Pediatric HESI Test Bank

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A 32 y.o. male patient is admitted to a medical unit with a diagnosis of Guillain-Barre Syndrome. His legs are weak, and he is unable to walk without assistance. Which of the ff. is most likely responsible for this syndrome?

  • A. Bacterial infection
  • B. High-fat diet
  • C. Heredity
  • D. Autoimmune reaction
Correct Answer: D

Rationale: Guillain-Barre Syndrome (GBS) is an autoimmune disorder where the body's immune system mistakenly attacks the peripheral nerves. This leads to inflammation that damages the nerves and interrupts their ability to send signals to the brain. In the case of the 32-year-old male patient with weak legs, the autoimmune reaction is most likely responsible for causing muscle weakness and difficulty walking. GBS typically presents with ascending muscle weakness starting in the legs and progressing upwards. It is essential to recognize this condition promptly as it can lead to severe complications such as respiratory failure. Treatment often involves supportive care and interventions to manage the autoimmune response.

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Which of the ff information should the nurse provide to clients who are prescribed rifampin?

  • A. Take medication with meals
  • B. Inform that contact lenses, if worn, may
  • C. Avoid wearing glasses become colored
  • D. Avoid tuna, aged cheese, and red wine
Correct Answer: B

Rationale: Rifampin is a medication known to cause harmless discoloration of bodily fluids, including tears and sweat. This discoloration can also affect contact lenses if worn by the individual taking rifampin. Therefore, it is important for the nurse to inform clients who are prescribed rifampin about this potential side effect to prevent any concerns or misunderstandings. It is advisable for clients to use glasses instead of contact lenses while taking rifampin to avoid this discoloration.

Which should the nurse recommend to prevent urinary tract infections in young girls?

  • A. Wear cotton underpants.
  • B. Limit bathing as much as possible.
  • C. Increase fluids; decrease salt intake.
  • D. Cleanse perineum with water after voiding.
Correct Answer: A

Rationale: Cotton underpants are recommended to prevent urinary tract infections in young girls because they allow for better air circulation, which helps keep the genital area dry and reduces the likelihood of bacterial growth. Synthetic materials can trap moisture and create a warm and moist environment that promotes bacterial infections. Therefore, wearing cotton underpants is a simple and effective way to promote good hygiene and prevent urinary tract infections in young girls.

Which of the following IV solutions is hypertonic?

  • A. Normal saline
  • B. 0.45% NaCl
  • C. 5% dextrose in 0.9% NaCl
  • D. 0.225% NaCl
Correct Answer: C

Rationale: A hypertonic solution has a higher concentration of solutes compared to the intracellular fluid. In this case, 5% dextrose in 0.9% NaCl is hypertonic because it has a higher osmolarity due to the combined effect of dextrose and sodium chloride. The dextrose contributes to the hypertonicity, making the overall solution more concentrated than the intracellular fluid.

A client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg PO daily. Which finding should the nurse recognize as an adverse effect?

  • A. Dysuria
  • B. Tachycardia
  • C. Leg cramps
  • D. Blurred vision
Correct Answer: B

Rationale: Levothyroxine is a synthetic form of thyroid hormone used to treat hypothyroidism. An adverse effect of levothyroxine therapy is the development of tachycardia, which is an abnormally rapid heart rate. This is due to the increased metabolic rate resulting from the thyroid hormone replacement. Dysuria (painful urination), leg cramps, and blurred vision are not typically associated with levothyroxine therapy for hypothyroidism.

A woman with pelvic inflammatory disease complains of lower abdominal pain. Which action should the nurse take first?

  • A. Have her rate her pain on a 0 to 10 scale
  • B. Administer antibiotics as ordered
  • C. Administer an analgesic as ordered
  • D. Teach the patient about causes and prevention of STDs
Correct Answer: B

Rationale: The first priority when a woman with pelvic inflammatory disease complains of lower abdominal pain is to administer antibiotics as ordered. Pelvic inflammatory disease is often caused by a bacterial infection, and prompt treatment with antibiotics is crucial to prevent complications such as infertility or chronic pelvic pain. Addressing the infection promptly is essential in managing the condition and preventing further spread of the infection. Once antibiotic therapy has been initiated, the nurse can proceed with other interventions such as pain management (C), patient education on STDs (D), and assessing pain level (A).

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