NUR 131 HESI EAQ Practice Exam 3
Question With Correct Answers
Which early sign of impending hydrocephalus would the nurse monitor for in an
| | | | | | | | | | | | |
infant who has had surgery for repair of a myelomeningocele?
| | | | | | | | |
(1) Frequent crying
| |
(2) Bulging fontanels
| |
(3) Change in vital signs
| | | |
(4) Difficulty with feeding
| | |
(2) Bulging fontanels
| |
RATIONALE:
(1) after closure spinal fluid can buildup and reach the brain causing an increase
| | | | | | | | | | | | | |
in ICP and thus bulging fontanels
| | | | |
would the nurse document on the child's clinical record? Select all that apply.
| | | | | | | | | | | | |
One, some, or all responses may be correct.
| | | | | | |
(1) Intake and output
| | |
(2) Measurement of pain
| | |
(3) Tolerance of low-residue diet
| | | |
(4) Frequency of dressing changes
| | | |
(5) Presence or absence of bowel sounds
| | | | | |
(1) Intake and output
| | |
(2) Measurement of pain
| | |
(5) Presence or absence of bowel sounds
| | | | | |
RATIONALE:
(1) pain is assessed because a laparoscopic surgery involves insufflating the
| | | | | | | | | | |
,abdomen with air which will cause pain until it's reabsorbed
| | | | | | | | |
(2) checking for bowel sounds with help determine how the child is adapting to
| | | | | | | | | | | | | |
the intestinal trauma caused by the surgery
| | | | | |
Which is the most important safety measure for the nurse to institute
| | | | | | | | | | | |
immediately when a 2-year-old child has a seizure?
| | | | | | |
(1) Monitoring the child's vital signs
| | | | |
(2) Padding the side rails of the toddler's crib
| | | | | | | |
(3) Placing the child in the side-lying position
| | | | | | |
(4) Bringing suction equipment to the bedside
| | | | | |
(3) Placing the child in the side-lying position
| | | | | | |
RATIONALE:
(1) maintaining a patent airway is the priority and the side-lying position helps
| | | | | | | | | | | | |
promote that by keeping the tongue away from the back of the pharynx and
| | | | | | | | | | | | | |
allowing saliva to flow out by gravity
| | | | | |
When assessing a toddler with autism spectrum disorder (ASD), which
| | | | | | | | | |
characteristic findings or behaviors would the nurse expect? Select all that apply.
| | | | | | | | | | | |
One, some, or all responses may be correct.
| | | | | | |
(1) The desire to hug the nurse
| | | | | |
(2) Flat, blank facial expression
| | | |
(3) Laughing when pulse is taken
| | | | |
(4) Inability to maintain eye contact
| | | | |
(5) Enjoys climbing on stairs and furniture
| | | | | |
(2) Flat, blank facial expression
| | | |
(3) Laughing when pulse is taken
| | | | |
(4) Inability to maintain eye contact
| | | | |
RATIONALE:
(1) characteristics expected from a toddler with ASD would be a flat effect,
| | | | | | | | | | | | |
inappropriate laughing while measuring pulse, lack of eye contact, and
| | | | | | | | | |
,humming/grunting
(2) tend to over-respond to environmental stimuli
| | | | | |
(3) will rarely hug anyone and would not enjoy climbing on furniture
| | | | | | | | | | |
While assessing a client's hair, the nurse notices the client has head lice. The
| | | | | | | | | | | | | |
nurse teaches the client about hair hygiene and lice control. Which client
| | | | | | | | | | | |
statement indicates an understanding of the teaching? Select all that apply. One,
| | | | | | | | | | | |
some, or all responses may be correct.
| | | | | |
(1) "I will clean my comb in ammonia water."
| | | | | | | |
(2) "I should use lindane-containing shampoo."
| | | | |
(3) "I should shampoo my hair in a tub or shower."
| | | | | | | | | |
(4) "I should use a dilute vinegar solution to loosen the nits."
| | | | | | | | | | |
(5) "I should use a shampoo treatment once every 24 hours."
| | | | | | | | | |
(1) "I will clean my comb in ammonia water."
| | | | | | | |
(4) "I should use a dilute vinegar solution to loosen the nits."
