Medical Surgical Assignment Exam HESI

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A young adult male is admitted to the intensive care unit with multiple rib fractures and severe pulmonary contusions after falling 20 feet from a rooftop. The Chest X-ray suggests acute Respiratory distress Syndrome. Which assessment finding warrants immediate intervention by the Nurse?

  • A. Apical pulse 58 bpm.
  • B. Core body temperature 100.8°F.
  • C. Tachypnea with dyspnea.
  • D. Multiple bruises over the chest area.
Correct Answer: C

Rationale: In a patient with multiple rib fractures, severe pulmonary contusions, and possible acute Respiratory Distress Syndrome (ARDS), tachypnea (rapid breathing) with dyspnea (shortness of breath) is a critical sign of respiratory distress that warrants immediate intervention by the nurse. Tachypnea and dyspnea indicate inadequate oxygenation and ventilation, which can lead to respiratory failure if not addressed promptly. The other options, such as apical pulse rate, core body temperature, and bruises over the chest area, are important assessments but do not directly indicate the immediate need for intervention in a patient with respiratory distress.

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A male client with Herpes Zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the etiology of this problem?

  • A. Pain
  • B. Nocturia
  • C. Dyspnea
  • D. Frequent cough
Correct Answer: A

Rationale: The correct answer is A: Pain. The pain caused by Herpes Zoster (shingles) can disrupt sleep patterns. It is a common symptom of shingles and can lead to difficulty falling asleep or staying asleep. Nocturia (B), dyspnea (C), and frequent cough (D) are not typically associated with shingles and would not directly cause difficulty sleeping in this scenario.

A client with Parkinson's disease is experiencing difficulty swallowing. Which intervention should the nurse implement to prevent aspiration?

  • A. Encourage the client to eat quickly.
  • B. Provide a straw for liquids.
  • C. Place the client in an upright position during meals.
  • D. Offer thin liquids.
Correct Answer: C

Rationale: Placing the client in an upright position during meals is the correct intervention to prevent aspiration in a client with Parkinson's disease. This position helps facilitate swallowing and reduces the risk of aspiration. Choice A is incorrect because encouraging the client to eat quickly can increase the risk of choking and aspiration. Choice B is not the best option as straws may not prevent aspiration effectively. Choice D is incorrect as thin liquids can actually increase the risk of aspiration in individuals with swallowing difficulties.

A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report to the HCP?

  • A. Weakness and fatigue
  • B. Intestinal cramping
  • C. Weight loss
  • D. Jaundiced sclera
Correct Answer: D

Rationale: The most important finding to report to the healthcare provider is a jaundiced sclera. Jaundice suggests liver involvement, which can be a sign of a serious underlying condition. Weakness and fatigue, intestinal cramping, and weight loss are important symptoms, but jaundice indicates a more urgent issue that needs immediate attention.

Parents of a school-age child ask the nurse for suggestions in helping the child who is demonstrating school avoidance. What is an appropriate suggestion by the nurse?

  • A. Take the child to the healthcare provider for testing.
  • B. Be firm and insist the child go to school.
  • C. Allow the child to stay home and rest.
  • D. Consult with the teacher at school.
Correct Answer: B

Rationale: When a child is demonstrating school avoidance, it is important for parents to be firm and insist that the child go to school. This helps establish a routine and prevents the behavior from becoming a pattern. Taking the child to the healthcare provider for testing (Choice A) may not be necessary at this stage as school avoidance is a behavioral issue. Allowing the child to stay home and rest (Choice C) may reinforce the avoidance behavior. While consulting with the teacher at school (Choice D) is important, the immediate focus should be on addressing the avoidance behavior at home.

A young client who is being taught how to use an inhaler for symptoms of asthma tells the nurse about the intention to use the inhaler but plans to continue smoking cigarettes. In evaluating the client's response, what is the best initial action by the nurse?

  • A. Explain the risks of smoking with asthma.
  • B. Revise the plan of care.
  • C. Encourage the client to reduce smoking gradually.
  • D. Provide resources for smoking cessation.
Correct Answer: B

Rationale: The best initial action by the nurse is to revise the plan of care. This is necessary to address the client's intention to continue smoking and ensure that appropriate support and education are provided. Choice A is not the best initial action as the client is already aware of the risks of smoking with asthma. Choice C might not be effective as the client's intention to continue smoking poses a significant risk to their health. Choice D, providing resources for smoking cessation, is important but revising the plan of care should come first to address the immediate concern.

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