Evolve Comprehensive Exam (Hesi) 2023 with well Explained Answers A 6 year old child is alert but quiet when brought to the emergency center with periobital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with the basilar skull fracture? - Correct Answer Rhinorrhoea or otorrhoea with halo sign Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt abdominal injuries.A 9 year old is hospitalized for the neutropenia and is placed in reverse isolation. The child asks the nurse " why do you have to wear a gown and mask when you are in my room?" How should the nurse respond? - Correct Answer " To protect you because you can get an infection very easily Reverse isolation precaution implement measures to protect the client from exposure to microorganisms from others (B). Although microbes are prevalent in all environments, (A) does not adequately answer the child's question. Reverse isolation should be implemented until the client's white blood cell increases (C). Neutropenia in this child does not place others (D) at risk for infection.A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent? - Correct Answer Obtain the permission of the custodial parent for the surgery.The client is a minor and cannot legally sign his own consent unless he is an emancipated minor, so the consent should be obtained from the guardian for this client, which is the custodial parent (B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the child has been adopted by the stepparent (C). The non- custodial parent does not need to co-sign this form (D).A 56 year old female client is receiving intracavitary radiation via a radium implant.Which nurse should be assigned to care for this client? - Correct Answer A nurse with marfran's syndrome who is postmenopausal.A client receiving intracavity radiation poses a radiation hazard as long as the intracavity radiation source is in place. A nurse's ability to care of this client is not affected by Marfan's syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles, ligaments and skeletal structures. The goal is to limit any one staff member's exposure to the calculated time span based on the half-life of radium, such as the 1 / 3
number of minutes at the bedside per day, so (A) should not be assigned. (C) should not be exposed to the radiation due to the possible effect on the fetus. A radiation exposure decreases the immune response in the client who should not be exposed to the potential inadvertent transmission of an infectious organism (D).A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem? - Correct Answer Denial related to the loss of a loved one.Based on the data provided, (C) is the best nursing diagnosis. This client is exhibiting symptoms of anxiety and the pain is too great for her to acknowledge, so she is denying the situation. Although she may seem confused (A), she is actually trying to deal with the pain through the defense mechanism of denial. (B) occurs after one year or longer following the loss. The client's husband died one month ago. (D) and depression are often related, and depression is sometimes described as unexpressed anger. However, this client has not acknowledged her loss (denial) and the anger is not yet realized.A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20.How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.) - Correct Answer 61 The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day; or 10 to 20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for each kilogram between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24. 19.5 kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24 hours = 61 mL/hour A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops.Which information is most important for the nurse to include in the teaching plan? - Correct Answer Avoid sharing towels and washcloths with siblings All of the information is important to include in the teaching plan, but it is most important to avoid spreading the bacterial infection. The child should avoid sharing towels and washcloths (D) and should stay home from school for the first 24 hours after antibiotics are started, to prevent contamination of others. (A, B, and C) are important measures to reduce the child's discomfort, but inhibiting the spread of the infection is the priority intervention.A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate action by the nurse can lessen the symptoms of this " TET" spell? - Correct Answer Place child in knee-chest positionThis pressure reduces the rush of blood flow through the septal hole and improves blood circulation. 2 / 3
The child should be placed on his or her back in the knee-to-chest position (B) to increase blood vessel resistance. The increased pressure reduces the rush of blood through the septal hole and improves blood circulation. (A) has nominal effects in hypercyanosis. (C) is self-regulating. (D) is not indicated for immediate relief of tet spells. It is used to improve cardiac output.A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement? - Correct Answer Demonstrate the wound care procedure to the PN while the PN assists It is within the PN's scope of practice to perform sterile wound care. The best learning of skills is through demonstration and return demonstration, therefore (D) promotes safe practice while allowing the PN the best opportunity to learn. (A) does not allow the PN to gain the experience needed to perform her role. (B) does not provide the best learning opportunity for the PN, or ensure safe practice. While (C) would provide a safe method for learning the wet-to-dry procedure, it doesn't address the problem immediately and is a more costly way for the PN to learn.A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? - Correct Answer Monitor for increased blood pressure and pulse Clients with alcohol dependency experience withdrawal symptoms, which include elevated blood pressure, pulse, and temperature, so (B) has the highest priority. (A) will prevent Korsakoff's syndrome (secondary dementia caused by thiamine deficiency, associated with malnutrition secondary to excessive alcohol intake), but this intervention does not have the priority of (B). (C and D) are important for alcohol detoxification, but do not have the priority of (B).A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care? - Correct Answer One chronic and one acute illness The plan of care should include goals that are specific for chronic and acute illnesses.Adult-onset diabetes is a life-long chronic disease, whereas influenza is an acute illness with a short term duration (C). (A, B, and D) do not include the correct duration categories for this situation.A client is admitted with a medical diagnosis of addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? - Correct Answer Hypotension, rapid weak pulse, and rapid respiratory rate The clinical manifestations of Addisonian crisis are often the manifestations of shock (C); the client is at risk for circulatory collapse and shock. (A) indicates clinical
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