA2sinceA2
burnsA2toA2theA2faceA2andA2chestA2placeA2theA2childA2atA2riskA2forA2smokeA2inhalationA2inju
ryA2andA2compromisedA2airway.
TheA2motherA2ofA2aA24-year-
oldA2childA2asksA2theA2nurseA2whatA2sheA2canA2doA2toA2helpA2herA2otherA2childrenA2copeA2
withA2theirA2sibling'sA2repeatedA2hospitalizations.A2WhichA2isA2theA2bestA2responseA2thatA2t
heA2nurseA2shouldA2offer?A2-A2Ans--
EncourageA2theA2motherA2toA2haveA2theA2childrenA2visitA2theA2hospitalizedA2sibling.
AND CORRECT VERIFIED ANSWERS
TheA2nurseA2isA2assessingA2aA22-year-
old.A2WhatA2behaviorA2indicatesA2thatA2theA2child'sA2languageA2developmentA2isA2withinA2
normalA2limits?A2-A2Ans--HalfA2ofA2child'sA2speechA2isA2understandable.
Rationale:
BetweenA2approximatelyA215A2andA224A2monthsA2ofA2age,A2aA2child'sA2speechA2isA2onlyA2h
alfA2understandable.A2AA2childA2canA2beginA2countingA2andA2nameA2colorsA2usuallyA2betw
eenA23A2andA25A2yearsA2ofA2age.A2AndA2aA2childA2isA2capableA2ofA2twoA2-
A2fourA2wordA2sentencesA2betweenA218A2monthsA2toA224A2monthsA2ofA2age.
AsA2partA2ofA2theA2physicalA2assessmentA2ofA2children,A2theA2nurseA2observesA2andA2palp
atesA2theA2fontanels.A2WhichA2child'sA2fontanelA2findingA2shouldA2beA2reportedA2toA2theA2h
ealthcareA2provider?A2-A2Ans--AA26-month-
oldA2withA2failureA2toA2thriveA2thatA2hasA2aA2closedA2anteriorA2fontanel.
Rationale:
AtA2sixA2monthsA2ofA2ageA2theA2anteriorA2fontanelA2shouldA2beA2open,A2andA2itA2shouldA2n
otA2beA2closedA2untilA2approximatelyA218A2monthsA2ofA2age.A2PrematureA2closureA2ofA2the
A2fontanelsA2isA2aA2conditionA2calledA2"craniosynostosis".A2TheA2onlyA2treatmentA2forA2this
A2conditionA2isA2surgeryA2toA2reopenA2theA2fontanels,A2toA2allowA2andA2accommodateA2the
A2infant'sA2growingA2brain,A2otherwiseA2ifA2notA2surgicalA2corrected,A2theA2infantA2willA2suff
erA2severeA2neurologicalA2damage.
TheA2nurseA2mustA2preventA2aA22-year-
oldA2withA2severeA2eczemaA2onA2theA2face,A2neck,A2andA2scalpA2fromA2scratchingA2theA2af
fectedA2areas.A2WhichA2nursingA2interventionA2isA2mostA2effectiveA2inA2preventingA2further
A2excoriationA2dueA2toA2theA2pruritis?A2-A2Ans--
PlaceA2elbowA2restraintsA2onA2theA2child'sA2arms.
Rationale:
ElbowA2restraintsA2preventA2armA2flexionA2andA2theA2abilityA2toA2reachA2toA2scratchA2theA2i
nvolvedA2areas,A2butA2doA2notA2inhibitA2useA2ofA2theA2handsA2forA2playA2activities.
TheA2nurseA2observesA2aA24-year-
oldA2boyA2inA2aA2daycareA2setting.A2WhichA2behaviorA2shouldA2theA2nurseA2considerA2nor
malA2forA2thisA2child?A2-A2Ans--
DemonstratesA2aggressivenessA2byA2boastingA2whenA2tellingA2aA2story.
