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Nursing Elites

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Medical Surgical HESI

1. The nurse is caring for a client with a suspected stroke. Which assessment finding is most indicative of a stroke?

Correct answer: B

Rationale: The correct answer is B: Sudden confusion and difficulty speaking. These are classic signs of a stroke, indicating a neurological deficit that requires urgent medical attention. Choices A, C, and D are less indicative of a stroke. Chest pain is more commonly associated with cardiac issues, gradual onset of weakness in the legs could be related to other conditions like peripheral neuropathy, and nausea/vomiting may suggest gastrointestinal problems rather than a stroke.

2. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement?

Correct answer: D

Rationale: Assisting the client to an upright position is the most appropriate intervention in this situation. Placing the client upright helps improve lung expansion by reducing diaphragmatic pressure, facilitating better air exchange, and increasing oxygenation. This position also aids in easing breathing efforts. Administering a sedative (Choice A) may further depress the respiratory system, worsening the breathing problem. Encouraging the client to drink water (Choice B) may not directly address the respiratory distress caused by COPD. Applying a high flow venturi mask (Choice C) may be beneficial in some cases but assisting the client to an upright position should be the priority to optimize respiratory function.

3. When performing an assessment of a child with recurrent abdominal pain (RAP), what symptom is the child most likely to experience?

Correct answer: B

Rationale: When assessing a child with recurrent abdominal pain (RAP), constipation is a common symptom. Children with RAP often experience periumbilical pain that is unrelated to eating, defecation, or exercise. While increased temperature, right quadrant pain, and exercise-associated pain can occur in various conditions, they are not typically associated with RAP in children.

4. When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that the infant should be placed in which position to sleep?

Correct answer: D

Rationale: The correct answer is D, supine. The American Academy of Pediatrics recommends placing infants on their back, or supine, to sleep as it has been shown to reduce the risk of SIDS. Choices A, B, and C are incorrect because placing infants on their right side, left side, or prone (on their stomach) respectively are not recommended sleeping positions due to the increased risk of SIDS associated with those positions.

5. The nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what?

Correct answer: C

Rationale: The correct answer is C: Cries vigorously. When the child cries vigorously, it increases the pressure in the right ventricle, allowing unoxygenated blood to enter the circulating volume, leading to cyanosis. This occurs due to the shunting of blood from the right side of the heart to the left side through the ventricular septal defect. Choices A, B, and D are incorrect because they do not directly impact the pressure in the right ventricle, which is crucial in causing cyanosis in this scenario.

Similar Questions

The nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what?
How should the nurse record the observation of a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands?
While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem?
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red, and the client reports a burning sensation. What action should the nurse take?
Parents of a 6-month-old child, who has just been diagnosed with iron deficiency anemia, ask why it was not diagnosed earlier. What would be the best response by the nurse?
Since children with attention deficit hyperactivity disorder (ADHD) take medication for long periods of time, side effects must be considered. How often should children be assessed for side effects of the drug therapy?
ATI TEAS 7 Exam Overview

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