HESI/Saunders Online Review- Module 10-
Physiological Health Problems |Questions
with 100% Correct Answers
A nurse is working in the emergency department. Which of the following clients should be
assessed first? - ✔️✔️D. A client with new-onset atrial fibrillation with a rate of 118 beats/min.
Rationale: The client with new-onset atrial fibrillation is at risk for complications associated with
the tachydysrhythmia. This dysrhythmia may result in decreased cardiac output because of
ineffective atrial contractions. Thrombi form in the atria as a result of the pooling of blood. All
of the other clients will require the nurse's attention, but the client who requires immediate
attention and is the most hemodynamically unstable is the one with atrial fibrillation.
A nurse is providing discharge instructions to a client after outpatient surgery for cataract
removal. The nurse determines that the client needs additional instructions if the client
indicates that he will: - ✔️✔️D. Expect to experience pain, nausea, and vomiting after the
procedure.
Rationale: If the client experiences any pain that is unrelieved, redness around the eye, or
nausea or vomiting, the physician must be notified, because such findings could be an
indication of increased intraocular pressure. Usually the client is given a follow-up appointment
on the day after the surgery, and the physician removes the eye patch at this time. The client is
instructed to limit activity to sitting in a chair, resting, and walking to the bathroom for 24
hours. Aspirin or medications containing aspirin should not be taken by the client; rather,
acetaminophen (Tylenol) should be used to alleviate discomfort.
A client arrives in the emergency department for treatment of a surface injury sustained when
sand blew into the eye. Which action does the nurse take first? - ✔️✔️A. Assessing the client's
vision.
Rationale: When a client has sustained a surface injury of the eye as a result of the introduction
of a foreign body, the nurse must first assess visual acuity. The eye is then assessed for corneal
,abrasions; this is followed by irrigation with sterile normal saline solution to gently remove the
particles. Ice would be placed on the eye if the client had sustained an eye contusion.
A nurse attending a recertification course in basic life support (BLS) for healthcare professionals
is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the
infant's pulse? - ✔️✔️D. Antecubital fossa of the arm.
Rationale: An infant's pulse should be checked at the brachial artery. The relatively short, fat
neck of an infant makes palpation of the carotid artery (neck) difficult. Palpation of the pulse in
the radial (wrist) and popliteal (behind the knee) area would also be difficult.
An emergency department nurse is caring for a client with acute pancreatitis who will be
admitted to the hospital. Into which position that will ease the abdominal pain does the nurse
assist the client? - ✔️✔️C. With the knees drawn up to the chest.
Rationale: Helping the client assume the fetal position (legs drawn up to the chest) will ease the
abdominal pain of pancreatitis. Other helpful positions include sitting up, leaning forward, and
flexing the legs (especially the left leg). Prone, supine with the legs straight, and side-lying with
the head of the bed flat are incorrect.
A client with chronic renal failure is undergoing his first hemodialysis treatment, and the nurse
is monitoring the client for signs of disequilibrium syndrome. For which signs of this syndrome
does the nurse monitor the client? - ✔️✔️B. Headache and confusion.
Rationale: Disequilibrium syndrome most often occurs in clients who are new to hemodialysis.
It is characterized by headache, confusion, decreasing level of consciousness, nausea, vomiting,
twitching, and, in some cases, seizure activity. It results from rapid removal of solutes from the
body during hemodialysis and a higher residual concentration gradient in the brain, caused by
the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing
brain swelling and onset of symptoms. It is prevented with the use of shorter dialysis times or
dialysis at a reduced blood flow rate. Irritability and generalized weakness, fever and
tachycardia, and bradycardia and hypothermia are not associated with disequilibrium
syndrome.
,A nurse in a newborn nursery receives a telephone call from the delivery room and is told that a
newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which
item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the
newborn's bedside? - ✔️✔️B. Sterile dressing.
Rationale: The newborn with spina bifida is at risk for infection before the closure of the gibbus.
A sterile normal saline dressing is placed over the gibbus to maintain moisture of the gibbus
and its contents. This prevents tearing or breakdown of the skin at the site. A flashlight may be
needed to closely assess the status of the gibbus but is not a priority item. A cardiac monitor is
not necessary. Blood pressure is difficult to assess during the newborn period and is not the
best indicator of infection. The blood pressure cuff would not be a priority item.
A nurse is administering care to a client with angina pectoris who is attached to a cardiac
monitor. The monitor alarm sounds, and the nurse notes the rhythm shown here. How does the
nurse interpret the rhythm? - ✔️✔️D.Ventricular tachycardia.
Rationale: Ventricular tachycardia is characterized by a ventricular rate of 100 to 250
times/min. There is a wide QRS complex and an absence of P waves. The rhythm is usually fairly
regular. In atrial fibrillation, multiple rapid impulses from many foci depolarize in the atria in a
totally disorganized manner at a rate of 350 to 600 times/min. The atria quiver, which can lead
to the formation of thrombi. No definitive P wave is observed, only fibrillatory waves before
each QRS. Sinus tachycardia is characterized by a normal sinus rhythm that is rapid (faster than
normal) in rate. Sinus bradycardia is characterized by a rhythm that is slower than normal.
