HESI RN
HESI Medical Surgical Test Bank
1. 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.
2. The parents of a 3-year-old boy with Duchenne muscular dystrophy (DMD) ask, 'How can our son have this disease? We are wondering if we should have any more children.' What information should the nurse provide these parents?
- A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
- B. The male infant had a viral infection that went unnoticed and untreated, leading to muscle damage.
- C. The lack of the protein dystrophin in the mother can impact the XXX muscle groups of males.
- D. Spinal cord damage due to birth trauma during a breech vaginal birth weakens the muscles.
Correct answer: A
Rationale: The correct answer is A. Duchenne muscular dystrophy is an X-linked recessive disorder, meaning the gene mutation causing DMD is located on the X chromosome. Males have one X chromosome and one Y chromosome, so if the X chromosome they inherit from their mother carries the mutated gene, they will develop DMD. Females have two X chromosomes, so they are carriers of the gene but are usually not affected by the disease. Therefore, the nurse should explain to the parents that DMD is an inherited X-linked recessive disorder that primarily affects male children in the family.
3. In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?
- A. Daily black, sticky stool
- B. Daily dark brown stool
- C. Firm brown stool every other day
- D. Soft light brown stool twice a day
Correct answer: A
Rationale: The correct answer is A: Daily black, sticky stool. Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. This finding indicates the presence of digested blood in the stool. Choices B, C, and D describe variations of normal stool color and consistency, which do not raise immediate concerns related to gastrointestinal bleeding.
4. A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?
- A. Carbon dioxide is converted in the kidneys for elimination.
- B. Blood oxygen levels are stimulating the respiratory rate.
- C. Hyperventilation is eliminating carbon dioxide rapidly.
- D. High levels of carbon dioxide have accumulated in the blood.
Correct answer: D
Rationale: The correct answer is D. High levels of carbon dioxide in the blood are indicative of respiratory acidosis, often due to inadequate ventilation. In respiratory acidosis, there is retention of carbon dioxide (hypercapnia) leading to an increase in carbonic acid levels in the blood, resulting in an acidic pH. Option A is incorrect because carbon dioxide elimination primarily occurs through the lungs, not the kidneys. Option B is incorrect because blood oxygen levels primarily affect the respiratory rate to regulate oxygen levels, not carbon dioxide levels. Option C is incorrect because hyperventilation would lead to a decrease, not an increase, in carbon dioxide levels.
5. A client is scheduled for surgery in the morning and is NPO. Which statement indicates that the client understands the reason for being NPO?
- A. Being NPO helps reduce the risk of nausea.
- B. I should not eat or drink anything to prevent complications during surgery.
- C. NPO reduces the risk of aspiration during surgery.
- D. NPO helps ensure the stomach is empty during surgery.
Correct answer: C
Rationale: The correct answer is C: 'NPO reduces the risk of aspiration during surgery.' When a client is NPO (nothing by mouth) before surgery, it is to prevent aspiration, which can lead to serious complications such as pneumonia. Choice A is incorrect because being NPO is more about preventing aspiration than nausea. Choice B is a general statement without specifying the reason for being NPO. Choice D is partially correct but does not emphasize the crucial aspect of preventing aspiration, which is the primary reason for fasting before surgery.