Rationale:
Four-year-oldA2childrenA2areA2aggressiveA2inA2theirA2behaviorA2andA2enjoyA2"taleA2telling"
,TheA2clinicA2nurseA2isA2takingA2theA2historyA2forA2aA2newA26-month-
oldA2client.A2TheA2motherA2reportsA2thatA2sheA2tookA2aA2greatA2dealA2ofA2aspirinA2whileA2pr
egnant.A2WhichA2assessmentA2shouldA2theA2nurseA2obtain?A2-A2Ans--
TypeA2ofA2reactionA2toA2loudA2noises.
Rationale:
OtotoxicityA2diminishesA2hearingA2acuityA2andA2causesA2symptomsA2ofA2tinnitusA2andA2ver
tigoA2inA2olderA2childrenA2whoA2canA2expressA2subjectiveA2symptoms,A2soA2assessingA2an
A2infant'sA2reactionA2toA2loudA2noisesA2helpsA2toA2determineA2anA2infant'sA2riskA2forA2aA2he
aringA2deficitA2relatedA2toA2aA2historyA2ofA2theA2motherA2takingA2anA2ototoxicA2drug,A2suchA
2asA2aspirin,A2whileA2pregnant.
WhenA2evaluatingA2theA2effectivenessA2ofA2interventionsA2toA2improveA2theA2nutritionalA2st
atusA2ofA2anA2infantA2withA2gastro-
esophagealA2reflux,A2whichA2interventionA2isA2mostA2importantA2forA2theA2nurseA2toA2imple
ment?A2-A2Ans--RecordA2weightA2daily.
Rationale:
TheA2mostA2definitiveA2measureA2ofA2improvedA2nutritionA2inA2anA2infantA2isA2obtainingA2th
eA2infant'sA2dailyA2weightA2atA2theA2sameA2timeA2andA2ideallyA2usingA2theA2sameA2scaleA2a
ndA2theA2infantA2fullyA2naked.
WhenA2takingA2theA2healthA2historyA2ofA2aA2child,A2theA2nurseA2knowsA2thatA2whichA2findin
gA2isA2anA2earlyA2indicationA2ofA2hypothyroidismA2inA2children?A2-A2Ans--
CessationA2ofA2growthA2inA2aA2childA2thatA2hadA2beenA2normal.
Rationale:
SinceA2theA2thyroidA2glandA2isA2responsibleA2forA2metabolism,A2cessationA2ofA2growthA2wh
ichA2wasA2previouslyA2withinA2normalA2range,A2isA2theA2mostA2commonA2signA2forA2hypoth
yroidismA2inA2children.
WhichA2measurementsA2shouldA2beA2usedA2toA2accuratelyA2calculateA2aA2pediatricA2medi
cationA2dosage?A2(SelectA2allA2thatA2apply.)A2-A2Ans--1.A2Child'sA2heightA2andA2weight.
2.A2NomogramA2determinedA2mathematicalA2constant.
Rationale:
TheA2mostA2accurateA2calculationsA2ofA2pediatricA2dosagesA2useA2theA2child'sA2heightA2an
dA2weight.A2TheA2child'sA2BSAA2isA2calculatedA2usingA2theA2squareA2rootA2ofA2weightA2inA2k
gA2timesA2heightA2inA2cmA2dividedA2byA23600A2orA2theA2squareA2rootA2ofA2weightA2inA2poun
dsA2timesA2heightA2inA2inchesA2dividedA2byA23131,A2thenA2theA2child'sA2BSAA2isA2multiplied
A2byA2theA2recommendedA2publishedA2doseA2perA2BSA.A2TheA2nomogramA2isA2usedA2toA2
plotA2theA2child'sA2heightA2andA2weight,A2andA2theA2pointA2atA2whichA2theyA2intersectA2isA2t
heA2BSAA2mathematicalA2constantA2usedA2toA2calculateA2theA2child'sA2dose.