A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which
of the following clinical manifestations, associated with this electrolyte imbalance, does the
nurse assess the client? Select all that apply. - ✔️✔️B.Muscle weakness C. Increased urine output
Rationale: Signs of hypercalcemia include muscle weakness, diminished deep tendon reflexes or
an absence thereof, increased urine output, decreased gastrointestinal motility, and increased
heart rate and blood pressure. Hyperactive deep tendon reflexes, the presence of the Chvostek
sign, and paresthesias are signs of hypocalcemia.
, A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of
new-onset glomerulonephritis. Which of the following findings would the nurse expect to note?
- ✔️✔️A.Hypertension.
Rationale: Hypertension is a common finding in glomerulonephritis. Gross hematuria resulting
in dark-brown or smoky tea-colored urine is also a classic symptom of glomerulonephritis. The
blood urea nitrogen and creatinine levels are increased only when there is an 80% decrease in
glomerular filtration rate and renal insufficiency is severe. A high potassium level results from
inadequate glomerular filtration.
A nurse is conducting the initial assessment of a child with rheumatic fever. Which question
does the nurse ask the parents to elicit information specific to the development of the disease?
- ✔️✔️D. "Has he had a sore throat in the last few months?"
Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or
partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract.
The nurse first determines whether the child had a sore throat or an unexplained fever within
the past 2 months. Asking the parents whether the child has had any loss of appetite,
complained of backache recently, or been excessively tired or lethargic will elicit information
unrelated to rheumatic fever.
A nurse provides home care instructions to a client with Ménière disease about measures to
control and treat vertigo. The nurse should tell the client to: - ✔️✔️A. Limit sodium in the diet.
Rationale: Limiting and fluids in the diet will help reduce the amount of endolymphatic fluid,
which is excessive in Ménière disease. The client's room should be darkened to reduce the
acute symptoms of vertigo. The client should limit head movement to prevent worsening of the
symptoms of vertigo.
A nurse answers the call bell of a client who has been fitted with an internal cervical radiation
implant, and the client states that she thinks that the implant has fallen out. The nurse checks
the client and sees the implant lying in the bed. Which action should the nurse take first? -
✔️✔️D. Using long-handled forceps to place the implant in a lead container.
Physiological Health Problems |Questions
with 100% Correct Answers
A nurse is working in the emergency department. Which of the following clients should be
assessed first? - ✔️✔️D. A client with new-onset atrial fibrillation with a rate of 118 beats/min.
Rationale: The client with new-onset atrial fibrillation is at risk for complications associated with
the tachydysrhythmia. This dysrhythmia may result in decreased cardiac output because of
ineffective atrial contractions. Thrombi form in the atria as a result of the pooling of blood. All
of the other clients will require the nurse's attention, but the client who requires immediate
attention and is the most hemodynamically unstable is the one with atrial fibrillation.
A nurse is providing discharge instructions to a client after outpatient surgery for cataract
removal. The nurse determines that the client needs additional instructions if the client
indicates that he will: - ✔️✔️D. Expect to experience pain, nausea, and vomiting after the
procedure.
Rationale: If the client experiences any pain that is unrelieved, redness around the eye, or
nausea or vomiting, the physician must be notified, because such findings could be an
indication of increased intraocular pressure. Usually the client is given a follow-up appointment
on the day after the surgery, and the physician removes the eye patch at this time. The client is
instructed to limit activity to sitting in a chair, resting, and walking to the bathroom for 24
hours. Aspirin or medications containing aspirin should not be taken by the client; rather,
acetaminophen (Tylenol) should be used to alleviate discomfort.
A client arrives in the emergency department for treatment of a surface injury sustained when
sand blew into the eye. Which action does the nurse take first? - ✔️✔️A. Assessing the client's
vision.
Rationale: When a client has sustained a surface injury of the eye as a result of the introduction
of a foreign body, the nurse must first assess visual acuity. The eye is then assessed for corneal
,abrasions; this is followed by irrigation with sterile normal saline solution to gently remove the
particles. Ice would be placed on the eye if the client had sustained an eye contusion.
A nurse attending a recertification course in basic life support (BLS) for healthcare professionals
is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the
infant's pulse? - ✔️✔️D. Antecubital fossa of the arm.
Rationale: An infant's pulse should be checked at the brachial artery. The relatively short, fat
neck of an infant makes palpation of the carotid artery (neck) difficult. Palpation of the pulse in
the radial (wrist) and popliteal (behind the knee) area would also be difficult.
An emergency department nurse is caring for a client with acute pancreatitis who will be
admitted to the hospital. Into which position that will ease the abdominal pain does the nurse
assist the client? - ✔️✔️C. With the knees drawn up to the chest.
