HESI RN
HESI Maternity Test Bank
1. At 35 weeks gestation, a client complains of 'pain whenever the baby moves.' The nurse notes a temperature of 101.2 F (38.4 C) with severe abdominal or uterine tenderness on palpation. What condition do these findings indicate?
- A. Round ligament strain.
- B. Chorioamnionitis.
- C. Abruptio placentae.
- D. Viral infection.
Correct answer: B
Rationale: The client's symptoms of fever and abdominal tenderness, along with the gestational age, are classic signs of chorioamnionitis, an infection of the amniotic fluid. Chorioamnionitis is a serious condition that requires prompt recognition and treatment to prevent maternal and fetal complications. Round ligament strain (Choice A) typically presents with sharp, stabbing pain on the sides of the abdomen and is not associated with fever or uterine tenderness. Abruptio placentae (Choice C) presents with sudden-onset vaginal bleeding and severe abdominal pain, often with a board-like uterus. Viral infections (Choice D) may present with a variety of symptoms, but the combination of fever, abdominal tenderness, and gestational age in this scenario points more towards chorioamnionitis.
2. A school nurse is developing a health risk screening protocol for use at an elementary school. What information is most important for the nurse to include in this protocol?
- A. annual flu vaccination status
- B. weight and height measurement
- C. total cholesterol level
- D. long bone deformity testing
Correct answer: B
Rationale: Weight and height measurements are crucial components of health screenings in children as they help assess growth patterns and identify potential health concerns such as obesity or growth disorders. Monitoring weight and height regularly can aid in early intervention and prevention of health issues. Annual flu vaccination status, total cholesterol level, and long bone deformity testing are not typically primary components of routine health screenings in elementary school children and may not directly contribute to identifying common health risks in this population.
3. What do you call a system involving other government Ministries, Non-Governmental Organizations, Politicians, Policy makers, Senior managers, the Community, Church organizations, and other concerned bodies and users of services?
- A. Community participation
- B. Peer consultation
- C. Multi-sectoral approach
- D. Appropriate technology
Correct answer: C
Rationale: A multi-sectoral approach involves collaboration among various sectors and stakeholders to address complex issues comprehensively. In this context, it ensures that different entities work together to provide inclusive and effective services. Choice A, 'Community participation,' focuses more on the involvement of the community specifically. Choice B, 'Peer consultation,' pertains to seeking advice or input from peers within the same field. Choice D, 'Appropriate technology,' refers to the use of suitable technology for a particular situation, which is not the primary focus of the described system.
4. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN?
- A. Test a stool specimen for occult blood
- B. Assist with the ambulation of a client with a chest tube
- C. Irrigate and redress a leg wound
- D. Admit a client from the emergency room
Correct answer: C
Rationale: Irrigating and redressing a leg wound is a common task within the PN's scope of practice, making this assignment appropriate. Tasks like testing stool specimens for occult blood and assisting with ambulation of a client with a chest tube may require a higher level of training and assessment, typically performed by RNs. Admitting a client from the emergency room involves a comprehensive assessment and decision-making process, which is usually within the RN's responsibility.
5. A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?
- A. Accept and document the client's wish to refrain from bathing.
- B. Offer to give the client a bed bath, avoiding the perineal area.
- C. Obtain written brochures about menstruation to give to the client.
- D. Teach the importance of personal hygiene during menstruation to the client.
Correct answer: D
Rationale: The priority for the nurse is to educate the client on the importance of personal hygiene during menstruation. Although it's crucial to respect the client's beliefs, providing education ensures the client receives accurate information to make informed decisions about her hygiene practices. By offering teaching first, the nurse can address any misconceptions or concerns the client may have while promoting optimal hygiene practices for overall well-being. Choice A should not be the first action as it does not address the client's potential misinformation about hygiene. Choice B is not ideal as it only offers a temporary solution without addressing the underlying issue. Choice C is not the priority as the immediate concern is the client's personal hygiene practices.