HESI RN
HESI Nutrition Practice Exam
1. A healthcare professional 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: The correct answer is B: Pupils fixed and dilated. Fixed and dilated pupils are a critical neurological sign that indicates severe neurological damage or brain herniation, posing a significant concern for the patient's condition. Flaccid paralysis (choice A) typically indicates lower motor neuron injury, while diminished spinal reflexes (choice C) and reduced sensory responses (choice D) may suggest various neurological issues but are not as acutely concerning as fixed and dilated pupils in this scenario.
2. A 2-year-old girl is brought to the clinic by her 17-year-old mother. When the nurse observes that the child is drinking sweetened soda from her bottle, what information should the nurse discuss with this mother?
- A. A 2-year-old should be speaking in 2-word phrases
- B. Dental caries is associated with drinking soda
- C. Drinking soda is related to childhood obesity
- D. Toddlers should be sleeping 10 hours a night
Correct answer: B
Rationale: Dental caries are a common concern when children consume sweetened sodas regularly.
3. A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription?
- A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
- B. Pulse rate of 68-78 BPM.
- C. Temperature of 99.5-99.7°F.
- D. Respiration rate of 24 breaths per minute.
Correct answer: A
Rationale: In this scenario, the correct answer is A. Clonidine, such as Catapres, is a medication that can lower blood pressure. Therefore, if a client has low blood pressure readings, like 90/62 mmHg to 92/58 mmHg, the registered nurse should withhold the clonidine prescription to prevent further lowering of blood pressure which could lead to adverse effects. Choices B, C, and D are incorrect because they are within normal ranges and do not present a contraindication for the administration of clonidine in this context.
4. A nursing assistant is measuring the blood pressure (BP) of a hypertensive client while a nurse observes. Which action on the part of the assistant would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply.
- A. Measuring the BP after the client has sat quietly for 5 minutes
- B. Having the client sit with the arm bared and supported at heart level
- C. Using a cuff with a rubber bladder that encircles less than 80% of the limb
- D. Measuring the BP after the client reports that he just drank a cup of coffee
Correct answer: C
Rationale: To ensure accurate blood pressure (BP) measurement, the cuff used should have a rubber bladder that encircles at least 80% of the limb being measured. This ensures proper compression and accurate readings. Choices A and B are correct practices as it is recommended to measure BP after the client has sat quietly for 5 minutes and to have the client sit with the arm bared and supported at heart level. Choice D is also a correct reason for intervention as the client should not have consumed caffeine or smoked tobacco within 30 minutes before BP measurement, as it can affect the accuracy of the reading.
5. The nurse in a community health clinic is interviewing a female client who has three children. The client tells the nurse that she has a new man in her life, with whom she is having a sexual relationship, and that they both smoke cigarettes. Which information is most important for the nurse to provide this client?
- A. Oral contraceptives should be started to prevent an unwanted pregnancy
- B. Children are more prone to upper respiratory infections if exposed to smoke at home
- C. Cigarette smoking increases the risk for peptic ulcers and emphysema
- D. A diaphragm and condom provide effective contraception when used together
Correct answer: D
Rationale: The most important information for the nurse to provide the client in this situation is that using both a diaphragm and a condom together provides effective contraception and also protects against sexually transmitted diseases (STDs). While oral contraceptives can help prevent unwanted pregnancies, using a barrier method like a diaphragm and a condom is crucial in this scenario where the client is engaging in a new sexual relationship. Choice B is important information but is not the top priority in this context. Choice C, although relevant, does not address the immediate concern of contraception and STD prevention. Therefore, the correct answer is D.