HESI RN
HESI Maternity 55 Questions Quizlet
1. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?
- A. The thyroxine level is low because the TSH level is high.
- B. High thyroxine levels do not normally occur in breastfeeding infants.
- C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.
- D. The TSH is high because of the low production of T4 by the thyroid.
Correct answer: D
Rationale: High TSH and low T4 levels indicate that the thyroid gland is not producing enough hormones, which is a sign of congenital hypothyroidism. In this case, the high TSH is a compensatory response by the body to stimulate the thyroid to produce more T4. Choice A is incorrect because TSH does not directly affect T4 levels; rather, it is the other way around where low T4 levels lead to high TSH levels. Choice B is incorrect because high thyroxine levels are not expected in congenital hypothyroidism. Choice C is incorrect as the thyroid gland should be producing normal levels of thyroxine shortly after birth, making this explanation unlikely in the context of congenital hypothyroidism.
2. A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now taste 'bitter'. He complains that he simply has no appetite. What action should the nurse implement?
- A. Suggest the use of alternative sources of protein such as dairy products and nuts.
- B. Encourage the client to eat smaller, more frequent meals.
- C. Offer nutritional supplements between meals.
- D. Discuss the possibility of appetite stimulants with the healthcare provider.
Correct answer: A
Rationale: Offering alternative protein sources like dairy products and nuts can help maintain nutrition when the client finds certain foods unpalatable, as in this case where beef, chicken, and eggs taste 'bitter'. Encouraging smaller, more frequent meals may not address the issue of unpalatable foods. Offering nutritional supplements between meals may not specifically address the problem of protein intake. Discussing appetite stimulants should be considered after exploring less invasive options first.
3. When discussing dietary preferences with a client adhering to a vegan diet, which dietary supplement should the nurse encourage the client to include in the dietary plan?
- A. Fiber
- B. Folate
- C. Ascorbic acid
- D. Vitamin B12
Correct answer: D
Rationale: Vitamin B12 is an essential nutrient predominantly found in animal products. Individuals following a vegan diet, which excludes animal products, are at a higher risk of vitamin B12 deficiency. Encouraging the client to include a vitamin B12 supplement in their dietary plan is crucial to prevent deficiency-related health issues. Choices A, B, and C are not specific to addressing the deficiency that vegan diets may cause. Fiber, folate, and ascorbic acid are important but do not directly address the risk of vitamin B12 deficiency in vegan diets.
4. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?
- A. Monitor urinary output
- B. Auscultate bowel sounds
- C. Observe appearance of stool
- D. Record percent of diet consumed
Correct answer: A
Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.
5. A 7-year-old child is admitted to the hospital with nephrotic syndrome. The nurse notes that the child has gained 3 pounds in the past 24 hours. What should the nurse do first?
- A. Administer a diuretic as prescribed
- B. Restrict the child’s fluid intake
- C. Notify the healthcare provider
- D. Measure the child’s abdominal girth
Correct answer: C
Rationale: In a child with nephrotic syndrome experiencing sudden weight gain, the priority action for the nurse is to notify the healthcare provider. This weight gain could indicate worsening edema or fluid retention, necessitating immediate medical evaluation and intervention. The healthcare provider can conduct a comprehensive assessment, order necessary tests, and adjust the treatment plan accordingly. Administering a diuretic, restricting fluid intake, or measuring abdominal girth should not be initiated without healthcare provider consultation to ensure appropriate management of the child's condition.