HESI MedSurg Exam with Verified Answers Graded A+
1. · Respiratory effort.
Guillain-Barre syndrome causes paralysis or weakness that typically starts at
the feet and progresses upwards. As the condition progresses, the nurse must
ensure that the client is able to breathe effectively.
Heuther,...
HESI MedSurg Exam with Verified Answers Graded A+
1. · Respiratory effort.
Guillain-Barre syndrome causes paralysis or weakness that typically starts at
the feet and progresses upwards. As the condition progresses, the nurse must
ensure that the client is able to breathe effectively.
Heuther, Understanding Pathophysiology, 6th ed. p. 412: Which assessment
is most important for the nurse to perform on a client who is hospitalized for
Guillain-Barre syndrome that is rapidly progressing?
· Respiratory effort.
· Unsteady gait.
· Intensity of pain.
· Ability to eat.
2. · Collect a culture of the penile discharge.
Penile discharge with painful urination is commonly associated with gonor-
rhea. The nurse should collect a culture of the penile discharge to determine
the cause of these symptoms. The cause must be determined or confirmed
through culture to identify the organism and ensure effective treatment.
Jarvis Physical Examination and Health Assessment, 6th edition: A male client
comes into the clinic with a history of penile discharge with painful, burning urination.
Which action should the nurse implement?
· Collect a culture of the penile discharge.
· Palpate the inguinal lymph nodes gently.
· Observe for scrotal swelling and redness.
· Express the discharge to determine color.
3. · Check for a pulse deficit.
A client with a past history of atrial fibrillation may return to that rhythm. Any
signs of atrial fibrillation, such as sudden onset shortness of breath, requires
further investigation. The nurse should assess this client for a pulse deficit
because this condition occurs with atrial fibrillation.
Jarvis. (2016); Physical Examination and Health Assessment, (Chap 19) 7th
ed., p. 481: A client with history of atrial fibrillation is admitted to the telemetry unit
with sudden onset of shortness of breath. The nurse observes a new irregular heart
rhythm and should perform which assessment at this time?
· Check for a pulse deficit.
· Palpate the apical impulse.
· Inspect jugular vein pulse.
· Examine for a carotid bruit.
, HESI MedSurg Exam with Verified Answers Graded A+
4. · A 24-year-old with shoulder and lower abdominal quadrant pain.
A 24-year-old with sudden onset of lower abdominal quadrant pain should
be assessed for an ectopic pregnancy. The pain can also be referred to the
shoulder and may be associated with vaginal bleeding.
Health Assessment for Nursing Practice, Wilson and Giddens. p.269: Which
client should be further assessed for an ectopic pregnancy?
· A 24-year-old with shoulder and lower abdominal quadrant pain.
· A 33-year-old with intermittent lower abdominal cramping.
· A 20-year-old with fever and right lower abdominal colic.
· A 40-year-old with jaundice and right lower abdominal pain.
5. · Drinks a six pack of beer every day.
Drinking six beers every day is the dietary assessment finding most important
for the nurse to address when caring for a client with diabetic nephropathy.
The usual can of beer is 12 ounces (355 mL). Clients with diabetes are
recommended to drink no more than 12 ounces of beer per day because
beer contains carbohydrates that can create unhealthy fluctuations in blood
glucose and promote poor glucose control. Nephropathy is exacerbated by
poor blood glucose control.: Which dietary assessment finding is most important
for the nurse to address when caring for a client with diabetic nephropathy?
· Drinks a six pack of beer every day.
· Enjoys a hamburger once a month.
· Eats fortified breakfast cereal daily.
· Consumes beans and rice every day.
6. · Cough brought on by swallowing.
A cough brought on by swallowing is a sign of dysphagia, which is a finding of
particular concern in a client with stomatitis. Dysphagia can cause numerous
problems, including airway obstruction, and should be reported to the health-
care provider immediately.
Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative
care, eight edition., Ch. 53, p. 1100.: Which assessment finding is of greatest
concern to the nurse who is caring for a client with stomatitis?
· Cough brought on by swallowing.
· Sore throat caused by speaking.
· Painful and dry oral cavity.
· Unintended weight loss.
7. · Altered sexual response.
Peripheral arterial disease (PAD) is a cardiovascular condition characterized
, HESI MedSurg Exam with Verified Answers Graded A+
by narrowing of the arteries and reduced blood flow to the extremities. PAD
is known to alter the blood flow to the male's penis and is associated with
erectile dysfunction in men.
Ignatavicius,. (2016). Medical-surgical nursing: Patient-centered collaborative
care, eight edition., Ch. 69, p. 1452.: The nurse is teaching a client diagnosed
with peripheral arterial disease. Which genitourinary system complication should
the nurse include in the teaching?
· Altered sexual response.
· Sterility.
· Urinary incontinence.
· Decreased pelvic muscle tone.
8. · Oral contraceptives.
Women older than 35 years old who smoke and take oral contraceptives have
an increased risk of myocardial infarction or stroke.
Ignatavicius, (2013). Medical-surgical nursing: Patient-centered collaborative
care, 7th ed.., Ch. 35, p. 694.: A 40-year-old female client has a history of smoking.
Which finding should the nurse identify as a risk factor for myocardia infarction?
· Oral contraceptives.
· Senile osteopenia.
· Levothyroxine therapy.
· Pernicious anemia.
9. · Decreased color perception.
Decreased color perception occurs with cataract formation. Cataract forma-
tion is also associated with blurred vision and a global loss of vision so
gradual that the client may not be aware of it.
Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative
care, eight edition., Ch. 47,: A client has been told that there is cataract formation
over both eyes. Which finding should the nurse expect when assessing the client?
· Decreased color perception.
· Presence of floaters.
· Loss of central vision.
· Reduced peripheral vision.
10. · New onset of coughing.
A pneumothorax (partial or complete lung collapse) is the potential complica-
tion of a thoracentesis. Manifestations of a pneumothorax include new onset
of a nagging cough, tachycardia, and an increased shallow respiration rate.
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