TheA2motherA2ofA2aA2preschool-
agedA2childA2asksA2theA2nurseA2ifA2itA2isA2allA2rightA2toA2administerA2bismuthA2subsalicylate
,A2(PeptoA2Bismol,A2Bismylate)A2toA2herA2sonA2whenA2heA2"hasA2aA2tummyA2ache."A2AfterA2
remindingA2theA2motherA2toA2checkA2theA2labelA2ofA2allA2over-the-
counterA2drugsA2forA2theA2presenceA2ofA2aspirin,A2whichA2instructionA2shouldA2theA2nurseA
2includeA2whenA2replyingA2toA2thisA2mother'sA2question?A2-A2Ans--
DoA2notA2giveA2ifA2theA2childA2hasA2chickenpox,A2theA2flu,A2orA2anyA2otherA2viralA2illness.
Rationale:
PeptoA2Bismol,A2BismylateA2containsA2subsalicylateA2andA2ifA2usedA2inA2theA2presenceA2of
A2aA2viralA2illness,A2thereA2isA2theA2potentialA2ofA2developingA2Reye'sA2syndrome,A2aA2som
etimesA2fatalA2conditionA2forA2children.
AtA28A2a.m.A2theA2unlicensedA2assistiveA2personnelA2(UAP)A2informsA2theA2chargeA2nurse
A2thatA2aA2femaleA2adolescentA2clientA2withA2acuteA2glomerulonephritisA2hasA2aA2bloodA2pr
essureA2ofA2210/110.A2TheA24A2a.m.A2bloodA2pressureA2readingA2wasA2170/88.A2TheA2clie
ntA2reportsA2toA2theA2UAPA2thatA2sheA2isA2upsetA2becauseA2herA2boyfriendA2didA2notA2visitA
2lastA2night.A2WhatA2actionA2shouldA2theA2nurseA2takeA2first?A2-A2Ans--
AdministerA2PRNA2prescriptionA2ofA2nifedipineA2(Procardia)A2sublingually.
Rationale:
AfterA2theA2nurseA2hasA2verifiedA2theA2client'sA2elevatedA2bloodA2pressure,A2theA2sublingu
alA2ProcardiaA2shouldA2beA2administeredA2firstA2becauseA2itA2lowersA2theA2bloodA2pressur
eA2veryA2quickly,A2beforeA2implementingA2anyA2ofA2theA2otherA2interventions.
WhatA2preoperativeA2nursingA2interventionA2shouldA2beA2includedA2inA2theA2planA2ofA2care
A2forA2anA2infantA2withA2pyloricA2stenosis?A2-A2Ans--ObserveA2forA2projectileA2vomiting.
Rationale:
InA2pyloricA2stenosis,A2theA2valveA2betweenA2stomachA2andA2smallA2intestineA2enlargesA2b
lockingA2theA2passageA2ofA2food.A2TheA2nurseA2needsA2toA2ensureA2suctioningA2equipmen
tA2isA2closedA2byA2toA2helpA2preventA2aspirationA2fromA2theA2projectileA2vomitingA2episode
sA2andA2monitorA2forA2theA2stateA2ofA2metabolicA2alkalosis,A2whichA2isA2aA2classicA2signA2of
A2pyloricA2stenosis.
TheA2nurseA2isA2teachingA2aA212-year-
oldA2maleA2adolescentA2andA2hisA2familyA2aboutA2takingA2injectionsA2ofA2growthA2hormone
A2forA2idiopathicA2hypopituitarism.A2WhichA2adverseA2symptoms,A2commonlyA2associatedA
2withA2growthA2hormoneA2therapy,A2shouldA2theA2nurseA2planA2toA2describeA2toA2theA2child
A2andA2hisA2family?A2-A2Ans--PolyuriaA2andA2polydipsia.
