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HESI - MEDICAL SURGICAL NURSING TEST QUESTIONS AND ANSWERS
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HESI - MEDICAL SURGICAL NURSING TEST QUESTIONS AND ANSWERS
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SAUNDERS HESI MED SURG questionsand answers
Thexnursexisxconductingxaxsessionxaboutxthexprinciplesxofxfirstxaidxandxisxdiscussingxthexin
terventionsxforxsnakebitextoxanxextremity.xThexnursexshouldxinformxthosexattendingxthexse
ssionxthatxthexfirstxpriorityxinterventionxinxthexeventxofxthisxoccurrencexisxwhichxaction?
1.xImmobilizexthexaffectedxextremity.
2.xRemovexjewelryxandxconstrictingxclothingxfromxthexvictim.
3.xPlacexthexextremityxinxaxpositionxsoxthatxitxisxbelowxthexlevelxofxthexheart.
4.xMovexthexvictimxtoxaxsafexareaxawayxfromxthexsnakexandxencouragexthexvictimxtoxrest.x-
xans✔✔4
Inxthexeventxofxaxsnakebite,xthexfirstxpriorityxisxtoxmovexthexvictimxtoxaxsafexareaxawayxfrom
xthexsnakexandxencouragexthexvictimxtoxrestxtoxdecreasexvenomxcirculation.xNext,xjewelryx
andxconstrictingxclothingxarexremovedxbeforexswellingxoccurs.xImmobilizingxthexextremityx
andxmaintainingxthexextremityxatxthexheartxlevelxwouldxbexdonexnext;xthesexactionsxlimitxth
exspreadxofxthexvenom.xThexvictimxisxkeptxwarmxandxcalm.xStimulantsxsuchxasxalcoholxorx
caffeinatedxbeveragesxarexnotxgivenxtoxthexvictimxbecausexthesexproductsxmayxspeedxthe
xabsorptionxofxthexvenom.xThexvictimxshouldxbextransportedxtoxanxemergencyxfacilityxasxs
oonxasxpossible.
Axclientxcallsxthexemergencyxdepartmentxandxtellsxthexnursexthatxhexcamexdirectlyxintoxco
ntactxwithxpoisonxivyxshrubs.xThexclientxtellsxthexnursexthatxhexcannotxseexanythingxonxthe
xskinxandxasksxthexnursexwhatxtoxdo.xThexnursexshouldxmakexwhichxresponse?
1.x"Comextoxthexemergencyxdepartment."
2.x"Applyxcalaminexlotionximmediatelyxtoxthexexposedxskinxareas."
3.x"Takexaxshowerximmediately,xlatheringxandxrinsingxseveralxtimes."
4.x"Itxisxnotxnecessaryxtoxdoxanythingxifxyouxcannotxseexanythingxonxyourxskin."x-xans✔✔3
Whenxanxindividualxcomesxinxcontactxwithxaxpoison
ivyxplant,xthexsapxfromxthexplantxformsxanxinvisiblexfilmxonxthexhumanxskin.xThexclientxsho
uldxbexinstructedxtoxcleansexthexareaxbyxshoweringximmediatelyxandxtoxlatherxthexskinxsev
eralxtimesxandxrinsexeachxtimexinxrunningxwater.xRemovingxthexpoisonxivyxsapxwillxdecrea
sexthexlikelihoodxofxirritation.xCalaminexlotion
mayxbexonexproductxrecommendedxforxusexifxdermatitis
,develops.xThexclientxdoesxnotxneedxtoxbexseenxinxthexemergencyxdepartmentxatxthisxtime.
Axclientxisxbeingxadmittedxtoxthexhospitalxforxtreatmentxofxacutexcellulitisxofxthexlowerxleftxle
g.xDuringxthexadmissionxassessment,xthexnursexexpectsxtoxnotexwhichxfinding?
1.xAnxinflammationxofxthexepidermisxonly
2.xAxskinxinfectionxofxthexdermisxandxunderlyingxhypodermis
3.xAnxacutexsuperficialxinfectionxofxthexdermisxandxlymphatics
4.xAnxepidermalxandxlymphaticxinfectionxcausedxbyxStaphylococcusx-xans✔✔2
Cellulitisxisxanxinfectionxofxthexdermisxandxunderlyingxhypodermisxthatxresultsxinxdeepxredx
erythemaxwithout
sharpxbordersxandxspreadsxwidelyxthroughoutxtissuexspaces.xThexskinxisxerythematous,xe
dematous,xtender,xandxsometimesxnodular.xErysipelasxisxanxacute,xsuperficial,xrapidlyxspr
eadingxinflammationxofxthexdermisxandxlymphatics.xThexinfectionxisxnotxsuperficialxandxext
endsxdeeperxthanxthexepidermis.
