Week 4 HESI/ EAQs

Question 1

During a physical assessment of an at-risk patient, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of which condition?

Euglycemia

Pneumonia

Rheumatic fever

Cardiac decompensation

Answer 1

Cardiac decompensation

Question 2

The nurse is caring for an infant with breathing difficulty. Upon auscultating the infant, the nurse finds that the infant has a murmur. What suggestion does the nurse give to the parents about infant care?

“Use formula milk.”

“Additional cardiac testing is necessary.”

“The infant should be wrapped in a thick blanket.”

“Maintain skin-to-skin contact with the mother.”

Answer 2

“Additional cardiac testing is necessary.”

Question 3

The nurse evaluates the blood pressure (BP) of a neonate and suspects a cardiac defect. What recordings of the neonate’s BP confirm a cardiac defect?

The BP in the lower extremities is 60/40 mm Hg and in the upper extremities is 70/50 mm Hg.

The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg.

The BP in the lower extremities is 70/40 mm Hg and in the upper extremities is 60/40 mm Hg.

The BP in the lower extremities is 80/40 mm Hg and in the upper extremities is 70/60 mm Hg.

Answer 3

The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg.

Question 4

The nurse observes on the cardiac monitor that a child admitted with diabetic ketoacidosis has a widening of the QT interval and the appearance of U wave after a flattened T wave. Which would the nurse conclude from such an observation?

The child has hypokalemia.

The child has hypovolemia.

The child has hypercalcemia.

The child has hyperkalemia.

Answer 4

The child has hypokalemia.

Question 5

For which reason would an infant with cyanosis undergo a hyperoxia test?

To identify the presence of congenital defects

To confirm streptococcal antibodies in the blood

To determine the oxygen level found in the blood

To determine the underlying cause of their cyanosis

Answer 5

To determine the underlying cause of their cyanosis

Question 6

Which education would the nurse provide the parent of an infant about how to treat a hypercyanotic spell following a crying episode?

Hold the infant in the knee-chest position

Place the infant in a semi-Fowler position

Administer oral fluids to prevent dehydration

Breastfeed the infant after they have calmed

Answer 6

Hold the infant in the knee-chest position

The nurse would teach the parent to Flex the hips and knees, as this decreases venous return to the heart from the legs. When venous return to the heart is decreased, the cardiac workload is decreased. Placing the child in a semi-Fowler position will not help to decrease the cardiac overload. Oral fluids are not administered to the child as this is will not relieve cyanosis. The child may not be able to feed orally, so the nurse would not advise breastfeeding the child.

Question 7

Which recommendation would the nurse provide the parent of an unrepaired cardiac defect about managing the illness at home?

Highlight the need to be extremely concerned about cyanotic spells

Advise the parent relax discipline and limit-setting to prevent crying

Emphasize promoting normalcy within the limits of the child’s condition

Stress the importance of reduced caloric intake to decrease cardiac demands

Answer 7

Emphasize promoting normalcy within the limits of the child’s condition

Question 8

Which complication is associated with the use of peripheral venous catheters?

Phlebitis

Cardiac dysfunction

Hirschsprung disease

Oxygen-induced carbon dioxide narcosis

Answer 8

Phlebitis

Question 9

Which cause may account for a sudden increase in heart rate in a postoperative infant?

Vagal stimulation

Decreased perfusion

Respiratory distress (late)

Increased intracranial pressure

Answer 9

Decreased perfusion

Question 10

Which action would the nurse take upon finding that the pulse distal to the cardiac catheter insertion site is weaker?

Elevate the affected extremity

Document findings in patient chart

Notify the provider of the abnormal finding

Apply warm compresses to the insertion site

Answer 10

Document findings in patient chart

Question 11

Cerebral palsy may result from a variety of causes. It is now known that which is the most common cause of cerebral palsy?

Birth asphyxia

Neonatal diseases

Cerebral trauma

Prenatal brain abnormalities

Answer 11

Prenatal brain abnormalities

Question 12

Which response from the child with cerebral palsy indicates to the nurse that the child is in pain?

