HESI RN
HESI 799 RN Exit Exam Capstone
1. The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention?
- A. A 17-year-old client with schizophrenia who is pacing the hallways
- B. An 18-year-old client with antisocial behavior who is being yelled at by other clients
- C. A 16-year-old client with depression who refuses to eat meals
- D. A 15-year-old client with anxiety who is quietly reading in a corner
Correct answer: B
Rationale: The client with antisocial behavior being yelled at by peers may escalate the situation, potentially leading to violence or self-harm. Addressing the situation quickly helps prevent harm and de-escalates the conflict. Choices A, C, and D do not present immediate risks that require urgent intervention compared to the potential danger of a conflict escalating to violence with the client exhibiting antisocial behavior.
2. A client in labor who received epidural anesthesia experiences a sudden drop in blood pressure. What action should the nurse take first?
- A. Administer oxygen via nasal cannula.
- B. Administer an intravenous fluid bolus.
- C. Prepare the client for an emergency cesarean section.
- D. Place the client in a lateral position.
Correct answer: D
Rationale: In a client experiencing a sudden drop in blood pressure after epidural anesthesia, the first action the nurse should take is to place the client in a lateral position. This position helps improve venous return and cardiac output by relieving aortocaval compression. Administering oxygen via nasal cannula may be necessary if the client shows signs of respiratory distress, but it is not the first priority in this situation. Administering an intravenous fluid bolus can help stabilize blood pressure, but repositioning the client takes precedence. Preparing the client for an emergency cesarean section is not indicated solely based on a sudden drop in blood pressure after epidural anesthesia; this step would be considered if other complications arise.
3. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?
- A. Flaccid paralysis
- B. Pupils fixed and dilated
- C. Diminished spinal reflexes
- D. Reduced sensory responses
Correct answer: B
Rationale: Fixed, dilated pupils are a sign of increased intracranial pressure or brain injury, indicating a potentially serious neurological condition. Flaccid paralysis, although concerning, may not always indicate immediate life-threatening issues. Diminished spinal reflexes and reduced sensory responses are important neurological assessments but are not as acutely concerning as fixed, dilated pupils in this context.
4. When assessing a recently delivered multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?
- A. The client delivered a large baby
- B. She is a gravida 6, para 5
- C. The client had a cesarean delivery
- D. The client had a prolonged labor
Correct answer: B
Rationale: A client with a higher gravida and para count is at greater risk for uterine atony, which can lead to postpartum hemorrhage. The uterus may be less effective at contracting after multiple pregnancies, causing increased vaginal bleeding. Choices A, C, and D are incorrect because delivering a large baby, having a cesarean delivery, or experiencing prolonged labor do not directly correlate with an increased risk of postpartum hemorrhage in a multigravida client as compared to the gravida and para count.
5. What pathophysiological events occur sequentially in the development of atherosclerosis?
- A. Foam cells release growth factors.
- B. Smooth muscle grows over fatty streaks creating fibrous plaques.
- C. Macrophages consume low-density lipoprotein (LDL) and create foam cells.
- D. Arterial endothelium injury causes inflammation.
Correct answer: D
Rationale: The correct sequence of pathophysiological events in the development of atherosclerosis starts with arterial endothelium injury causing inflammation. This inflammation triggers the formation of foam cells by macrophages consuming low-density lipoprotein (LDL). Subsequently, smooth muscle grows over fatty streaks, creating fibrous plaques. Therefore, option D is the correct answer. Choices A, B, and C are incorrect because they do not reflect the accurate chronological order of events in the pathogenesis of atherosclerosis.
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