HESI Critical Care Exam 2024
Terms in this set (124)
B. A nurse with Marfan's syndrome who is
A 56-year-old female client
postmenopausal.
is receiving intracavitary
RATIONALE:
radiation via a radium
A client receiving intracavity radiation poses a radiation
implant. Which
hazard as long as the intracavity
nurse should be assigned to
radiation source is in place. A nurse's ability to care of
care for this client?
this client is not affected by Marfan's
A. The nurse who is caring
syndrome (B), which is a hereditary disorder of
for another client receiving
connective tissues, bones, muscles, ligaments
intracavitary radiation.
and skeletal structures. The goal is to limit any one staff
B. A nurse with Marfan's
member's exposure to the calculated
syndrome who is
time span based on the half-life of radium, such as the
postmenopausal.
number of minutes at the bedside per day,
C. A nurse with oncology
so (A) should not be assigned. (C) should not be
experience who may be
exposed to the radiation due to the possible
pregnant.
effect on the fetus. A radiation exposure decreases the
D. The nurse who is caring
immune response in the client who should
for another client who has
not be exposed to the potential inadvertent transmission
Clostridium difficile.
of an infectious organism (D).
,1.A client who has active Assign the client to a negative air-flow room
tuberculosis (TB) is admitted RATIONALE:
to the medical unit. What Active tuberculosis requires implementation of airborne
action is most precautions, so the client should be
important for the nurse to assigned to a negative pressure air-flow room (D).
implement? Although (A and C) should be implemented
A. Fit the client with a for clients in isolation with contact precautions, it is most
respirator mask. important that air flow from the room
B. Assign the client to a is minimized when the client has TB. (B) should be
negative air-flow room. implemented when the client leaves the
C. Don a clean gown for isolation environment.
client care.
D. Place an isolation cart in
the hallway
2.A client is receiving Administer the medication
atenolol (Tenormin) 25 mg RATIONALE:
PO after a myocardial Atenolol, a beta-blocker, blocks the beta receptors of
infarction. The nurse the sinoatrial node to reduce the heart rate,
determines the client's so the medication should be administered (C) because
apical pulse is 65 beats per the client's apical pulse is greater than 60.
minute. What action should (A, B, and D) are not indicated at this time.
the nurse
implement
next?
A. Measure the blood
pressure.
B. Reassess the apical pulse.
C. Notify the healthcare
provider.
D. Administer the
medication.
,3.The nurse is assessing a Hyperthyroidism
client and identifies a bruit Rationale:Hyperthyroidism (D) is an enlargement of the
over the thyroid. This finding thyroid gland, often referred to as a goiter, and a
is consistent bruit may be auscultated over the goiter due to an
with which interpretation? increase in glandular vascularity which
A. Hypothyroidism. increases as the thyroid gland becomes hyperactive. A
B. Thyroid cyst. bruit is not common with (A, B, and C).
C. Thyroid cancer.
D. Hyperthyroidism
A 6-year-old child is alert Rhinorrhoea or otorrhoea with Halo sign.
but quiet when brought to RATIONALE:
the emergency center with Raccoon eyes (periorbital ecchymosis) and Battle's sign
periorbital ecchymosis and (ecchymosis behind the ear over the
ecchymosis behind the mastoid process) are both signs of a basilar skull
ears. The nurse suspects fracture, so the nurse should assess for possible
potential child abuse and meningeal tears that manifest as a Halo sign with CSF
continues to assess the leakage from the ears or nose (D). (A) is
child for additional consistent with orbital fractures. (B) occurs with
manifestations of a basilar wrenching traumas of the shoulder or arm
skull fracture. What fractures. (C) occurs with blunt abdominal injuries.
assessment finding would
be consistent with a basilar
skull fracture?
A. Hematemesis and
abdominal distention.
B. Asymmetry of the face
and eye movements.
C. Rhinorrhoea or
otorrhoea with Halo sign.
D. Abnormal position and
movement of the arm.
, The nurse is assessing a Grave's disease
client who complains of RATIONALE:
weight loss, racing heart This client is exhibiting symptoms associated with
rate, and difficulty hyperthyroidism or Grave's disease (A),
sleeping. The nurse which is an autoimmune condition affecting the thyroid.
determines the client has (B, C, and D) are not associated with
moist skin with fine hair, these symptoms.
prominent eyes, lid
retraction, and a staring
expression. These findings
are consistent with which
disorder?
A. Grave's disease.
B. Multiple sclerosis.
C. Addison's disease.
D. Cushing syndrome.
The nurse is assessing an Ptosis on the left eyelid
older client and determines Rationale: Ptosis is the term to describe an eyelid droop
that the client's left upper that covers a large portion of the iris (A), which
eyelid droops, may result from oculomotor nerve or eyelid muscle
covering more of the iris disorder. (B) is characterized by rapid,
than the right eyelid. Which rhythmic movement of both eyes. (C) is a distortion of
description should the the lens of the eye, causing decreased
nurse use to visual acuity. (D) is a term used to describe a protrusion
document this finding? of the eyeballs that occurs with
A. A nystagmus on the left. hyperthyroidism.
B. Exophthalmos on the
right.
