HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 of 5
A 9-month-old with Tay-Sachs disease is admitted due to seizures. Which assessment is most important for the nurse to obtain?
Correct Answer: D
Rationale: Exaggerated startle reaction is specific to Tay-Sachs and may trigger seizures, making it critical to assess. Other findings are less urgent.
Question 2 of 5
An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LHRH) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?
Correct Answer: D
Rationale: LHRH injections delay puberty, allowing the child to reach puberty with peers, aligning sexual maturity. Other statements misalign with treatment goals.
Question 3 of 5
Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
Correct Answer: B
Rationale: Rising water levels during inspiration and falling during expiration, known as tidaling, indicate proper chest tube function, as it reflects pressure changes in the pleural space. Continuing to monitor the drainage system ensures ongoing assessment of drainage characteristics without disrupting the system unnecessarily.
Question 4 of 5
An infant who is developmentally delayed has a ventricular peritoneal (VP) shunt for hydrocephalus. The nurse makes a postoperative home visit to assess the child's progress. During the visit, the mother tells the nurse, 'When the shunt is removed, the pressure in my baby's head will be gone.' Which response should the nurse provide?
Correct Answer: B
Rationale: The shunt is typically a permanent device that may need replacement as the child grows to manage fluid drainage. Other responses are incorrect or misleading about shunt management.
Question 5 of 5
A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?
Correct Answer: D
Rationale: Sudden testicular pain and swelling suggest testicular torsion, a medical emergency requiring immediate provider notification for evaluation and possible surgery.