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