HESI: Medical-Surgical Assignment Exam and Rationale
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1. Which assessment is most important for the nurse to perform on a client
who is hospitalized for Guillain-Barre syndrome that is rapidly progressing?
A: Respiratory effort.
B: Unsteady gait.
C: Intensity of pain.
D: Ability to eat.
Ans: A: Respiratory Effort
Rationale (Guillain-Barre syndrome causes paralysis or weakness that typically
starts at the feet and progresses upwards. As the condition progresses, the nurse
must ensure that the client is able to breathe effectively.)
2. A male client comes into the clinic with a history of penile discharge with
painful, burning urination. Which action should the nurse implement?
A: Collect a culture of the penile discharge.
B: Palpate the inguinal lymph nodes gently.
C: Observe for scrotal swelling and redness.
D: Express the discharge to determine color
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, Ans: A: Collect a culture of the penile discharge.
Rationale (Penile discharge with painful urination is commonly associated with
gonorrhea. The nurse should collect a culture of the penile discharge to determine the
cause of these symptoms. The cause must be determined or confirmed through
culture to identify the organism and ensure effective treatment.)
3. A client with history of atrial fibrillation is admitted to the telemetry unit with
sudden onset of shortness of breath. The nurse observes a new irregular heart
rhythm and should perform which assessment at this time?
A: Check for a pulse deficit.
B: Palpate the apical impulse.
C: Inspect jugular vein pulse.
D: Examine for a carotid bruit.
Ans: A: Check for a pulse deficit.
Rationale (A client with a past history of atrial fibrillation may return to that rhythm.
Any signs of atrial fibrillation, such as sudden onset shortness of breath, requires
further investigation. The nurse should assess this client for a pulse deficit
because this condition occurs with atrial fibrillation.)
4. Which client should be further assessed for an ectopic pregnancy?
A: A 24-year-old with shoulder and lower abdominal quadrant pain.
B: A 33-year-old with intermittent lower abdominal cramping.
C: A 20-year-old with fever and right lower abdominal colic.
D: A 40-year-old with jaundice and right lower abdominal pain.
Ans: A: A 24-year-old
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, with shoulder and lower abdominal quadrant pain.
Rationale (A 24-year-old with sudden onset of lower abdominal quadrant pain
should be assessed for an ectopic pregnancy. The pain can also be referred to the
shoulder and may be associated with vaginal bleeding.)
5. Which dietary assessment finding is most important for the nurse to ad-
dress when caring for a client with diabetic nephropathy?
A: Drinks a six pack of beer every day.
B: Enjoys a hamburger once a month.
C: Eats fortified breakfast cereal daily.
D: Consumes beans and rice every day.
Ans: A: Drinks a six pack of beer every day.
(Drinking six beers every day is the dietary assessment finding most important for
the nurse to address when caring for a client with diabetic nephropathy. The usual
can of beer is 12 ounces (355 mL). Clients with diabetes are recommended to drink
no more than 12 ounces of beer per day because beer contains carbohydrates that
can create unhealthy fluctuations in blood glucose and promote poorglucose control.
Nephropathy is exacerbated by poor blood glucose control.)
6. Which assessment finding is of greatest concern to the nurse who is caring
for a client with stomatitis?
A: Cough brought on by swallowing.
B: Sore throat caused by speaking.
C: Painful and dry oral cavity.
D: Unintended weight loss.
Ans: A: Cough brought on by swallowing.
Rationale A cough brought on by swallowing is a sign of dysphagia, which is a
finding
of particular concern in a client with stomatitis. Dysphagia can cause numerous
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, problems, including airway obstruction, and should be reported to the healthcare
provider immediately.
7. The nurse is teaching a client diagnosed with peripheral arterial disease.
Which genitourinary system complication should the nurse include in the
teaching?
A: Altered sexual response.
B: Sterility.
C: Urinary incontinence.
D: Decreased pelvic muscle tone.
Ans: A: Altered sexual response.
Rationale Peripheral arterial disease (PAD) is a cardiovascular condition
characterized by narrowing of the arteries and reduced blood flow to the extremities
PAD is known to
https://www.stuvia.com/user/whimsy
Questions and Verified Answers () 100%
Guarantee Pass - UPDATED
1. Which assessment is most important for the nurse to perform on a client
who is hospitalized for Guillain-Barre syndrome that is rapidly progressing?
