Medical Surgical Assignment Exam HESI Quizlet

Medical Surgical Assignment Exam HESI Quizlet Related

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An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?

  • A. Collect a urine specimen for culture analysis
  • B. Review the client's fluid intake prior to bedtime
  • C. Palpate the bladder above the symphysis pubis
  • D. Obtain a fingerstick glucose level
Correct Answer: C

Rationale: Palpating the bladder above the symphysis pubis is the most appropriate intervention in this scenario. It helps assess for urinary retention, which is a common issue in older males presenting with symptoms like difficulty starting urinary stream and feeling of incomplete bladder emptying. Collecting a urine specimen for culture analysis (Choice A) may be necessary in other situations like suspected urinary tract infection. Reviewing the client's fluid intake (Choice B) is important but does not directly address the current issue of urinary retention. Obtaining a fingerstick glucose level (Choice D) is not relevant to the client's urinary symptoms.

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Recurrent abdominal pain (RAP) is most often seen in school-age or adolescent children. The nurse should assess closely for what potential problem?

  • A. Physical problems
  • B. Relational problems
  • C. Eating disorders
  • D. Emotional problems
Correct Answer: D

Rationale: The correct answer is D: 'Emotional problems.' Recurrent abdominal pain (RAP) in children is frequently associated with emotional factors rather than physical issues, relational problems, or eating disorders. Children may manifest emotional distress through physical symptoms like abdominal pain, making it crucial for nurses to assess for emotional problems as a potential cause.

A client with a spinal cord injury at the level of T1 is at risk for autonomic dysreflexia. Which symptom is indicative of this condition?

  • A. Hypotension
  • B. Tachycardia
  • C. Severe headache
  • D. Flushed skin below the level of injury
Correct Answer: C

Rationale: Corrected Rationale: Autonomic dysreflexia is a condition commonly seen in clients with spinal cord injuries at T6 or above. It is characterized by a sudden onset of severe hypertension, pounding headache, profuse sweating, nasal congestion, and flushing of the skin above the level of injury. The severe headache is a key symptom resulting from uncontrolled hypertension. Choices A, B, and D are incorrect as autonomic dysreflexia typically presents with hypertension, not hypotension, tachycardia, or flushed skin below the level of injury.

A client reports new onset hearing loss bilaterally after taking a medication with known ototoxic effects. Which type of hearing loss should the nurse suspect?

  • A. Conductive
  • B. Sensorineural
  • C. Mixed
  • D. Central
Correct Answer: B

Rationale: The correct answer is B: Sensorineural. Ototoxic medications can lead to sensorineural hearing loss by affecting the inner ear or auditory nerve. Conductive hearing loss is related to issues in the middle or outer ear, not typically caused by ototoxic medications. Mixed hearing loss is a combination of conductive and sensorineural components. Central hearing loss is related to the central nervous system, not commonly caused by ototoxic medications. Therefore, in this case, the nurse should suspect sensorineural hearing loss.

Following a bout of diarrhea, which foods should be offered to the school-age child?

  • A. Apricots and peaches
  • B. Chocolate milk
  • C. Applesauce and milk
  • D. Bananas and rice
Correct Answer: D

Rationale: After rehydration, it is important to offer foods that are nonirritating to the bowel to the child. Bananas and rice are considered the best options as they are least likely to irritate the gastrointestinal tract. Apricots, peaches, and applesauce are fruits that may cause GI irritation, while milk, including chocolate milk, can also be irritating to the bowel. Therefore, the optimal choice for a child recovering from diarrhea would be bananas and rice.

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

  • A. An old friend with eczema came for a visit.
  • B. Recently received an influenza immunization.
  • C. A grandson and his new dog recently visited.
  • D. Corticosteroid cream was applied to eczema.
Correct Answer: C

Rationale: The correct answer is C. Contact with the grandson's new dog could have introduced new allergens or irritants, exacerbating the eczema symptoms. Choice A is unrelated to the exacerbation of symptoms. Choice B, receiving an influenza immunization, is unlikely to directly cause an exacerbation of eczema symptoms. Choice D, applying corticosteroid cream, is a common treatment for eczema and would not likely be the cause of the exacerbation.

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