Rationale:
SignsA2andA2symptomsA2ofA2diabetesA2orA2hyperglycemiaA2needA2toA2beA2reported.A2Clien
tsA2whoA2areA2receivingA2growthA2hormonesA2shouldA2beA2monitoredA2toA2detectA2elevate
dA2bloodA2sugarsA2andA2glucoseA2intolerance.
, WhichA2findingA2inA2aA219-year-
oldA2femaleA2clientA2shouldA2triggerA2furtherA2assessmentA2byA2theA2nurse?A2-A2Ans--
MenstruationA2hasA2notA2occurred.
Rationale:
MenstruationA2isA2anA2expectedA2secondaryA2sexA2characteristicA2thatA2occursA2withA2pub
escenceA2andA2typicallyA2occursA2betweenA2theA2agesA2ofA210A2toA217,A2soA2theA2factA2the
A2clientA2isA218A2yearsA2oldA2andA2hasA2notA2experienceA2menarche,A2shouldA2promptA2fur
therA2investigationA2toA2determineA2theA2causeA2ofA2thisA2primaryA2amenorrhea.
DuringA2administrationA2ofA2aA2bloodA2transfusion,A2aA2childA2complainsA2ofA2chills,A2head
ache,A2andA2nausea.A2WhichA2actionA2shouldA2theA2nurseA2implement?A2-A2Ans--
StopA2theA2infusionA2immediatelyA2andA2notifyA2theA2healthcareA2provider.
Rationale:
TheA2childA2isA2exhibitingA2signsA2ofA2aA2reactionA2toA2theA2bloodA2transfusion.A2TheA2bloo
dA2transfusionA2shouldA2beA2stoppedA2immediatelyA2andA2theA2healthcareA2providerA2notifi
ed.
TheA2nurseA2isA2assessingA2aA213-year-
oldA2girlA2withA2suspectedA2hyperthyroidism.A2WhichA2questionA2isA2mostA2importantA2forA2
theA2nurseA2toA2askA2herA2duringA2theA2admissionA2interview?A2-
A2Ans--"AreA2youA2experiencingA2anyA2typeA2ofA2nervousness?"
Rationale:
AssessingA2theA2client'sA2psychophysiologicA2stateA2uponA2admissionA2isA2aA2priority,A2an
dA2nervousness,A2apprehension,A2hyperexcitability,A2andA2palpitationsA2areA2signsA2ofA2h
yperthyroidism.A2WeightA2lossA2(evenA2withA2aA2heartyA2appetite)A2occursA2inA2thoseA2with
A2hyperthyroidism,A2butA2assessingA2theA2client'sA2neurologicalA2stateA2hasA2aA2higherA2pr
iority.
AA2childA2isA2rescuedA2fromA2aA2burningA2houseA2andA2broughtA2toA2theA2emergencyA2roo
mA2withA2partial-
thicknessA2burnsA2onA2theA2faceA2andA2chest.A2WhichA2actionA2shouldA2theA2nurseA2imple
mentedA2first?A2-A2Ans--AssessA2theA2child'sA2respiratoryA2status.
Rationale:
AssessingA2theA2airwayA2andA2theA2respiratoryA2statusA2isA2theA2highestA2priorityA2sinceA2
burnsA2toA2theA2faceA2andA2chestA2placeA2theA2childA2atA2riskA2forA2smokeA2inhalationA2inju
ryA2andA2compromisedA2airway.
TheA2motherA2ofA2aA24-year-
oldA2childA2asksA2theA2nurseA2whatA2sheA2canA2doA2toA2helpA2herA2otherA2childrenA2copeA2
withA2theirA2sibling'sA2repeatedA2hospitalizations.A2WhichA2isA2theA2bestA2responseA2thatA2t
heA2nurseA2shouldA2offer?A2-A2Ans--
EncourageA2theA2motherA2toA2haveA2theA2childrenA2visitA2theA2hospitalizedA2sibling.
