HESI RN
Pediatric HESI
1. Which nursing intervention is most important to include in the plan of care for a child with acute glomerulonephritis?
- A. Encourage fluid intake.
- B. Promote complete bed rest.
- C. Weigh the child daily.
- D. Administer vitamin supplements.
Correct answer: C
Rationale: Weighing the child daily is crucial in managing a child with acute glomerulonephritis as it helps in monitoring fluid retention, which is a key concern in this condition. Daily weight monitoring allows healthcare providers to assess changes in fluid status and adjust treatment accordingly. It is an essential component of the care plan to ensure the child's health status is closely monitored during the management of acute glomerulonephritis. Encouraging fluid intake (Choice A) is generally beneficial but may not be the priority in this case where fluid retention needs close monitoring. Promoting complete bed rest (Choice B) can be important but may not be the most critical intervention. Administering vitamin supplements (Choice D) may not directly address the immediate concerns related to fluid retention in acute glomerulonephritis.
2. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which laboratory value requires immediate intervention?
- A. Serum glucose of 600 mg/dL
- B. Serum osmolarity of 320 mOsm/kg
- C. Serum sodium of 130 mEq/L
- D. Serum potassium of 5.0 mEq/L
Correct answer: B
Rationale: A serum osmolarity of 320 mOsm/kg is concerning in a client with HHS because it indicates severe dehydration and hyperosmolarity, which requires immediate intervention. In HHS, the elevated serum osmolarity leads to neurological symptoms and can result in serious complications if not addressed promptly. While a high serum glucose level (choice A) is typical in HHS, the osmolarity is a more direct indicator of dehydration and severity. Serum sodium (choice C) and potassium levels (choice D) are important but do not pose an immediate threat to the client's condition compared to the severe hyperosmolarity indicated by a high serum osmolarity level.
3. A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?
- A. Wear a cotton bra.
- B. Increase nursing time gradually.
- C. Correctly place the infant on the breast.
- D. Manually express a small amount of milk before nursing.
Correct answer: C
Rationale: The most effective instruction to prevent nipple soreness when breastfeeding is to correctly place the infant on the breast. Proper latch-on techniques ensure that the baby is properly positioned, reducing the risk of nipple soreness. When the baby is positioned correctly, they can nurse effectively without causing discomfort to the mother.
4. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client?
- A. Have you lost interest in activities you used to enjoy?
- B. Has your ability to think or concentrate decreased?
- C. How many consecutive hours do you sleep at night?
- D. Do you hear sounds or voices that others do not hear?
Correct answer: D
Rationale: Inquiring about hallucinations is crucial for assessing the return of psychotic symptoms due to discontinuation of antipsychotic medication. Hearing sounds or voices that others do not hear can indicate the presence of auditory hallucinations, a common symptom in schizophrenia. Choices A, B, and C are important aspects to assess in clients with schizophrenia, but in this scenario, the priority is to determine if the client is experiencing hallucinations, which can be a sign of worsening psychotic symptoms.
5. The client has been diagnosed with primary aldosteronism. Which of the following clinical findings would the nurse expect?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypercalcemia
Correct answer: B
Rationale: Primary aldosteronism involves the overproduction of aldosterone by the adrenal glands. Aldosterone increases potassium excretion, leading to hypokalemia. Therefore, in primary aldosteronism, the nurse would expect to find hypokalemia, not hyperkalemia (choice A), hyponatremia (choice C), or hypercalcemia (choice D).