A: Respiratory effort.
B: Unsteady gait.
C: Intensity of pain.
D: Ability to eat.
Ans: A: Respiratory Effort
Rationale (Guillain-Barre syndrome causes paralysis or weakness that typically
starts at the feet and progresses upwards. As the condition progresses, the nurse
must ensure that the client is able to breathe effectively.)
2. A male client comes into the clinic with a history of penile discharge with
painful, burning urination. Which action should the nurse implement?
A: Collect a culture of the penile discharge.
B: Palpate the inguinal lymph nodes gently.
C: Observe for scrotal swelling and redness.
D: Express the discharge to determine color
https://www.stuvia.com/user/whimsy
, Ans: A: Collect a culture of the penile discharge.
Rationale (Penile discharge with painful urination is commonly associated with
gonorrhea. The nurse should collect a culture of the penile discharge to determine the
cause of these symptoms. The cause must be determined or confirmed through
culture to identify the organism and ensure effective treatment.)
3. A client with history of atrial fibrillation is admitted to the telemetry unit with
sudden onset of shortness of breath. The nurse observes a new irregular heart
rhythm and should perform which assessment at this time?
A: Check for a pulse deficit.
B: Palpate the apical impulse.
C: Inspect jugular vein pulse.
D: Examine for a carotid bruit.
Ans: A: Check for a pulse deficit.
Rationale (A client with a past history of atrial fibrillation may return to that rhythm.
Any signs of atrial fibrillation, such as sudden onset shortness of breath, requires
further investigation. The nurse should assess this client for a pulse deficit
because this condition occurs with atrial fibrillation.)
4. Which client should be further assessed for an ectopic pregnancy?
A: A 24-year-old with shoulder and lower abdominal quadrant pain.
B: A 33-year-old with intermittent lower abdominal cramping.
C: A 20-year-old with fever and right lower abdominal colic.
D: A 40-year-old with jaundice and right lower abdominal pain.
Ans: A: A 24-year-old
https://www.stuvia.com/user/whimsy
, with shoulder and lower abdominal quadrant pain.
Rationale (A 24-year-old with sudden onset of lower abdominal quadrant pain
should be assessed for an ectopic pregnancy. The pain can also be referred to the
shoulder and may be associated with vaginal bleeding.)
5. Which dietary assessment finding is most important for the nurse to ad-
dress when caring for a client with diabetic nephropathy?
A: Drinks a six pack of beer every day.
B: Enjoys a hamburger once a month.
C: Eats fortified breakfast cereal daily.
D: Consumes beans and rice every day.
Ans: A: Drinks a six pack of beer every day.
(Drinking six beers every day is the dietary assessment finding most important for
the nurse to address when caring for a client with diabetic nephropathy. The usual
can of beer is 12 ounces (355 mL). Clients with diabetes are recommended to drink
no more than 12 ounces of beer per day because beer contains carbohydrates that
can create unhealthy fluctuations in blood glucose and promote poorglucose control.
Nephropathy is exacerbated by poor blood glucose control.)
6. Which assessment finding is of greatest concern to the nurse who is caring
for a client with stomatitis?
A: Cough brought on by swallowing.
B: Sore throat caused by speaking.
C: Painful and dry oral cavity.
D: Unintended weight loss.
Ans: A: Cough brought on by swallowing.
Rationale A cough brought on by swallowing is a sign of dysphagia, which is a
finding
of particular concern in a client with stomatitis. Dysphagia can cause numerous
https://www.stuvia.com/user/whimsy
, problems, including airway obstruction, and should be reported to the healthcare
provider immediately.
7. The nurse is teaching a client diagnosed with peripheral arterial disease.
Which genitourinary system complication should the nurse include in the
teaching?
A: Altered sexual response.
B: Sterility.
C: Urinary incontinence.
D: Decreased pelvic muscle tone.
Ans: A: Altered sexual response.
Rationale Peripheral arterial disease (PAD) is a cardiovascular condition
characterized by narrowing of the arteries and reduced blood flow to the extremities
PAD is known to
https://www.stuvia.com/user/whimsy
