HESI RN
HESI RN Med Surg Adult Health Questions
Question 1 of 5
A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?
Correct Answer: C
Rationale: Profuse diaphoresis and a severe, pounding headache are hallmark signs of autonomic dysreflexia, which occurs in individuals with spinal cord injuries at or above T6 due to an exaggerated autonomic response to stimuli like a full bladder, causing severe hypertension and related symptoms.
Question 2 of 5
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?
Correct Answer: A
Rationale: Using antibacterial soap can be too harsh and irritating for the skin undergoing radiation treatment. Gentle cleansing with mild soap is recommended to avoid skin irritation.
Question 3 of 5
The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for?
Correct Answer: D
Rationale: A lumbar puncture is the definitive diagnostic procedure for bacterial meningitis, allowing analysis of cerebrospinal fluid (CSF) to identify bacteria and other infection indicators.
Question 4 of 5
Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?
Correct Answer: A
Rationale: Auscultating bowel sounds helps assess gastrointestinal function and identify complications like ileus, which can cause abdominal pressure and nausea.
Question 5 of 5
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes mellitus (DM). Which outcome should the nurse include in the plan of care for this client?
Correct Answer: C
Rationale: Achieving a hemoglobin A1C of less than 7% in 3 months is a measurable outcome indicating good glycemic control, which helps prevent diabetic complications like blurred vision.