HESI RN
HESI Medical Surgical Test Bank
1. An adult who was recently diagnosed with glaucoma tells the nurse, 'it feels like I am driving through a tunnel.' The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?
- A. Maintain prescribed eye drop regimen
- B. Avoid frequent eye pressure measurements
- C. Wear prescription glasses
- D. Eat a diet high in carotene
Correct answer: A
Rationale: The correct answer is A: Maintain prescribed eye drop regimen. In glaucoma, maintaining the prescribed eye drop regimen is crucial for controlling intraocular pressure, which helps in preventing vision loss. Consistent use of eye drops as directed can slow down the progression of the disease and preserve vision. Choice B is incorrect because avoiding frequent eye pressure measurements does not address the primary treatment for glaucoma. Choice C is incorrect as wearing prescription glasses may be helpful for vision correction but does not directly address the management of glaucoma. Choice D is incorrect because while a diet high in carotene may promote overall eye health, it is not the most important instruction for managing glaucoma.
2. During an annual physical at the corporate clinic, a male employee expresses to the RN that his high-stress job is causing trouble in his personal life. He mentions getting so angry while driving to and from work that he has considered 'getting even' with other drivers. How should the RN respond?
- A. “Anger is contagious and could lead to major confrontations.”
- B. “Try not to let your anger cause you to act impulsively.”
- C. “Expressing your anger to a stranger could lead to an unsafe situation.”
- D. “It seems like there are many situations that make you feel angry.”
Correct answer: B
Rationale: The correct response for the RN is to advise the employee not to act impulsively when feeling angry. This approach helps the individual learn to manage anger in a constructive manner, reducing the likelihood of potential conflicts. Choice A is incorrect because although acknowledging that anger can escalate into confrontations is valid, it does not provide immediate guidance on managing the anger. Choice C focuses on the dangers of expressing anger to strangers but does not address the core issue of managing anger. Choice D simply acknowledges the employee's feelings without providing guidance on how to address the situation effectively.
3. What is the triangular space lying between the vaginal and rectal canals?
- A. Pelvic floor
- B. Perineum
- C. Vestibule
- D. Perineal body
Correct answer: B
Rationale: The correct answer is B: Perineum. The perineum is the triangular space located between the vaginal and rectal canals. It is a region containing various muscles, nerves, and blood vessels that support the pelvic floor. Choice A, Pelvic floor, refers to the structure supporting the organs in the pelvic cavity, not the space between the vaginal and rectal canals. Choice C, Vestibule, is the space within the labia minora containing the openings of the urethra and vagina, not the area between the vaginal and rectal canals. Choice D, Perineal body, is a fibromuscular mass in the perineum area but not the space between the vaginal and rectal canals.
4. The healthcare provider is caring for a client with hyperparathyroidism. Which laboratory result requires immediate intervention?
- A. Serum calcium of 11 mg/dL.
- B. Serum phosphorus of 3 mg/dL.
- C. Serum magnesium of 1.8 mg/dL.
- D. Serum albumin of 4 g/dL.
Correct answer: A
Rationale: A serum calcium level of 11 mg/dL indicates hypercalcemia, which can be a complication of hyperparathyroidism and requires immediate intervention. Hypercalcemia can lead to serious complications such as cardiac dysrhythmias, renal failure, and neurologic symptoms. Monitoring and managing serum calcium levels are crucial in clients with hyperparathyroidism. Serum phosphorus, magnesium, and albumin levels are important to assess in clients with hyperparathyroidism, but they do not require immediate intervention as hypercalcemia poses a more urgent risk.
5. What principle about patient-nurse communication should guide a nurse's fear of 'saying the wrong thing' to a patient?
- A. Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation.
- B. The patient is more interested in talking to you than listening to what you have to say and is not likely to be offended.
- C. Considering the patient's history, there is little chance that the comment will do any actual harm.
- D. Most people with a mental illness have by necessity developed a high tolerance for forgiveness.
Correct answer: A
Rationale: The correct principle guiding nurse-patient communication is that patients value genuine acceptance, respect, and concern. Choice A is the correct answer because showing genuine care and concern for the patient's situation fosters a positive and therapeutic relationship. Choice B is incorrect as effective communication involves active listening and responding appropriately, not assuming the patient is only interested in talking. Choice C is incorrect because a patient's history does not guarantee immunity to harm from inappropriate comments. Choice D is incorrect as it generalizes individuals with mental illness and forgiveness, which is not directly related to communication fears.