HESI ADULT HEALTH 2 ACTUAL EXAM COMPLETE
QUESTIONS AND CORRECT VERIFIED
ANSWERS(DETAILED ANSWERS)|ALREADY GRADED
A+|100% GUARANTEED PASS!
A female patient's complex symptomatology over the past year has culminated
in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's
following statements demonstrates the need for further teaching about the
disease?
A. "I'll try my best to stay out of the sun this summer."
B. "I know that I probably have a high chance of getting arthritis."
C. "I'm hoping that surgery will be an option for me in the future."
D. "I understand that I'm going to be vulnerable to getting infections." -
ANSWER-c. SLE carries an increased risk of infection, sun damage, and arthritis.
Surgery is not a key treatment modality for SLE.
Midazolam (Versed) has been ordered for a patient to be administered by
injection 30 minutes prior to a colonoscopy. The nurse informs the patient that
one of the most common side effects of this medication is which effect?
A. Decreased heart rate
B. Amnesia
C. Constipation
,D. Dry mouth - ANSWER-b. Versed is known to cause amnesia and anxiolysis as
well as sedation and is therefore commonly used prior to certain procedures.
The nurse is caring for a patient admitted with a spinal cord injury following a
motor vehicle accident. The patient exhibits a complete loss of motor, sensory,
and reflex activity below the injury level. The nurse recognizes this condition as
which of the following?
A. Central cord syndrome
B. Spinal shock syndrome
C. Anterior cord syndrome
D. Brown-Séquard syndrome - ANSWER-b. About 50% of people with acute
spinal cord injury experience a temporary loss of reflexes, sensation, and motor
activity that is known as spinal shock. Central cord syndrome is manifested by
motor and sensory loss greater in the upper extremities than the lower
extremities. Anterior cord syndrome results in motor and sensory loss but not
reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor
function and contralateral loss of sensory function.
Which of the following clinical manifestations would the nurse interpret as
representing neurogenic shock in a patient with acute spinal cord injury?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses - ANSWER-a. Neurogenic shock is due to the loss of
vasomotor tone caused by injury and is characterized by hypotension and
bradycardia. Loss of sympathetic innervation causes peripheral vasodilation,
venous pooling, and a decreased cardiac output.
,The nurse is caring for a patient admitted 1 week ago with an acute spinal cord
injury. Which of the following assessment findings would alert the nurse to the
presence of autonomic dysreflexia?
A. Tachycardia
B. Hypotension
C. Hot, dry skin
D. Throbbing headache - ANSWER-d. Autonomic dysreflexia is related to reflex
stimulation of the sympathetic nervous system reflected by hypertension,
bradycardia, throbbing headache, and diaphoresis.
When planning care for a patient with a C5 spinal cord injury, which nursing
diagnosis is the highest priority?
A. Risk for impairment of tissue integrity caused by paralysis
B. Altered patterns of urinary elimination caused by quadriplegia
C. Altered family and individual coping caused by the extent of trauma
D. Ineffective airway clearance caused by high cervical spinal cord injury -
ANSWER-d. Maintaining a patent airway is the most important goal for a
patient with a high cervical fracture. Although all of these are appropriate
nursing diagnoses for a patient with a spinal cord injury, respiratory needs are
always the highest priority. Remember the ABCs.
The nurse is providing care for a patient who has been diagnosed with Guillain-
Barré syndrome. Which of the following assessments should the nurse
prioritize?
A. Pain assessment
B. Glasgow Coma Scale
C. Respiratory assessment
, D. Musculoskeletal assessment - ANSWER-c. Although all of the assessments
are necessary in the care of patients with Guillain-Barré syndrome, the acute
risk of respiratory failure necessitates vigilant monitoring of the patient's
respiratory status.
Which of the following signs and symptoms in a patient with a T4 spinal cord
injury should alert the nurse to the possibility of autonomic dysreflexia?
A. Headache and rising blood pressure
B. Irregular respirations and shortness of breath
C. Decreased level of consciousness or hallucinations
D. Abdominal distention and absence of bowel sounds - ANSWER-a. Among the
manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg
systolic) and a throbbing headache. Respiratory manifestations, decreased level
of consciousness, and gastrointestinal manifestations are not characteristic.
Which of the following interventions should the nurse perform in the acute
care of a patient with autonomic dysreflexia?
A. Urinary catheterization
B. Administration of benzodiazepines
C. Suctioning of the patient's upper airway
D. Placement of the patient in the Trendelenburg position - ANSWER-a.
Because the most common cause of autonomic dysreflexia is bladder irritation,
immediate catheterization to relieve bladder distention may be necessary. The
patient should be positioned upright. Benzodiazepines are contraindicated and
suctioning is likely unnecessary.
Which of the following characteristics of a patient's recent seizure is congruent
with a partial seizure?
