HESI CAT
A 1-month-old infant with a ventricular septal defect (VSD) is examined in the cardiology
clinic. What sign related to this disorder does the nurse expect to find when assessing this
infant?
1
Bradycardia at rest
2
Activity-related cyanosis
3
Bounding peripheral pulses
4
Murmur at the left sternal border - ANS-4
A murmur at the left sternal border is the most characteristic finding in infants and children
with a VSD. A left-to-right shunt is caused by the flow of blood from the higher pressure left
ventricle to the lower pressure right ventricle. Children with VSDs generally have
tachycardia and are often acyanotic. A bounding peripheral pulse is not a common finding in
children with a VSD.
A 15-year-old client tearfully states that her father has been sexually abusing her for the
past 8 years. What statement should the nurse initially respond with?
1
"Which type of incidents preceded the abuse?"
2
"Sharing this information is a positive step in getting help."
3
"I have to report this to child protective services right now."
4
"What kinds of things does he do to you when he abuses you?" - ANS-2
"Sharing this information is a positive step in getting help" is an emotionally supportive
response; it demonstrates that sharing this information is acceptable and provides hope that
the client will get help. The client needs support, and asking what incidents preceded the
abuse may precipitate or increase feelings of guilt. Telling the client that the abuse must be
reported immediately to child protective services is not a priority at this time and may
interfere with future sharing; the client needs immediate emotional support. If the client asks
what the father did as part of the abuse, it suggests that she doesn't know what she's talking
about; regardless of whether the abuse is real or imagined, the client needs support. A
16-year-old boy with a diagnosis of adolescent adjustment disorder and his family are
beginning family therapy. What is the best initial nursing approach?
1
Setting long-term goals for the family
2
Letting the client express his feelings first
3
Having the parents explain their rationale for setting firm limits
A 1-month-old infant with a ventricular septal defect (VSD) is examined in the cardiology
clinic. What sign related to this disorder does the nurse expect to find when assessing this
infant?
1
Bradycardia at rest
2
Activity-related cyanosis
3
Bounding peripheral pulses
4
Murmur at the left sternal border - ANS-4
A murmur at the left sternal border is the most characteristic finding in infants and children
with a VSD. A left-to-right shunt is caused by the flow of blood from the higher pressure left
ventricle to the lower pressure right ventricle. Children with VSDs generally have
tachycardia and are often acyanotic. A bounding peripheral pulse is not a common finding in
children with a VSD.
A 15-year-old client tearfully states that her father has been sexually abusing her for the
past 8 years. What statement should the nurse initially respond with?
1
"Which type of incidents preceded the abuse?"
2
"Sharing this information is a positive step in getting help."
3
"I have to report this to child protective services right now."
4
"What kinds of things does he do to you when he abuses you?" - ANS-2
"Sharing this information is a positive step in getting help" is an emotionally supportive
response; it demonstrates that sharing this information is acceptable and provides hope that
the client will get help. The client needs support, and asking what incidents preceded the
abuse may precipitate or increase feelings of guilt. Telling the client that the abuse must be
reported immediately to child protective services is not a priority at this time and may
interfere with future sharing; the client needs immediate emotional support. If the client asks
what the father did as part of the abuse, it suggests that she doesn't know what she's talking
about; regardless of whether the abuse is real or imagined, the client needs support. A
16-year-old boy with a diagnosis of adolescent adjustment disorder and his family are
beginning family therapy. What is the best initial nursing approach?
1
Setting long-term goals for the family
2
Letting the client express his feelings first
3
Having the parents explain their rationale for setting firm limits
