HESI CAT exam Test Bank. All new for !/ HESI Computerized Adaptive Testing (CAT) Test Bank With Rationales.

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 2-month-old infant with the diagnosis of heart failure is discharged with a prescription for oral digoxin 0.05 mg every 12 hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item should the nurse teach the mother to use when administering the medication? 1 Nipple 2 Calibrated syringe 3 Plastic measuring spoon 4 Bottle containing an ounce of water - ANS 2 A calibrated syringe or dropper provides the most accurate measurement of the medication. Using a nipple or spoon is not an accurate way to measure medication. If the dose of medication is diluted and the infant does not drink the entire ounce, the resulting dose will be insufficient. A 2-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia major (Cooley anemia). The parents are told that there is no cure, but the anemia can be treated with frequent blood transfusions. The father tells the nurse he is glad that there is a treatment that "fixes" his child's problem. Before responding, the nurse should recall that blood transfusions do what? 1 Correct the anemia, but may cause other problems 2 Reverse the anemia, but also present a risk of hepatitis 3 Are a supportive treatment; fewer will be needed as the child grows older 4 Are a replacement for defective red blood cells; they are like giving insulin to a person with diabetes - ANS 1 Excess iron from hemolysis of the replaced red blood cells is deposited in the organs and body tissue, causing hemosiderosis. Chelation therapy is then required. With the practice of aseptic technique and screening of donated blood, hepatitis should not occur. Red blood cell replacement depends on the child's hematologic picture; the number of transfusions is not related to age. Although red blood cells are replaced, it is erroneous to compare this treatment with insulin therapy. A 6-year-old child with autism is nonverbal and makes limited eye contact. What should the nurse do initially to promote social interaction? 1 Encourage the child to sing songs with the nurse. 2 Engage in parallel play while sitting next to the child. 3 Provide opportunities for the child to play with other children. 4 Use therapeutic holding when the child does not respond to verbal interactions. - ANS 2 Entering the child's world in a nonthreatening way helps promote trust and eventual interaction with the nurse. Using therapeutic holding may be necessary when a child initiates self-mutilating behaviors. Singing songs with the child participating or providing opportunities for the child to play with other children is unrealistic at this time; playing with others is a long-term objective. 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. Asking what the father did as part of the abuse implies that the client does not know what she is talking about; the client needs support, whether the abuse is real or imagined.