Thexclinicxnursexassessesxthexskinxofxaxclientxwithxpsoriasisxafterxthexclientxhasxusedxaxne
wxtopicalxtreatmentxforx2xmonths.xThexnursexidentifiesxwhichxcharacteristicsxasximprovem
entxinxthexmanifestationsxofxpsoriasis?x(SELECTxALLxTHATxAPPLY)
1.xPresencexofxstriae
2.xPalpablexradialxpulses
3.xAbsencexofxanyxecchymosisxonxthexextremities
4.xThinnerxandxdecreasexinxthexnumberxofxreddishxpapules
5.xScarcexamountxofxsilvery-whitexscalyxpatchesxonxthexarmsx-xans✔✔4,x5
Psoriasisxskinxlesionsxincludexthickxreddenedxpapulesxorxplaquesxcoveredxbyxsilvery-
whitexpatches.xAxdecreasexinxthexseverityxofxthesexskinxlesionsxisxnotedxasxanximproveme
nt.xThexpresencexofxstriaex(stretchxmarks),xpalpablexpulses,xorxlackxofxecchymosisxisxnotxr
elatedxtoxpsoriasis.
Thexclinicxnursexnotesxthatxthexhealthxcarexproviderxhasxdocumentedxaxdiagnosisxofxherp
esxzosterx(shingles)xinxthexclient'sxchart.xBasedxonxanxunderstandingxofxthexcausexofxthisx
disorder,xthexnursexdeterminesxthatxthisxdefinitivexdiagnosisxwasxmadexbyxwhichxdiagnost
icxtest?x
1.xPositivexpatchxtestx
2.xPositivexculturexresultsx
3.xAbnormalxbiopsyxresultsx
4.xWood'sxlightxexaminationxindicativexofxinfectionx-xans✔✔2x
Withxthexclassicxpresentationxofxherpesxzoster,xthe
clinicalxexaminationxisxdiagnostic.xHowever,xviralxculturexofxthexlesionxprovidesxaxdefinitiv
exdiagnosis.xHerpesxzosterx(shingles)xisxcausedxbyxaxreactivationxofxthexvaricella-
zosterxvirus,xthexvirusxthatxcausesxchickenpox.xAxpatchxtestxisxaxskinxtestxthatxinvolvesxthe
,xadministrationxofxanxallergenxtoxthexsurfacexofxthexskinxtoxidentifyxspecificxallergies.xAxbio
psyxwouldxprovidexaxcytologicalxexaminationxofxtissue.xInxaxWood'sxlightxexamination,xthex
skinxisxviewedxunderxultravioletxlightxtoxidentifyxsuperficialxinfectionsxofxthexskin.
Axclientxreturnsxtoxthexclinicxforxfollow-
upxtreatmentxfollowingxaxskinxbiopsyxofxaxsuspiciousxlesionxperformedx1xweekxago.xThexbi
opsyxreportxindicatesxthatxthexlesionxisxaxmelanoma.xThexnursexunderstandsxthatxmelano
maxhasxwhichxcharacteristics?x(SELECTxALLxTHATxAPPLY.)
1.xLesionxisxpainfulxtoxtouch.
2.xLesionxisxhighlyxmetastatic.
3.xLesionxisxaxnevusxthatxhasxchangesxinxcolor.
4.xSkinxunderxthexlesionxisxreddenedxandxwarmxtoxtouch.
5.xLesionxoccursxinxbodyxareaxexposedxtoxoutdoorxsunlight.x-xans✔✔2,x3
Melanomasxarexpigmentedxmalignantxlesionsxoriginatingxinxthexmelanin-
producingxcellsxofxthexepidermis.xMelanomasxcausexchangesxinxaxnevusx(mole),xincluding
xcolorxandxborders.xThisxskinxcancerxisxhighlyxmetastatic,xandxaxperson'sxsurvivalxdepend
sxonxearlyxdiagnosisxandxtreatment.xMelanomasxarexnotxpainfulxorxaccompaniedxbyxsignxo
fxinflammation.xAlthoughxsunxexposurexincreasesxthexriskxofxmelanoma,xlesionsxarexmostx
commonlyxfoundxonxthexupperxbackxandxlegsxandxon
thexsolesxandxpalmsxofxpersonsxwithxdarkxskin.
Whenxassessingxaxlesionxdiagnosedxasxbasalxcellxcarcinoma,xthexnursexmostxlikelyxexpec
tsxtoxnotexwhichxfindings?x(SELECTxALLxTHATxAPPLY.)