| | | | | | | | | | |
(5) "I should use a shampoo treatment once every 24 hours."
| | | | | | | | | |
recommendations for lice treatment | | |
(1) lindane can be used but could have serious side effects
| | | | | | | | | |
(2) should not wash hair in tub or shower because this could cause the lice to be
| | | | | | | | | | | | | | | | |
able to migrate to other spots
| | | | |
(3) soaking combs in ammonia water can help enhance lice control
| | | | | | | | | |
(4) nits can be loosened with dilute vinegar solution
| | | | | | | |
(5) shampooing should be done at least once every 24-48 hours
| | | | | | | | | |
Which pathophysiological rationale explains why a client who is 4 days
| | | | | | | | | | |
postabdominal surgery has not passed flatus and has hypoactive bowel sounds
| | | | | | | | | | |
and why a paralytic ileus is suspected of developing?
| | | | | | | |
(1) Decreased blood supply
| | |
(2) Impaired neural functioning
| | |
(3) Perforation of the bowel wall
| | | | |
(4) Obstruction of the bowel lumen
| | | | |
, (2) Impaired neural functioning
| | |
RATIONALE:
(1) paralytic ileus occurs when neurological impulses diminish result from
| | | | | | | | | |
anesthesia, infection, or surgery | | |
necrosis results when..?
| |
there is an interference in blood supply
| | | | | |
s/s of perforation of the bowel include
| | | | | |
(1) pain
|
(2) peritonitis
|
initial s/s of bowel obstruction
| | | |
(1) increased peristalsis and bowel sounds
| | | | |
Which topical medication is typically used to treat a client with acne vulgaris?
| | | | | | | | | | | | |
Select all that apply. One, some, or all responses may be correct.
| | | | | | | | | | |
(1) Mupirocin
|
(2) Gentamicin
|
(3) Clindamycin
|
(4) Erythromycin
|
(5) Metronidazole
|
(3) Clindamycin
|
(4) Erythromycin
|
RATIONALE:
medicines for impetigo | |
(1) mupirocin
|
medicine for gram (-) organisms
| | | |
(1) gentamicin
|
Question With Correct Answers
Which early sign of impending hydrocephalus would the nurse monitor for in an
| | | | | | | | | | | | |
infant who has had surgery for repair of a myelomeningocele?
| | | | | | | | |
(1) Frequent crying
| |
(2) Bulging fontanels
| |
(3) Change in vital signs
| | | |
(4) Difficulty with feeding
| | |
(2) Bulging fontanels
| |
RATIONALE:
(1) after closure spinal fluid can buildup and reach the brain causing an increase
| | | | | | | | | | | | | |
in ICP and thus bulging fontanels
| | | | |
would the nurse document on the child's clinical record? Select all that apply.
| | | | | | | | | | | | |
One, some, or all responses may be correct.
| | | | | | |
(1) Intake and output
| | |
(2) Measurement of pain
| | |
(3) Tolerance of low-residue diet
| | | |
(4) Frequency of dressing changes
| | | |
(5) Presence or absence of bowel sounds
| | | | | |
(1) Intake and output
| | |
(2) Measurement of pain
| | |
(5) Presence or absence of bowel sounds
| | | | | |
RATIONALE:
(1) pain is assessed because a laparoscopic surgery involves insufflating the
| | | | | | | | | | |
,abdomen with air which will cause pain until it's reabsorbed
| | | | | | | | |
(2) checking for bowel sounds with help determine how the child is adapting to
| | | | | | | | | | | | | |
the intestinal trauma caused by the surgery
| | | | | |
Which is the most important safety measure for the nurse to institute
| | | | | | | | | | | |
immediately when a 2-year-old child has a seizure?
| | | | | | |
(1) Monitoring the child's vital signs
| | | | |
(2) Padding the side rails of the toddler's crib
| | | | | | | |
(3) Placing the child in the side-lying position
| | | | | | |
(4) Bringing suction equipment to the bedside
| | | | | |
(3) Placing the child in the side-lying position
| | | | | | |
RATIONALE:
(1) maintaining a patent airway is the priority and the side-lying position helps
| | | | | | | | | | | | |
promote that by keeping the tongue away from the back of the pharynx and
| | | | | | | | | | | | | |
allowing saliva to flow out by gravity
| | | | | |
When assessing a toddler with autism spectrum disorder (ASD), which
| | | | | | | | | |
characteristic findings or behaviors would the nurse expect? Select all that apply.