QUESTIONS AND CORRECT VERIFIED
ANSWERS(DETAILED ANSWERS)|ALREADY GRADED
A+|100% GUARANTEED PASS!
A female patient's complex symptomatology over the past year has culminated
in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's
following statements demonstrates the need for further teaching about the
disease?
A. "I'll try my best to stay out of the sun this summer."
B. "I know that I probably have a high chance of getting arthritis."
C. "I'm hoping that surgery will be an option for me in the future."
D. "I understand that I'm going to be vulnerable to getting infections." -
ANSWER-c. SLE carries an increased risk of infection, sun damage, and arthritis.
Surgery is not a key treatment modality for SLE.
Midazolam (Versed) has been ordered for a patient to be administered by
injection 30 minutes prior to a colonoscopy. The nurse informs the patient that
one of the most common side effects of this medication is which effect?
A. Decreased heart rate
B. Amnesia
C. Constipation
,D. Dry mouth - ANSWER-b. Versed is known to cause amnesia and anxiolysis as
well as sedation and is therefore commonly used prior to certain procedures.
The nurse is caring for a patient admitted with a spinal cord injury following a
motor vehicle accident. The patient exhibits a complete loss of motor, sensory,
and reflex activity below the injury level. The nurse recognizes this condition as
which of the following?
A. Central cord syndrome
B. Spinal shock syndrome
C. Anterior cord syndrome
D. Brown-Séquard syndrome - ANSWER-b. About 50% of people with acute
spinal cord injury experience a temporary loss of reflexes, sensation, and motor
activity that is known as spinal shock. Central cord syndrome is manifested by
motor and sensory loss greater in the upper extremities than the lower
extremities. Anterior cord syndrome results in motor and sensory loss but not
reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor
function and contralateral loss of sensory function.
Which of the following clinical manifestations would the nurse interpret as
representing neurogenic shock in a patient with acute spinal cord injury?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses - ANSWER-a. Neurogenic shock is due to the loss of
vasomotor tone caused by injury and is characterized by hypotension and
bradycardia. Loss of sympathetic innervation causes peripheral vasodilation,
venous pooling, and a decreased cardiac output.
,The nurse is caring for a patient admitted 1 week ago with an acute spinal cord
injury. Which of the following assessment findings would alert the nurse to the
presence of autonomic dysreflexia?
A. Tachycardia
B. Hypotension
C. Hot, dry skin
D. Throbbing headache - ANSWER-d. Autonomic dysreflexia is related to reflex
stimulation of the sympathetic nervous system reflected by hypertension,
bradycardia, throbbing headache, and diaphoresis.
When planning care for a patient with a C5 spinal cord injury, which nursing
diagnosis is the highest priority?
A. Risk for impairment of tissue integrity caused by paralysis
B. Altered patterns of urinary elimination caused by quadriplegia
C. Altered family and individual coping caused by the extent of trauma
D. Ineffective airway clearance caused by high cervical spinal cord injury -
ANSWER-d. Maintaining a patent airway is the most important goal for a
patient with a high cervical fracture. Although all of these are appropriate
nursing diagnoses for a patient with a spinal cord injury, respiratory needs are
always the highest priority. Remember the ABCs.
The nurse is providing care for a patient who has been diagnosed with Guillain-
Barré syndrome. Which of the following assessments should the nurse
prioritize?
A. Pain assessment
B. Glasgow Coma Scale
C. Respiratory assessment
, D. Musculoskeletal assessment - ANSWER-c. Although all of the assessments
are necessary in the care of patients with Guillain-Barré syndrome, the acute
risk of respiratory failure necessitates vigilant monitoring of the patient's
respiratory status.
Which of the following signs and symptoms in a patient with a T4 spinal cord
injury should alert the nurse to the possibility of autonomic dysreflexia?
A. Headache and rising blood pressure
B. Irregular respirations and shortness of breath
C. Decreased level of consciousness or hallucinations
D. Abdominal distention and absence of bowel sounds - ANSWER-a. Among the
manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg
systolic) and a throbbing headache. Respiratory manifestations, decreased level
of consciousness, and gastrointestinal manifestations are not characteristic.
Which of the following interventions should the nurse perform in the acute
care of a patient with autonomic dysreflexia?
A. Urinary catheterization
B. Administration of benzodiazepines
C. Suctioning of the patient's upper airway
D. Placement of the patient in the Trendelenburg position - ANSWER-a.
Because the most common cause of autonomic dysreflexia is bladder irritation,
immediate catheterization to relieve bladder distention may be necessary. The
patient should be positioned upright. Benzodiazepines are contraindicated and
suctioning is likely unnecessary.
Which of the following characteristics of a patient's recent seizure is congruent
with a partial seizure?