Crying

Moaning

Telling the nurse to stop

Showing the nurse where the pain is

Answer 12

Moaning

Question 13

Which statement describes the major goal of therapy for children with cerebral palsy?

Reverse degenerative processes that have occurred.

Cure the underlying defect causing the disorder.

Prevent spread to individuals in close contact with the child.

Recognize the disorder early and promote optimal development.

Answer 13

Recognize the disorder early and promote optimal development.

Question 14

Which is a preferred medication or treatment to prevent cerebral edema in a comatose child?

Sedatives

Osmotherapy

Corticosteroids

Barbiturates

Answer 14

Osmotherapy

Question 15

Which body function can be inferred from observing the balance and coordination status of a child?

Joint function

Bone function

Cerebral function

Cerebellar function

Answer 15

Cerebellar function

Question 16

The nurse is doing a neurologic assessment on a 2-month-old infant following a car accident. Moro, tonic neck, and withdrawal reflexes are present. Which would the nurse recognize that these reflexes suggest?

Neurologic health

Severe brain damage

Decorticate posturing

Decerebrate posturing

Answer 16

Neurologic health

Question 17

The nurse is caring for a 5-year-old child who had a craniotomy. The nurse is assessing the neurologic status of the child and has checked the level of consciousness, pupillary activity, and reflexes. Which additional item would the nurse assess in the patient?

Blood pressure

Motor function

Rectal temperature

Head circumference

Answer 17

Motor function

Question 18

The nurse is caring for a 10-year-old child with a history of diabetes mellitus who recently had brain surgery. On assessment, the nurse finds that the body temperature has risen to 103°F. Which is an appropriate interpretation by the nurse?

Children with diabetes mellitus usually develop an infection after surgery.

High body temperature is common in children after surgical procedures.

Cerebral edema after brain surgery exerts pressure on the hypothalamus.

Excessive viscid secretions result in inadequate respiratory ventilation.

Answer 18

Cerebral edema after brain surgery exerts pressure on the hypothalamus.

Question 19

Which is an additional assessment the nurse would perform in a child who shows other symptoms of hydrocephalus, such as sluggish pupils and dilation of scalp veins during crying?

Evaluates the electroencephalogram (EEG) reports

Assesses for signs of bacterial meningitis

Measures the child’s head circumference

Assesses the child’s motor functions

Answer 19

Measures the child’s head circumference

Question 20

The nurse is caring for an infant who sustained a head injury during a fall. The infant presents with signs of increased intracranial pressure (ICP). Which is an appropriate nursing action in this context?

Weighing the infant daily before feeding

Elevating the infant’s head higher than the hips

Checking the infant’s reflexes every 15 minutes

Providing stimulation to check the level of consciousness

Answer 20

Elevating the infant’s head higher than the hips

Question 21

The nurse is planning care for a school-age child with bacterial meningitis. Which would the plan include?

Keeping environmental stimuli at a minimum

Avoiding giving pain medications that could dull sensorium

Measuring head circumference to assess developing complications

Having the child move head side to side at least every 2 hours

Answer 21

Keeping environmental stimuli at a minimum

Question 22

The nurse is assessing a neonate with hydrocephaly. What observation reported by the nurse would be consistent with the neonate’s condition?

A body weight of 7 pounds

A heart rate 120 beats/min

A head-to-heel length of 55 cm

A head circumference greater than chest circumference

Answer 22

A head circumference greater than chest circumference

Question 23

The nurse auscultates a neonate in resting position and hears a murmur. What further assessments should the nurse make to know if the infant has any cardiac defects?

Monitor blood pressure (BP) in the upper extremities

Measure the circumference of the head

Assess movements of the lower extremities

Assess BP in all four extremities

Answer 23

Assess BP in all four extremities

Question 24

Why are infants particularly vulnerable to acceleration-deceleration head injuries?

The anterior fontanel is not yet closed.

The nervous tissue is not well developed.

The scalp of the head has extensive vascularity.

