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Foundations Hesi
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Foundations HesiA 16-year-old client has a blood pressure reading of 119/75. What is the approximate
pulse pressure? - ANS-Ans: 44 Rationale
The difference between the systolic and diastolic pressure is called the pulse pressure.
The given blood pressure is 119/75. The difference between 119 and 75 is 44.
A 50-year-old client being seen for a routine physical asks why a stool specimen for
occult blood testing has been prescribed when there is no history of health problems.
What is an appropriate nursing response?
"You will need to ask your healthcare provider; it is not part of the usual tests for people
your age."
"There must be concern of a family history of colon cancer; that is a primary reason for
an occult blood stool test."
"It is performed routinely starting at your age as part of an assessment for colon
cancer."
"There must have been a positive finding after a digital rectal examination performed by
your healthcare provider." - ANS-Ans: C Rationale
The primary reason for a stool specimen for guaiac occult blood testing is that it is part
of a routine examination for colon cancer in any client over the age of 40. Age, family
history of polyps, and a positive finding after a digital rectal examination are factors
related to colon cancer and secondary reasons for the occult blood test (guaiac test).
A 50-year-old client with a 30-year history of smoking reports a chronic cough and
shortness of breath related to chronic obstructive pulmonary disease (COPD). The
clinical data on admission are as follows: a heart rate of 100, a blood pressure of
138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen
saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates
a positive outcome? Select all that apply.
Radial pulse: 70
Temperature: 37 °C
Respiratory rate: 14
,Blood pressure: 110/70
Oxygen saturation: 92% - ANS-Ans:C,D,E Rationale
The respiratory rate ranges in older adults from 12 to 20 breaths/min and this range
may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus a
rate decrease to 14 breaths/min indicates a positive outcome. COPD may also cause
high blood pressure. Thus, a blood pressure of 110/70 obtained during therapy indicates
a positive outcome. The normal oxygen saturation rate should be 95 to 100%. An
oxygen saturation increase from 88% to 92% indicates a positive outcome of the
therapy. The radial pulse indicates a positive outcome of the therapy if the client has a
history of heart disease. A body temperature reading of 36.8 °C is considered normal
and not a sign of COPD.
A client arrives at a health clinic stating, "I am here to have my tuberculin skin test
read." The nurse notes that there is a 7-mm indurated area at the injection site. Which
statement made by the nurse correctly describes this result?
"The result indicates that you have active tuberculosis."
"The result indicates that you are infected with the tuberculosis organism."
"The result indicates that there are no tuberculin antibodies in your system."
"The result indicates that you have a secondary infection related to the tuberculin
organism." - ANS-Ans: B Rationale
An indurated area 5 mm or larger noted 48 to 72 hours after the tuberculin test indicates
that the person is infected with the tuberculin organism. A positive tuberculin skin test
accompanied by fever, coughing, weakness, and positive chest x-ray are manifestations
of active tuberculosis. The other choices are incorrect.
A client complains of pain in the ear. While examining the client, a nurse finds swelling
in front of the left ear. Which lymph node does the nurse expect to be involved?
Mastoid
Occipital
Submental
,Pre-auricular - ANS-Ans: D Rationale
The pre-auricular lymph node is located in front of the ear and in this situation would be
edematous. The mastoid or posterior auricular lymph node is present behind the ear.
The occipital lymph nodes are located in the back of the head, near the occipital bone of
the skull. Submental lymph nodes are located below the chin.
A client complains of rapid, involuntary movement of the eyes after a minor eye injury. A
nurse assesses the client and finds that it is a disorder of the cranial nerves. Which
condition does the nurse suspect?
Cataract
Glaucoma
Nystagmus
Strabismus - ANS-Ans: C Rationale
Nystagmus is a condition defined by rapid, involuntary, rhythmical oscillation of the
eyes. This condition is caused by local injury to the eye muscles and supporting
structures. A cataract is a condition in which the opacity of the lens will be increased;
this disorder is commonly related to age. Glaucoma is intraocular structural damage
resulting from elevated intraocular pressure. Strabismus is a congenital condition in
which both eyes do not focus on an object simultaneously. In this condition, the eyes
appear crossed.
A client complains of sudden muscle weakness during times of anger or laughter that
may occur at any time during the day. Which condition should be suspected in this
client?
Insomnia
Cataplexy
Narcolepsy
Sleep apnea - ANS-Ans: B Rationale
Cataplexy is a condition in which muscle weakness occurs suddenly during times of
intense emotion, such as anger, sadness, or laughter. A cataplexic attack may occur at
any time during the day. Insomnia is a condition in which a person has chronic difficulty
falling asleep. A person with narcolepsy also experiences frequent awakenings from
, sleep, short periods of sleep or nonrestorative sleep, or some combination thereof.
Narcolepsy is a dysfunction of the mechanisms that regulate sleeping and waking
states. Sleep apnea is a disorder characterized by a lack of airflow through the nose
and mouth for periods of 10 seconds or longer during sleep.
A client develops an allergic reaction when a student nurse is performing a physical
assessment. Which statement made by the student nurse in response to this incident
indicates the need for further teaching?
"Type I immune response to latex has an immediate onset."
"Type I immune reaction to latex leads to release of IgE antibodies."
"The client's first exposure to latex will cause a type IV allergic reaction."
"Type IV immune response to latex occurs after 12 to 48 hours after exposure." -
ANS-Ans: C Rationale
Both type I and type IV hypersensitive reactions require prior exposure to cause an
immune response in a subsequent exposure. The most immediate immune response is
a type I reaction, in which the body produces IgE antibodies against the allergen. A type
IV immune response occurs 12 to 48 hours after the exposure to the allergen and is
referred to as a delayed hypersensitivity response.
A client has a fever spike that is combined with normal temperature levels. The client's
body temperature returns to a normal body temperature at least once a day. Which type
of fever can be assessed in the client?
Sustained
Relapsing
Remittent
Intermittent - ANS-Ans: D Rationale
An intermittent fever is characterized by fever spikes interspersed with normal
temperatures. In this type of fever, the body temperature returns to normal at least once
in 24 hours. In the case of sustained fever, there is a constant body temperature greater
than 38ºC. In relapsing fever, there is an occurrence of periods of febrile episodes with
acceptable temperature values. In remittent fever, the body temperature increases and
decreases without returning to normal body temperature levels.
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