1.xAnxirregularlyxshapedxlesion
2.xAxsmallxpapulexwithxaxdry,xroughxscale
3.xAxfirm,xnodularxlesionxtoppedxwithxcrust
4.xAxpearlyxpapulexwithxaxcentralxcraterxandxaxwaxyxborder
5.xLocationxinxthexbaldxspotxatopxthexheadxthatxisxexposedxtoxoutdoorxsunlightx-
xans✔✔4,x5
Basalxcellxcarcinomaxappearsxasxaxpearlyxpapulexwith
axcentralxcraterxandxrolledxwaxyxborder.xExposurextoxultravioletxsunlightxisxaxmajorxriskxfac
tor.xAxmelanomaxisxanxirregularlyxshapedxpigmentedxpapulexorxplaquexwithxaxred-,xwhite-,x
orxblue-
tonedxcolor.xActinicxkeratosis,xaxpremalignantxlesion,xappearsxasxaxsmallxmaculexorxpapul
exwithxaxdry,xrough,xadherentxyellowxorxbrownxscale.xSquamousxcellxcarcinomaxisxaxfirm,x
nodularxlesionxtoppedxwithxaxcrustxorxaxcentralxareaxofxulceration.
Axclientxarrivingxatxthexemergencyxdepartmentxhasxexperiencedxfrostbitextoxthexrightxhand
.xWhichxfindingxwouldxthexnursexnotexonxassessmentxofxthexclient'sxhand?
1.xAxpink,xedematousxhand
2.xFieryxredxskinxwithxedemaxinxthexnailxbeds
, 3.xBlackxfingertipsxsurroundedxbyxanxerythematousxrash
4.xAxwhitexcolorxtoxthexskin,xwhichxisxinsensitivextoxtouchx-xans✔✔4
Assessmentxfindingsxinxfrostbitexincludexaxwhitexor
bluexcolor;xthexskinxwillxbexhard,xcold,xandxinsensitivextoxtouch.xAsxthawingxoccurs,xflushin
gxofxthexskin,xthexdevelopmentxofxblistersxorxblebs,xorxtissuexedemaxappears.xOptionsx1,x2
,xandx3xarexincorrect.
Thexeveningxnursexreviewsxthexnursingxdocumentationxinxaxclient'sxchartxandxnotesxthatxt
hexdayxnursexhasxdocumentedxthatxthexclientxhasxaxstagexIIxpressurexulcerxinxthexsacralxar
ea.xWhichxfindingxwouldxthexnursexexpectxtoxnotexonxassessmentxofxthexclient'sxsacralxare
a?
1.xIntactxskin
2.xFull-thicknessxskinxloss
3.xExposedxbone,xtendon,xorxmuscle
4.xPartial-thicknessxskinxlossxofxthexdermisx-xans✔✔4
InxaxstagexIIxpressurexulcer,xthexskinxisxnotxintact.
Partial-
thicknessxskinxlossxofxthexdermisxhasxoccurred.xItxpresentsxasxaxshallowxopenxulcerxwithxa
xred-pinkxwoundxbed,xwithoutxslough.xItxmayxalsoxpresentxasxanxintactxorxopen/
rupturedxserum-filledxblister.xThexskinxisxintactxinxstagexI.xFull-
thicknessxskinxlossxoccursxinxstagexIII.xExposedxbone,xtendon,xorxmusclexisxpresentxinxsta
gexIV
Anxadultxclientxwasxburnedxinxanxexplosion.xThexburnxinitiallyxaffectedxthexclient'sxentirexfa
cex(anteriorxhalfxofxthexhead)xandxthexupperxhalfxofxthexanteriorxtorso,xandxtherexwerexcirc
umferentialxburnsxto
thexlowerxhalfxofxbothxarms.xThexclient'sxclothesxcaughtxonxfire,xandxthexclientxran,xcausing
xsubsequentxburnxinjuriesxtoxthexposteriorxsurfacexofxthexheadxandxthexupperxhalfxofxthexp
osteriorxtorso.
Usingxthexrulexofxnines,xwhatxwouldxbexthexextentxofxthexburnxinjury?
1.x18%
2.x24%
3.x36%
4.x48%x-xans✔✔3
Accordingxtoxthexrulexofxnines,xwithxthexinitialxburn,
thexanteriorxhalfxofxthexheadxequalsx4.5%,xthexupperxhalfxofxthexanteriorxtorsoxequalsx9%,x
andxthexlowerxhalfxofxbothxarmsxequalsx9%.xThexsubsequentxburnxincludedxthexposteriorxh
alfxofxthexhead,xequalingx4.5%,xandxthexupperxhalfxofxposteriorxtorso,xequalingx9%.xThisxto
talsx36%.
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