HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75 mg IM every 4 weeks. The client begins developing a puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?
Correct Answer: C
Rationale: In this scenario, the correct intervention is to complete the abnormal involuntary movement scale (AIMS) for the client. The client is exhibiting signs of tardive dyskinesia, a potential side effect of antipsychotic medications like haloperidol. AIMS is a standardized tool used to assess and monitor movement disorders, including tardive dyskinesia. By completing the AIMS assessment, the nurse can objectively evaluate the severity of the client's symptoms and determine the necessity for further intervention or medication adjustments. Discontinuing the medication immediately (Option A) is not recommended without proper assessment and evaluation of the client's symptoms. Abruptly stopping antipsychotic medications can lead to withdrawal symptoms and exacerbation of underlying psychiatric conditions. Increasing the dose of haloperidol (Option B) would be contraindicated as the client is already experiencing extrapyramidal side effects. Increasing the dose can further worsen these symptoms. Monitoring the client for signs of agitation (Option D) is important in general care but does not address the specific issue of tardive dyskinesia. Without proper assessment using the AIMS tool, the nurse may miss the opportunity to address the side effects effectively. Educationally, this scenario highlights the importance of thorough assessment, using appropriate tools, and understanding the side effects of medications in psychiatric nursing practice. It emphasizes the need for a systematic approach to managing medication side effects to ensure optimal client care and safety.
Question 2 of 5
The mother of a 2-day-old infant girl expresses concern about a 'flea bite' type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) This is a common newborn rash that will resolve after several days. This response is accurate because the description of a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen is indicative of erythema toxicum, a benign and self-limiting rash commonly seen in newborns. It typically appears in the first few days of life and resolves on its own without any treatment. Option A) We need to monitor the rash for signs of worsening or fever is incorrect because erythema toxicum is a harmless condition and does not require monitoring for worsening or fever. Option B) Your baby may have an allergic reaction to laundry detergent is incorrect as this type of rash does not indicate an allergic reaction to laundry detergent. It is a common and harmless skin condition in newborns. Option D) This is likely a bacterial infection requiring antibiotics is incorrect as erythema toxicum is not caused by a bacterial infection and does not necessitate antibiotic treatment. From an educational perspective, it is crucial for nurses to be able to differentiate between common newborn rashes to provide accurate information and reassure parents. Understanding the characteristics, causes, and management of common newborn rashes like erythema toxicum is essential for providing quality care and guidance to parents of newborns.
Question 3 of 5
A client is receiving 30 mg of enoxaparin subcutaneously twice a day. In assessing adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor?
Correct Answer: B
Rationale: In the context of a client receiving enoxaparin, a low molecular weight heparin, monitoring the platelet count is crucial. Enoxaparin works by inhibiting blood clot formation, which can lead to a condition called heparin-induced thrombocytopenia (HIT), characterized by a significant drop in platelet count. Monitoring platelet levels helps detect this potentially life-threatening adverse effect early. Hemoglobin level (Option A) is not directly affected by enoxaparin and is not the most important value to monitor in this case. Activated partial thromboplastin time (aPTT) (Option C) and Prothrombin time (PT) (Option D) are more commonly used to monitor the effects of unfractionated heparin, not enoxaparin, which has a more predictable anticoagulant response and does not require routine monitoring based on these values. In an educational context, understanding the rationale behind monitoring specific laboratory values for patients on anticoagulant therapy is critical for nurses to provide safe and effective care. Emphasizing the importance of monitoring platelet count in this scenario can help nurses recognize and respond promptly to adverse effects, ultimately improving patient outcomes.
Question 4 of 5
A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) Immunizations can trigger a relapse of the disease, so get plenty of extra rest. This is the most appropriate response because immunizations can potentially stimulate an immune response that may exacerbate symptoms in individuals with autoimmune conditions like multiple sclerosis. Encouraging the young woman to rest can help her body recover and manage any potential flare-up more effectively. Option B is incorrect because visual problems could be related to the immunizations in the context of multiple sclerosis. Option C, increasing fluid intake, may be beneficial for overall health but is not directly addressing the potential relapse triggered by the immunizations. Option D, immediate consultation for steroid therapy, is not the first-line intervention and should be reserved for cases where symptoms worsen significantly or if there is a confirmed relapse. From an educational perspective, this scenario highlights the importance of understanding the potential effects of immunizations on individuals with autoimmune conditions. Nurses play a crucial role in providing tailored education and support to help patients manage their health proactively. It also emphasizes the significance of rest and self-care in managing chronic conditions like multiple sclerosis during potential exacerbations.
Question 5 of 5
The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Arterial blood gases. After administering surfactant to a preterm newborn with respiratory distress symptoms like nasal flaring, grunting, and sternal retractions, monitoring arterial blood gases is crucial. Arterial blood gases provide vital information about the newborn's oxygenation and ventilation status, helping the nurse assess the effectiveness of the surfactant therapy in improving gas exchange. Option A) Bowel sounds, while important for assessing gastrointestinal function, is not the priority in this case where the focus is on respiratory distress. Option B) Heart rate, though important for overall assessment, is not as directly related to the effectiveness of surfactant therapy in improving respiratory function. Option D) Apnea episodes are significant in preterm newborns but in this context, monitoring arterial blood gases takes precedence as it directly reflects the respiratory status and the impact of surfactant therapy on oxygenation and ventilation. Educationally, this question underscores the importance of prioritizing assessments based on the patient's condition and the interventions provided, highlighting the critical role of arterial blood gases in evaluating respiratory function in neonates with respiratory distress.