HESI RN
HESI Nutrition Exam
1. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?
- A. Cut the child's hair short to remove the nits
- B. Apply warm soaks to the head twice daily
- C. Wash the child's linen and clothing in a bleach solution
- D. Application of pediculicides
Correct answer: D
Rationale: Pediculicides are the recommended treatment for lice and should be used to eliminate the infestation.
2. A 2-year-old child with respiratory syncytial virus (RSV) is being treated in the hospital. What should the healthcare provider monitor for in this child?
- A. Increased urine output.
- B. Decreased respiratory rate.
- C. Labored breathing.
- D. Improved appetite.
Correct answer: C
Rationale: Labored breathing is a critical sign of worsening respiratory distress in children with RSV. It indicates that the child's condition may be deteriorating, requiring prompt intervention to ensure adequate oxygenation and prevent respiratory failure. Monitoring for labored breathing allows healthcare providers to promptly assess and manage the child's respiratory status, potentially preventing further complications associated with RSV infection.
3. When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow Coma Scale (GCS) every two hours. For the past 8 hours, the client's GCS score has been 14. What does this GCS finding indicate about the client?
- A. Neurologically stable without indications of increased ICP.
- B. At risk for neurological deterioration.
- C. Experiencing mild cognitive impairment.
- D. In need of immediate medical intervention.
Correct answer: A
Rationale: A GCS score of 14 indicates that the client is neurologically stable without indications of increased ICP. It suggests that the client's neurological status is relatively intact, with only mild impairment, if any. This finding reassures the nurse that there are currently no signs of deterioration or immediate need for intervention. Choice B is incorrect because a GCS score of 14 does not necessarily indicate immediate risk for neurological deterioration. Choice C is incorrect as mild cognitive impairment is not typically inferred from a GCS score of 14. Choice D is incorrect as immediate medical intervention is not warranted based on a GCS score of 14 without other concerning symptoms.
4. Which nursing diagnosis is a priority for a 4-year-old child diagnosed with nephrotic syndrome?
- A. Impaired urinary elimination.
- B. Risk for infection.
- C. Fluid volume excess.
- D. Risk for impaired skin integrity.
Correct answer: C
Rationale: In a child with nephrotic syndrome, fluid volume excess is a priority nursing diagnosis due to the risk of edema and related complications. This patient may experience significant fluid retention, leading to edema, hypertension, and potential respiratory distress. Monitoring and managing fluid volume excess are crucial in preventing further complications and supporting the child's health during nephrotic syndrome. The other options are not the priority in this case. Impaired urinary elimination is not typically a primary concern in nephrotic syndrome. While infection is a risk due to compromised immunity, fluid volume excess poses a more immediate threat to the child's health. Risk for impaired skin integrity may be a concern secondary to edema, but addressing fluid volume excess takes precedence.
5. A 38-week primigravida who works at a desk job and sits at a computer for 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?
- A. Wear support stockings.
- B. Reduce salt in her diet.
- C. Move about every hour.
- D. Avoid constrictive clothing.
Correct answer: C
Rationale: During pregnancy, especially in the third trimester, it is common for women to experience swelling due to decreased circulation. Encouraging the patient to move about every hour helps prevent blood pooling in the lower extremities by promoting circulation. This simple activity can help alleviate swelling and discomfort associated with prolonged sitting.