HESI RN
HESI Medical Surgical Test Bank
1. The healthcare provider is assessing an older Caucasian male who has a history of peripheral vascular disease. The healthcare provider observes that the man's left great toe is black. The discoloration is probably a result of:
- A. Atrophy.
- B. Contraction.
- C. Gangrene.
- D. Rubor.
Correct answer: C
Rationale: Gangrene refers to dead, blackened tissue, often a result of chronic ischemia in clients with peripheral vascular disease. Atrophy (Choice A) is the wasting away or decrease in size of tissue or organ. Contraction (Choice B) refers to the shortening or tightening of a muscle or other body part. Rubor (Choice D) is a red discoloration of the skin, often associated with inflammation or poor circulation, but not typically presenting as blackening like gangrene.
2. A client recovering from extracorporeal shock wave lithotripsy for renal calculi has an ecchymotic area on the right lower back. What action should the nurse take?
- A. Administer fresh-frozen plasma.
- B. Apply an ice pack to the site.
- C. Place the client in the prone position.
- D. Obtain serum coagulation test results.
Correct answer: B
Rationale: After extracorporeal shock wave lithotripsy, ecchymosis can occur due to bleeding into the tissues from the shock waves. Applying an ice pack helps reduce the extent and discomfort of bruising. Administering fresh-frozen plasma and obtaining coagulation test results are not necessary as ecchymosis after this procedure is common and does not indicate a bleeding disorder that requires immediate intervention. Placing the client in the prone position will not address the bleeding or bruising in this situation.
3. In assessing cancer risk, which woman is at greatest risk of developing breast cancer?
- A. A 35-year-old multipara who never breastfed.
- B. A 50-year-old whose mother had unilateral breast cancer.
- C. A 55-year-old whose mother-in-law had bilateral breast cancer.
- D. A 20-year-old whose menarche occurred at age 9.
Correct answer: B
Rationale: The correct answer is B because family history of breast cancer, specifically in the mother, is a significant risk factor for developing breast cancer. The age of 50 is also a risk factor for breast cancer. Choice A is less likely as breastfeeding can actually reduce the risk of breast cancer. Choice C is less relevant since the risk is higher with a direct family member. Choice D, although early menarche is a risk factor, the age of the individual is much lower compared to the other age-related risk factors.
4. Which of the following is a characteristic symptom of multiple sclerosis (MS)?
- A. Muscle atrophy.
- B. Severe pain.
- C. Vision problems.
- D. Hearing loss.
Correct answer: C
Rationale: Vision problems are a characteristic symptom of multiple sclerosis (MS) due to demyelination of the optic nerve. This can lead to issues such as optic neuritis, blurred vision, double vision, or even total vision loss. Muscle atrophy (Choice A) is not a primary symptom of MS but can occur as a secondary effect of decreased mobility. Severe pain (Choice B) is not a typical symptom of MS, though some individuals may experience pain related to muscle spasms or other factors. Hearing loss (Choice D) is not commonly associated with MS unless there is an unrelated concurrent condition affecting the auditory system.
5. While assessing a female client who is chronically fatigued and was recently diagnosed with adrenal insufficiency, the client tells the nurse that she is very nervous that her hospitalization will cause her to lose her job. Which intervention should the nurse implement first?
- A. Teach the client about the risk for infection.
- B. Offer support and care measures to reduce anxiety and stress.
- C. Encourage the client to rest quietly to reduce fatigue.
- D. Place a referral to social services to discuss financial options.
Correct answer: B
Rationale: In this scenario, the priority intervention for the nurse is to offer support and care measures to reduce anxiety and stress. Addressing the client's emotional distress is crucial as the stress can exacerbate adrenal insufficiency. While teaching the client about the risk for infection (Choice A) is important, addressing the immediate emotional needs takes precedence. Encouraging the client to rest quietly (Choice C) is beneficial but does not directly address the client's current distress about job loss. Referring the client to social services (Choice D) for financial options is important, but at this moment, addressing the client's anxiety is the priority to promote emotional well-being.
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