HESI RN
HESI Quizlet Fundamentals
1. A client in the early stages of Alzheimer’s disease is very anxious and frequently asks about her deceased parents. Which intervention should the nurse implement to reduce the client’s anxiety?
- A. Remind the client that her parents have passed away
- B. Ask the client about her favorite memories with her parents
- C. Engage the client in an activity to distract her from thinking about her parents
- D. Reorient the client to the present reality and surroundings
Correct answer: C
Rationale: Engaging the client in an activity to distract her from thinking about her deceased parents is the most appropriate intervention to reduce anxiety. This approach helps shift the focus away from distressing thoughts and can provide comfort and a sense of calm to the client.
2. _______ is a lytic enzyme released by the sperm.
- A. Hyaluronidase
- B. Trypsin
- C. Helicase
- D. None of the above
Correct answer: A
Rationale: Hyaluronidase is the correct answer. It is a lytic enzyme released by the sperm to help penetrate the egg's protective layer. Trypsin is a digestive enzyme produced in the pancreas, not released by sperm. Helicase is an enzyme involved in DNA replication, not released by sperm. 'None of the above' is incorrect as hyaluronidase fits the description provided in the question.
3. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?
- A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
- B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
- C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
- D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.
Correct answer: C
Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.
4. Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscular dystrophy. Which finding warrants immediate intervention by the nurse?
- A. Extremity muscle weakness.
- B. Bilateral eyelid drooping.
- C. Inability to swallow pills.
- D. Evidence of hypoventilation.
Correct answer: D
Rationale: The correct answer is D: Evidence of hypoventilation. In a client with muscular dystrophy and progressive kyphoscoliosis, hypoventilation indicates respiratory muscle weakness and can lead to life-threatening respiratory distress. Immediate intervention is crucial to prevent complications. Choices A, B, and C are incorrect because while extremity muscle weakness, bilateral eyelid drooping, and inability to swallow pills are concerning symptoms in muscular dystrophy, evidence of hypoventilation poses a more immediate threat to the client's respiratory status.
5. A client with atrial fibrillation is prescribed warfarin. Which instruction should the nurse include in the teaching?
- A. Maintain a consistent intake of leafy green vegetables
- B. Use an electric razor when shaving
- C. Monitor blood pressure daily
- D. Avoid eating bananas and oranges
Correct answer: B
Rationale: Clients on warfarin are at increased risk of bleeding due to its anticoagulant effects. Using an electric razor reduces the risk of cuts and bleeding, which is an important safety precaution. While leafy greens should not be avoided, their intake should be consistent to maintain a stable level of vitamin K in the body. Monitoring blood pressure daily is important for other conditions but not directly related to warfarin therapy. Avoiding bananas and oranges is not a standard instruction for clients on warfarin.