HESI RN
Reproductive Health Exam
1. Herpes simplex type 2 (HSV-2) does not cause cold sores of the lips:
- A. True.
- B. False.
- C. Depends on the person.
- D. Not enough information.
Correct answer: B
Rationale: Herpes simplex type 2 (HSV-2) typically causes genital herpes, not cold sores on the lips. Cold sores on the lips are commonly caused by herpes simplex type 1 (HSV-1). Therefore, the statement that HSV-2 causes cold sores of the lips is incorrect. Choice B, 'False,' is the correct answer. Choice A is incorrect because HSV-2 does not cause cold sores on the lips. Choice C, 'Depends on the person,' is incorrect as the cause of cold sores is predominantly linked to HSV-1. Choice D, 'Not enough information,' is also incorrect as this information is well-established in medical knowledge.
2. The nurse is providing discharge instructions to a client who has had a stroke. Which intervention should the nurse recommend to prevent aspiration during meals?
- A. Encourage the client to take large bites of food
- B. Advise the client to eat quickly to prevent fatigue
- C. Offer the client thin liquids with meals
- D. Instruct the client to sit upright while eating
Correct answer: D
Rationale: Instructing the client to sit upright while eating is crucial to prevent aspiration in stroke clients. This position helps in safe swallowing and reduces the risk of food or liquid entering the airway. Encouraging the client to take large bites of food (Choice A) can increase the risk of choking and aspiration. Advising the client to eat quickly (Choice B) may lead to fatigue and compromise safe swallowing. Offering thin liquids (Choice C) can also increase the risk of aspiration in stroke clients, as thicker liquids are usually recommended to prevent aspiration.
3. A client with deep vein thrombosis (DVT) is receiving heparin and reports tarry stools. What should the nurse do?
- A. Prepare to administer warfarin.
- B. Assess characteristics of the client's pain.
- C. Monitor stools for blood and review PTT results.
- D. Continue the heparin and prepare to administer Vitamin K.
Correct answer: C
Rationale: When a client on heparin reports tarry stools, it can be indicative of gastrointestinal bleeding. The correct action for the nurse is to monitor the stools for blood and review the Partial Thromboplastin Time (PTT) results. This is essential to detect any potential bleeding complications associated with heparin therapy. Option A is incorrect because warfarin is not the immediate intervention for tarry stools in a client on heparin. Option B is irrelevant to the situation described. Option D is incorrect as Vitamin K is the antidote for warfarin, not heparin.
4. A client with type 1 DM is experiencing signs of hypoglycemia. The nurse should expect which of the following symptoms?
- A. Tachycardia
- B. Polyuria
- C. Flushed skin
- D. Dry mouth
Correct answer: A
Rationale: In a client experiencing hypoglycemia, tachycardia is a common symptom. This occurs due to the release of adrenaline in response to low blood glucose levels, which stimulates the heart to beat faster. Polyuria, the increased production of urine, flushed skin, and dry mouth are not typical symptoms of hypoglycemia. Polyuria is more commonly associated with conditions like diabetes insipidus or uncontrolled diabetes mellitus. Flushed skin and dry mouth are not direct physiological responses to low blood sugar levels.
5. A client is admitted with ascites, malnutrition, and recent complaints of spitting up blood. What assessment finding warrants immediate intervention by the nurse?
- A. Capillary refill of 8 seconds
- B. Bruises on arms and legs
- C. Round and tight abdomen
- D. Pitting edema in lower legs
Correct answer: C
Rationale: A round and tight abdomen suggests fluid accumulation from ascites, which could signal a more severe underlying condition requiring immediate intervention. This finding indicates increased intra-abdominal pressure, which can lead to respiratory compromise or other serious complications. Capillary refill time, bruises on arms and legs, and pitting edema in the lower legs are important assessments but do not directly indicate the need for immediate intervention as a round and tight abdomen does in this case.