Level 3 HESI Review

A widowed woman is being admitted for emergency cardiac surgery by the nurse. She is asking the nurse questions about who will make decisions for her if something goes wrong during her surgery. Which of these is the correct course of action for the nurse?

• The nurse is not involved with advance directives. She should alert a social worker that the patient needs help establishing advance directives.

• The nurse should inform and educate this client about advance directives, help coordinate their creation, and ensure they are in the medical record.

• The nurse should inform and educate this client that the nurse will act as a healthcare proxy for the patient, should the client be rendered incapable of making medical decisions for herself.

• The nurse should inform the physician and advocate for the delay of surgery until the patient seeks legal counsel.

Answer explanation

According to the Patient Self Determination Act of 1990, it is the nurse’s legal duty to inform and educate clients on advance directives upon admission to any healthcare facility. This includes assessment of whether or not the client requires advance directives, facilitating the creation of the documents, and ensuring they are part of the medical record. The nurse may not act as a healthcare proxy for the client.

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?

• Prepare to administer recombinant tissue plasminogen activator (rt-PA).

• Discuss the precipitating factors that caused the symptoms.

• Schedule for A STAT computer tomography (CT) scan of the head.

• Notify the speech pathologist for an emergency consultation.

Answer explanation

A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use rt-PA. Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:

• A negative Kernig’s sign.

• A positive Brudzinski’s sign.

• Absence of nuchal rigidity.

• A Glascow Coma Scale score of 15.

Answer explanation

Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski’s sign, and positive Kernig’s sign. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. Brudzinski’s sign is characterized by reflexive flexion of the knees and hips following passive neck flexion. To elicit this sign, the examiner places one hand on the patient’s chest and the other hand behind the patient’s neck. The examiner then passively flexes the neck forward and assesses whether the knees and hips flex.

Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. The Kernig sign is one of the eponymous clinical signs of meningitis. This test typically is performed in patients while supine and is described as resistance (or pain) with passive extension of the knees. This resistance is thought to be due to meningeal inflammation in the setting of meningitis or other clinical entities that may irritate the meninges.

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

• Cholesterol level

• Pupil size and pupillary response

• Bowel sounds

• Echocardiogram

Answer explanation

It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact. Pupil size and equality is determined by a balance between parasympathetic and sympathetic innervation. Response to light reflects the combined function of the optic (II) and oculomotor (III) cranial nerves.

The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to

determine if the fetus has

• hemophilia.

• a neural tube defect.

• sickle cell anemia.

• a normal lecithin/sphingomyelin (L/S) ratio.

Answer explanation

An open neural tube allows a high level of AFP to seep into the amniotic fluid and enter the maternal serum. Hemophilia is a genetic defect and is best detected with chromosomal studies

such as chorionic villus sampling or amniocentesis. Sickle cell is a genetic defect and is best detected with chromosomal studies such as chorionic villus sampling or amniocentesis. L/S

ratios are determined with an amniocentesis, which is usually done in the third trimester.

The nurse is presenting to a group of parents whose children are suspected of having autism spectrum disorder (ASD).Which statement by the nurse should be included?

• "The features of autism are typically apparent by the time a child is 3 years of age."

• "You should notice deficits in your child by the age of 5."

• "A feature of ASD is the ability to understand nonverbal behavior."

• "A child with ASD should be able to successfully engage in imaginative play."

Answer explanation

The essential features of ASD (social deficits, language impairment, and repetitive behaviors) typically become apparent by the time a child is 3 years of age, not 5. The child with ASD is unable to read nonverbal behavior or engage in imaginative play.

A prenatal client has been scheduled for induction of labor and tells the nurse she does not understand why her cervix needs to be softened with misoprostol. She asks, "Won't it be faster if we just start the Pitocin?" Which explanation from the nurse would be most accurate?

• Cervical ripening decreases the likelihood of failed induction.

• It is advisable to decline cervical ripening because it does not improve outcomes.

• Softening of the cervix does not occur in normal labor, but is required for induction.

• Misoprostol is the only effective method of cervical ripening.

Answer explanation

Cervical ripening decreases the duration of induction, Pitocin administration, and the incidence of failed induction. It is an evidenced-based intervention that clients should be encouraged to consider when indicated. Softening of the cervix normally occurs in late pregnancy or early labor. There are several other methods of cervical ripening, including Cervidil and intracervical balloon catheters.

A patient is receiving treatment for Crohn's Disease. Which food found on the patient's food tray should the patient avoid?

• Fresh salad

• White rice

• Baked chicken

• Cooked skinless apples

Answer explanation

Patients who are experiencing flare-ups of Crohn's Disease should avoid high fiber foods, foods that are hard to digest, spicy foods, dairy products etc. Therefore, the patient should avoid a fresh salad. This contain vegetables which are high in fiber and hard to digest. The gut needs to rest. It is best for the patient to consume low fiber and high protein foods. White rice and fruits/vegetables that are cooked/skinless are low in fiber. Baked chicken is a good source of protein for the patient.

A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital’s disaster plan is activated and the wounded are brought to the hospital. You’re helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor?

• Red

• Yellow

• Green

• Black

Answer explanation

The answer is C: Green tags are for patients who have MINOR injuries. If the patient can walk around they are tagged as green. Sometimes they are referred to as the “walking wounded”. The red tag indicates the patient must be seen first because they have life-threatening injuries, but could survive if treated quickly. The black tag is placed on the wounded that are dying or have expired. Yellow tags are for those who will need treatment in the next two hours but are stable at this time.

A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan?

• 1.) Restrict food and fluids.

• 2.) Reduce external stimuli.

• 3.) Monitor blood glucose levels.

• 4.) Maintain the client in a supine position.

Answer explanation

The client with severe preeclampsia is kept on bed rest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a seizure should be kept to a minimum. Food and fluid are not restricted unless specifically prescribed by the health care provider. The client is instructed to rest in a left lateral position to decrease pressure on the vena cava, thereby increasing cardiac perfusion of vital organs.