C. Ptosis on the left eyelid.
D. Astigmatism on the right.
Terms in this set (124)
B. A nurse with Marfan's syndrome who is
A 56-year-old female client
postmenopausal.
is receiving intracavitary
RATIONALE:
radiation via a radium
A client receiving intracavity radiation poses a radiation
implant. Which
hazard as long as the intracavity
nurse should be assigned to
radiation source is in place. A nurse's ability to care of
care for this client?
this client is not affected by Marfan's
A. The nurse who is caring
syndrome (B), which is a hereditary disorder of
for another client receiving
connective tissues, bones, muscles, ligaments
intracavitary radiation.
and skeletal structures. The goal is to limit any one staff
B. A nurse with Marfan's
member's exposure to the calculated
syndrome who is
time span based on the half-life of radium, such as the
postmenopausal.
number of minutes at the bedside per day,
C. A nurse with oncology
so (A) should not be assigned. (C) should not be
experience who may be
exposed to the radiation due to the possible
pregnant.
effect on the fetus. A radiation exposure decreases the
D. The nurse who is caring
immune response in the client who should
for another client who has
not be exposed to the potential inadvertent transmission
Clostridium difficile.
of an infectious organism (D).
,1.A client who has active Assign the client to a negative air-flow room
tuberculosis (TB) is admitted RATIONALE:
to the medical unit. What Active tuberculosis requires implementation of airborne
action is most precautions, so the client should be
important for the nurse to assigned to a negative pressure air-flow room (D).
implement? Although (A and C) should be implemented
A. Fit the client with a for clients in isolation with contact precautions, it is most
respirator mask. important that air flow from the room
B. Assign the client to a is minimized when the client has TB. (B) should be
negative air-flow room. implemented when the client leaves the
C. Don a clean gown for isolation environment.
client care.
D. Place an isolation cart in
the hallway
2.A client is receiving Administer the medication
atenolol (Tenormin) 25 mg RATIONALE:
PO after a myocardial Atenolol, a beta-blocker, blocks the beta receptors of
infarction. The nurse the sinoatrial node to reduce the heart rate,
determines the client's so the medication should be administered (C) because
apical pulse is 65 beats per the client's apical pulse is greater than 60.
minute. What action should (A, B, and D) are not indicated at this time.
the nurse
implement
next?
A. Measure the blood
pressure.
B. Reassess the apical pulse.
C. Notify the healthcare
provider.
D. Administer the
medication.
,3.The nurse is assessing a Hyperthyroidism
client and identifies a bruit Rationale:Hyperthyroidism (D) is an enlargement of the
over the thyroid. This finding thyroid gland, often referred to as a goiter, and a
is consistent bruit may be auscultated over the goiter due to an
with which interpretation? increase in glandular vascularity which
A. Hypothyroidism. increases as the thyroid gland becomes hyperactive. A
B. Thyroid cyst. bruit is not common with (A, B, and C).
C. Thyroid cancer.
D. Hyperthyroidism
A 6-year-old child is alert Rhinorrhoea or otorrhoea with Halo sign.
but quiet when brought to RATIONALE:
the emergency center with Raccoon eyes (periorbital ecchymosis) and Battle's sign
periorbital ecchymosis and (ecchymosis behind the ear over the
ecchymosis behind the mastoid process) are both signs of a basilar skull
ears. The nurse suspects fracture, so the nurse should assess for possible
potential child abuse and meningeal tears that manifest as a Halo sign with CSF
continues to assess the leakage from the ears or nose (D). (A) is
child for additional consistent with orbital fractures. (B) occurs with
manifestations of a basilar wrenching traumas of the shoulder or arm
skull fracture. What fractures. (C) occurs with blunt abdominal injuries.
assessment finding would
be consistent with a basilar
skull fracture?
A. Hematemesis and
abdominal distention.
B. Asymmetry of the face
and eye movements.
C. Rhinorrhoea or
otorrhoea with Halo sign.
D. Abnormal position and
movement of the arm.
, The nurse is assessing a Grave's disease
client who complains of RATIONALE:
weight loss, racing heart This client is exhibiting symptoms associated with
rate, and difficulty hyperthyroidism or Grave's disease (A),
sleeping. The nurse which is an autoimmune condition affecting the thyroid.
determines the client has (B, C, and D) are not associated with
moist skin with fine hair, these symptoms.
prominent eyes, lid
retraction, and a staring
expression. These findings
are consistent with which
disorder?
A. Grave's disease.
B. Multiple sclerosis.
C. Addison's disease.
D. Cushing syndrome.
The nurse is assessing an Ptosis on the left eyelid
older client and determines Rationale: Ptosis is the term to describe an eyelid droop
that the client's left upper that covers a large portion of the iris (A), which
eyelid droops, may result from oculomotor nerve or eyelid muscle
covering more of the iris disorder. (B) is characterized by rapid,
than the right eyelid. Which rhythmic movement of both eyes. (C) is a distortion of
description should the the lens of the eye, causing decreased
nurse use to visual acuity. (D) is a term used to describe a protrusion
document this finding? of the eyeballs that occurs with
A. A nystagmus on the left. hyperthyroidism.
B. Exophthalmos on the
right.
C. Ptosis on the left eyelid.
D. Astigmatism on the right.