Rationale: Helping the client assume the fetal position (legs drawn up to the chest) will ease the
abdominal pain of pancreatitis. Other helpful positions include sitting up, leaning forward, and
flexing the legs (especially the left leg). Prone, supine with the legs straight, and side-lying with
the head of the bed flat are incorrect.
A client with chronic renal failure is undergoing his first hemodialysis treatment, and the nurse
is monitoring the client for signs of disequilibrium syndrome. For which signs of this syndrome
does the nurse monitor the client? - ✔️✔️B. Headache and confusion.
Rationale: Disequilibrium syndrome most often occurs in clients who are new to hemodialysis.
It is characterized by headache, confusion, decreasing level of consciousness, nausea, vomiting,
twitching, and, in some cases, seizure activity. It results from rapid removal of solutes from the
body during hemodialysis and a higher residual concentration gradient in the brain, caused by
the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing
brain swelling and onset of symptoms. It is prevented with the use of shorter dialysis times or
dialysis at a reduced blood flow rate. Irritability and generalized weakness, fever and
tachycardia, and bradycardia and hypothermia are not associated with disequilibrium
syndrome.
,A nurse in a newborn nursery receives a telephone call from the delivery room and is told that a
newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which
item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the
newborn's bedside? - ✔️✔️B. Sterile dressing.
Rationale: The newborn with spina bifida is at risk for infection before the closure of the gibbus.
A sterile normal saline dressing is placed over the gibbus to maintain moisture of the gibbus
and its contents. This prevents tearing or breakdown of the skin at the site. A flashlight may be
needed to closely assess the status of the gibbus but is not a priority item. A cardiac monitor is
not necessary. Blood pressure is difficult to assess during the newborn period and is not the
best indicator of infection. The blood pressure cuff would not be a priority item.
A nurse is administering care to a client with angina pectoris who is attached to a cardiac
monitor. The monitor alarm sounds, and the nurse notes the rhythm shown here. How does the
nurse interpret the rhythm? - ✔️✔️D.Ventricular tachycardia.
Rationale: Ventricular tachycardia is characterized by a ventricular rate of 100 to 250
times/min. There is a wide QRS complex and an absence of P waves. The rhythm is usually fairly
regular. In atrial fibrillation, multiple rapid impulses from many foci depolarize in the atria in a
totally disorganized manner at a rate of 350 to 600 times/min. The atria quiver, which can lead
to the formation of thrombi. No definitive P wave is observed, only fibrillatory waves before
each QRS. Sinus tachycardia is characterized by a normal sinus rhythm that is rapid (faster than
normal) in rate. Sinus bradycardia is characterized by a rhythm that is slower than normal.
A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which
of the following clinical manifestations, associated with this electrolyte imbalance, does the
nurse assess the client? Select all that apply. - ✔️✔️B.Muscle weakness C. Increased urine output
Rationale: Signs of hypercalcemia include muscle weakness, diminished deep tendon reflexes or
an absence thereof, increased urine output, decreased gastrointestinal motility, and increased
heart rate and blood pressure. Hyperactive deep tendon reflexes, the presence of the Chvostek
sign, and paresthesias are signs of hypocalcemia.
, A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of
new-onset glomerulonephritis. Which of the following findings would the nurse expect to note?
- ✔️✔️A.Hypertension.
Rationale: Hypertension is a common finding in glomerulonephritis. Gross hematuria resulting
in dark-brown or smoky tea-colored urine is also a classic symptom of glomerulonephritis. The
blood urea nitrogen and creatinine levels are increased only when there is an 80% decrease in
glomerular filtration rate and renal insufficiency is severe. A high potassium level results from
inadequate glomerular filtration.
A nurse is conducting the initial assessment of a child with rheumatic fever. Which question
does the nurse ask the parents to elicit information specific to the development of the disease?
- ✔️✔️D. "Has he had a sore throat in the last few months?"
Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or
partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract.
The nurse first determines whether the child had a sore throat or an unexplained fever within
the past 2 months. Asking the parents whether the child has had any loss of appetite,
complained of backache recently, or been excessively tired or lethargic will elicit information
unrelated to rheumatic fever.
A nurse provides home care instructions to a client with Ménière disease about measures to
control and treat vertigo. The nurse should tell the client to: - ✔️✔️A. Limit sodium in the diet.
Rationale: Limiting and fluids in the diet will help reduce the amount of endolymphatic fluid,
which is excessive in Ménière disease. The client's room should be darkened to reduce the
acute symptoms of vertigo. The client should limit head movement to prevent worsening of the
symptoms of vertigo.
A nurse answers the call bell of a client who has been fitted with an internal cervical radiation
implant, and the client states that she thinks that the implant has fallen out. The nurse checks
the client and sees the implant lying in the bed. Which action should the nurse take first? -
✔️✔️D. Using long-handled forceps to place the implant in a lead container.