| | | | | | | | | | | |
One, some, or all responses may be correct.
| | | | | | |
(1) The desire to hug the nurse
| | | | | |
(2) Flat, blank facial expression
| | | |
(3) Laughing when pulse is taken
| | | | |
(4) Inability to maintain eye contact
| | | | |
(5) Enjoys climbing on stairs and furniture
| | | | | |
(2) Flat, blank facial expression
| | | |
(3) Laughing when pulse is taken
| | | | |
(4) Inability to maintain eye contact
| | | | |
RATIONALE:
(1) characteristics expected from a toddler with ASD would be a flat effect,
| | | | | | | | | | | | |
inappropriate laughing while measuring pulse, lack of eye contact, and
| | | | | | | | | |
,humming/grunting
(2) tend to over-respond to environmental stimuli
| | | | | |
(3) will rarely hug anyone and would not enjoy climbing on furniture
| | | | | | | | | | |
While assessing a client's hair, the nurse notices the client has head lice. The
| | | | | | | | | | | | | |
nurse teaches the client about hair hygiene and lice control. Which client
| | | | | | | | | | | |
statement indicates an understanding of the teaching? Select all that apply. One,
| | | | | | | | | | | |
some, or all responses may be correct.
| | | | | |
(1) "I will clean my comb in ammonia water."
| | | | | | | |
(2) "I should use lindane-containing shampoo."
| | | | |
(3) "I should shampoo my hair in a tub or shower."
| | | | | | | | | |
(4) "I should use a dilute vinegar solution to loosen the nits."
| | | | | | | | | | |
(5) "I should use a shampoo treatment once every 24 hours."
| | | | | | | | | |
(1) "I will clean my comb in ammonia water."
| | | | | | | |
(4) "I should use a dilute vinegar solution to loosen the nits."
| | | | | | | | | | |
(5) "I should use a shampoo treatment once every 24 hours."
| | | | | | | | | |
recommendations for lice treatment | | |
(1) lindane can be used but could have serious side effects
| | | | | | | | | |
(2) should not wash hair in tub or shower because this could cause the lice to be
| | | | | | | | | | | | | | | | |
able to migrate to other spots
| | | | |
(3) soaking combs in ammonia water can help enhance lice control
| | | | | | | | | |
(4) nits can be loosened with dilute vinegar solution
| | | | | | | |
(5) shampooing should be done at least once every 24-48 hours
| | | | | | | | | |
Which pathophysiological rationale explains why a client who is 4 days
| | | | | | | | | | |
postabdominal surgery has not passed flatus and has hypoactive bowel sounds
| | | | | | | | | | |
and why a paralytic ileus is suspected of developing?
| | | | | | | |
(1) Decreased blood supply
| | |
(2) Impaired neural functioning
| | |
(3) Perforation of the bowel wall
| | | | |
(4) Obstruction of the bowel lumen
| | | | |
, (2) Impaired neural functioning
| | |
RATIONALE:
(1) paralytic ileus occurs when neurological impulses diminish result from
| | | | | | | | | |
anesthesia, infection, or surgery | | |
necrosis results when..?
| |
there is an interference in blood supply
| | | | | |
s/s of perforation of the bowel include
| | | | | |
(1) pain
|
(2) peritonitis
|
initial s/s of bowel obstruction
| | | |
(1) increased peristalsis and bowel sounds
| | | | |
Which topical medication is typically used to treat a client with acne vulgaris?
| | | | | | | | | | | | |
Select all that apply. One, some, or all responses may be correct.
| | | | | | | | | | |
(1) Mupirocin
|
(2) Gentamicin
|
(3) Clindamycin
|
(4) Erythromycin
|
(5) Metronidazole
|
(3) Clindamycin
|
(4) Erythromycin
|
RATIONALE:
medicines for impetigo | |
(1) mupirocin
|
medicine for gram (-) organisms
| | | |
(1) gentamicin
|
