HESI RN
HESI Medical Surgical Test Bank
1. Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?
- A. Elevate extremities on pillows
- B. Evaluate edema for pitting
- C. Assess pulses with a vascular Doppler
- D. Wrap the feet with warmed blankets
Correct answer: C
Rationale: In this scenario, the priority action for the nurse is to assess pulses with a vascular Doppler. The absence of palpable pedal pulses following an abdominal aortic aneurysm repair raises concerns about compromised blood flow, which could lead to serious complications like ischemia or thrombosis. Evaluating and confirming the presence or absence of pulses is crucial to guide further interventions. Elevating extremities on pillows (Choice A) may be beneficial for managing edema, but it is not the immediate priority when pulses are not palpable. Evaluating edema for pitting (Choice B) can provide additional information about fluid status but does not address the primary concern of absent pulses. Wrapping the feet with warmed blankets (Choice D) is not appropriate in this situation and may not address the underlying vascular issue.
2. A client with a diagnosis of schizophrenia is exhibiting negative symptoms such as anhedonia and social withdrawal. Which intervention should be a priority for the nurse?
- A. Encourage participation in group activities.
- B. Administer prescribed antipsychotic medication.
- C. Assist the client in setting realistic goals.
- D. Promote engagement in social interactions.
Correct answer: A
Rationale: Encouraging participation in group activities is a priority intervention for a client with schizophrenia exhibiting negative symptoms like anhedonia and social withdrawal. Group activities provide structured social interactions and can help the client gradually re-engage with others, potentially reducing social withdrawal and improving social skills. Administering antipsychotic medication (Choice B) is essential in managing positive symptoms of schizophrenia such as hallucinations and delusions, not negative symptoms like anhedonia and social withdrawal. While assisting the client in setting realistic goals (Choice C) is important for overall care, addressing social withdrawal and anhedonia is more immediate. Promoting engagement in social interactions (Choice D) is beneficial, but encouraging participation in group activities provides a structured and supportive environment that can specifically target the negative symptoms being exhibited.
3. When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. What action should the nurse take?
- A. Tell him to take the medication then verify the dosage at the next healthcare team meeting.
- B. Withhold the medication until the dosage can be confirmed.
- C. Inform him that he may refuse the medication and document whether or not he takes it.
- D. Explain to the client that the dosage has been changed.
Correct answer: B
Rationale: Withholding the medication until the dosage can be confirmed ensures patient safety and accuracy in treatment.
4. When assessing a male client, the nurse finds that he is fatigued and experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which condition?
- A. Hyperphosphatemia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hypokalemia
Correct answer: D
Rationale: The symptoms of fatigue, muscle weakness, leg cramps, and cardiac dysrhythmias are classic manifestations of hypokalemia. Potassium plays a vital role in muscle function and cardiac conduction, so a deficiency can lead to these symptoms. Checking the client’s laboratory values for potassium levels will help confirm the presence of hypokalemia.
5. A menstrual disorder with irregular or continuous bleeding from the uterus is known as:
- A. Menorrhagia
- B. Metrorrhagia
- C. Polymenorrhoea
- D. Epimenorrhoea
Correct answer: B
Rationale: Metrorrhagia is the correct term for irregular or continuous bleeding from the uterus. Menorrhagia refers to heavy menstrual bleeding, not necessarily irregular. Polymenorrhoea is characterized by frequent menstrual periods, while Epimenorrhoea is not a recognized medical term related to menstrual disorders.