HESI RN
HESI Medical Surgical Test Bank
1. A client with diabetes begins to cry and says, 'I just cannot stand the thought of having to give myself a shot every day.' Which of the following would be the best response by the nurse?
- A. If you do not give yourself your insulin shots, you will die.
- B. We can teach your daughter to give the shots so you will not have to do it.
- C. I can arrange to have a home care nurse give you the shots every day.
- D. What is it about giving yourself the insulin shots that bothers you?
Correct answer: D
Rationale: The correct response is option D because it is an open-ended question that allows the client to express their feelings and concerns. This approach facilitates a therapeutic communication process by encouraging the client to verbalize their thoughts, emotions, and fears related to giving themselves insulin shots. Option A is incorrect as it uses a fear-inducing statement that may not be helpful in addressing the client's emotional needs. Option B assumes involvement of a family member without exploring the client's feelings further. Option C offers a solution without addressing the client's underlying concerns and emotions, potentially overlooking essential aspects of client-centered care.
2. Which of the following is a common cause of chronic liver disease?
- A. Alcohol abuse.
- B. Hepatitis C infection.
- C. Obesity.
- D. Smoking.
Correct answer: B
Rationale: Hepatitis C infection is a common cause of chronic liver disease due to its long-term effects on the liver. Hepatitis C can lead to liver inflammation, fibrosis, cirrhosis, and even liver cancer. Alcohol abuse can also cause liver damage, but hepatitis C infection is specifically known for its chronic impact on liver health. Obesity and smoking, while detrimental to overall health, are not typically direct causes of chronic liver disease like hepatitis C infection.
3. While assessing a female client who is chronically fatigued and was recently diagnosed with adrenal insufficiency, the client tells the nurse that she is very nervous that her hospitalization will cause her to lose her job. Which intervention should the nurse implement first?
- A. Teach the client about the risk for infection.
- B. Offer support and care measures to reduce anxiety and stress.
- C. Encourage the client to rest quietly to reduce fatigue.
- D. Place a referral to social services to discuss financial options.
Correct answer: B
Rationale: In this scenario, the priority intervention for the nurse is to offer support and care measures to reduce anxiety and stress. Addressing the client's emotional distress is crucial as the stress can exacerbate adrenal insufficiency. While teaching the client about the risk for infection (Choice A) is important, addressing the immediate emotional needs takes precedence. Encouraging the client to rest quietly (Choice C) is beneficial but does not directly address the client's current distress about job loss. Referring the client to social services (Choice D) for financial options is important, but at this moment, addressing the client's anxiety is the priority to promote emotional well-being.
4. A client is to have a transsphenoidal hypophysectomy to remove a large, invasive pituitary tumor. The nurse should instruct the client that the surgery will be performed through an incision in the:
- A. Back of the mouth.
- B. Nose.
- C. Sinus channel below the right eye.
- D. Upper gingival mucosa in the space between the upper gums and lip.
Correct answer: D
Rationale: The correct answer is D: Upper gingival mucosa in the space between the upper gums and lip. A transsphenoidal hypophysectomy involves accessing the pituitary gland through an incision in the upper gingival mucosa, providing direct access to the pituitary gland without external scars. Choices A, B, and C are incorrect because the surgery is not performed through the back of the mouth, the nose, or the sinus channel below the right eye. It is crucial for the client to understand the specific location of the incision to ensure accurate preoperative education and expectations.
5. Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?
- A. Elevate extremities on pillows
- B. Evaluate edema for pitting
- C. Assess pulses with a vascular Doppler
- D. Wrap the feet with warmed blankets
Correct answer: C
Rationale: In this scenario, the priority action for the nurse is to assess pulses with a vascular Doppler. The absence of palpable pedal pulses following an abdominal aortic aneurysm repair raises concerns about compromised blood flow, which could lead to serious complications like ischemia or thrombosis. Evaluating and confirming the presence or absence of pulses is crucial to guide further interventions. Elevating extremities on pillows (Choice A) may be beneficial for managing edema, but it is not the immediate priority when pulses are not palpable. Evaluating edema for pitting (Choice B) can provide additional information about fluid status but does not address the primary concern of absent pulses. Wrapping the feet with warmed blankets (Choice D) is not appropriate in this situation and may not address the underlying vascular issue.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99