HESI RN
HESI Medical Surgical Exam
1. A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?
- A. Complaints of chest pain and shortness of breath
- B. Hypotension and venous pooling in the extremities
- C. Profuse diaphoresis and severe, pounding headache
- D. Pain and burning sensation upon urination and hematuria
Correct answer: C
Rationale: Autonomic dysreflexia is a life-threatening condition commonly seen in clients with spinal cord injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure due to a noxious stimulus below the level of injury, often a distended bladder. The exaggerated sympathetic response leads to vasoconstriction, resulting in symptoms such as profuse diaphoresis (sweating) and a severe, pounding headache. These symptoms are the body's attempt to lower blood pressure. Complaints of chest pain and shortness of breath (Choice A) are not typical findings in autonomic dysreflexia. Hypotension and venous pooling (Choice B) are opposite manifestations of autonomic dysreflexia, which is characterized by hypertension. Pain and burning sensation upon urination and hematuria (Choice D) are indicative of a urinary tract infection and not specific to autonomic dysreflexia.
2. What is the most common cause of coronary artery disease?
- A. Atherosclerosis.
- B. Hyperlipidemia.
- C. Diabetes.
- D. Smoking.
Correct answer: A
Rationale: The correct answer is Atherosclerosis. It is the primary cause of coronary artery disease, as it involves the buildup of plaque in the arteries, restricting blood flow to the heart. Hyperlipidemia (choice B) contributes to atherosclerosis by increasing cholesterol levels in the blood but is not the direct cause of coronary artery disease. Diabetes (choice C) can accelerate atherosclerosis due to high blood sugar levels, but it is not the most common cause. Smoking (choice D) is a significant risk factor for developing coronary artery disease but is not the primary cause.
3. When preparing a client who has had a total laryngectomy for discharge, what instruction is most important for the nurse to include in the discharge teaching?
- A. Recommend that the client carry suction equipment at all times.
- B. Instruct the client to have writing materials with them at all times.
- C. Tell the client to carry a medic alert card stating that they are a total neck breather.
- D. Tell the client not to travel alone.
Correct answer: C
Rationale: The most crucial instruction for a client who has had a total laryngectomy is to carry a medic alert card stating that they are a total neck breather. This is important because if they experience a cardiac arrest, mouth-to-neck breathing may be required. Choice A about carrying suction equipment is not the most critical as the client may not always need it. Choice B is not as essential as having a medic alert card. Choice D is not directly related to the client's safety due to their laryngectomy.
4. A client scheduled for the surgical creation of an ileal conduit expresses anxiety and asks about having a drainage tube. How should the nurse respond?
- A. I will ask the provider to prescribe you an antianxiety medication.
- B. Would you like to discuss the procedure with your doctor once more?
- C. I think it would be nice to not have to worry about finding a bathroom.
- D. Would you like to speak with someone who has an ileal conduit?
Correct answer: D
Rationale: The most appropriate response for the nurse is to offer the client the opportunity to speak with someone who has undergone the same procedure. This allows the client to gain insight, ask questions, and share concerns with someone who has firsthand experience, which can help alleviate anxiety and promote a positive self-image. Seeking an antianxiety medication does not address the client's emotional concerns or promote a positive attitude towards the procedure. Discussing the procedure with the doctor again may provide more information but may not offer the same level of emotional support and understanding as speaking with someone who has lived through the experience. Commenting on the convenience of not having to search for a bathroom minimizes the client's anxiety and overlooks the emotional aspect of the client's concerns.
5. Assessment of the diabetic client for common complications should include examination of the:
- A. Abdomen.
- B. Lymph glands.
- C. Pharynx.
- D. Eyes.
Correct answer: D
Rationale: The correct answer is D: Eyes. Diabetic clients are at high risk of developing complications such as diabetic retinopathy, making regular eye examinations crucial. Assessing the eyes helps in early detection and management of diabetic eye diseases. Choices A, B, and C are incorrect because while they may be relevant in certain assessments, they are not commonly associated with complications specific to diabetes. Examination of the abdomen, lymph glands, and pharynx are not typically part of routine assessments for common complications in diabetic clients.
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