Musculoskeletal support of head is insufficient.

Answer 24

Musculoskeletal support of head is insufficient.

Question 25

The nurse is assessing the neurologic activity of a neonate. What observation should the nurse report? The ability to suck Head circumference Head-to-toe measurements Abdominal movements

Answer 25

The ability to suck

Question 26

Which nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child? Suctioning the child frequently Providing environmental stimulation Turning the head side to side every hour Avoiding activities that cause pain or crying

Answer 26

Avoiding activities that cause pain or crying

Question 27

Which measurement scale does the nurse use to assess the level of consciousness (LOC) in a child? Glasgow Coma Scale (GCS) Doll's head maneuver Caloric test Oculovestibular response

Answer 27

Glasgow Coma Scale (GCS)

Question 28

The nurse is performing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. Which is the most appropriate nursing assessment in this case? Reactivity of pupils Doll's head maneuver Oculovestibular response Funduscopic examination to identify papilledema

Answer 28

Reactivity of pupils

Question 29

A 9-month-old infant sustained a head injury during an automobile collision. The infant is quiet and has a prominent hematoma on the right temporal area. Which assessment finding is most important for the nurse to report? Persistent vomiting Temperature of 99.6°F Positive Babinski reflex Heart rate of 110 beats/per minute

Answer 29

Persistent vomiting

Question 30

Which is an important nursing intervention when caring for a child with myelomeningocele in the postoperative stage? Place child on the side to decrease pressure on the spinal cord. Apply a heat lamp to facilitate drying and toughening of the sac. Keep skin clean and dry to prevent irritation from diarrheal stools. Measure head circumference and examine fontanels for signs that might indicate developing hydrocephalus.

Answer 30

Measure head circumference and examine fontanels for signs that might indicate developing hydrocephalus.

Question 31

Which medication helps reduce intracranial pressure (ICP) elevations greater than 20 to 25 mm Hg in a child? Phenytoin Rectal diazepam Mannitol Ibuprofen

Answer 31

Mannitol

Question 32

The nurse is assessing risk factors for injury at a well visit for an 8-year-old child. Which question by the nurse is the most important to ask the caregivers? "Do you keep all medications safely locked up?" "Do you leave your child unattended in the bathtub?" "Does your child use a safety helmet when riding a bike?" "Have you discussed the dangers of drugs and alcohol with your child?"

Answer 32

"Does your child use a safety helmet when riding a bike?"

Question 33

Which position would the nurse select for an infant with congestive heart failure to promote maximum chest expansion and reduce respiratory distress? "Prone positioning." "A 45-degree angle." "Supine positioning." "Knee-chest position."

Answer 33

"A 45-degree angle."

Question 34

Which teaching does the nurse provide to the parents about the computed tomography (CT) scan that is prescribed for their child with head trauma? "This scan helps detect structural brain abnormalities." "This scan helps detect the severity of the trauma." "This scan is done to assess cerebral edema." "This scan will help identify any seizure activity."

Answer 34

"This scan helps detect the severity of the trauma."

Question 35

A 5-year-old female child has been sent to the school nurse for urinary incontinence three times in the past 2 days. The nurse would recommend to the parent that the child be evaluated for which condition first? School phobia Emotional causes Possible urinary tract infection Possible structural defects of the urinary tract

Answer 35

Possible urinary tract infection

Question 36

A child with a renal transplant is reported to have diminished urinary output. Which would the nurse infer from the report? The patient is suffering from poststreptococcal infection. The kidney is being rejected by the body due to graft rejection. The kidney that has been recently introduced has suffered an injury. The urinary output remains low after renal transplants during the first month.

Answer 36

The kidney is being rejected by the body due to graft rejection.

Question 37

The nurse observes that a child has diminished urinary output and shows signs of lethargy and dehydration following surgery. Which condition does the nurse suspect in the child? Seizures Chronic renal failure Acute kidney injury (AKI) Acute glomerulonephritis (AGN)

Answer 37

Acute kidney injury (AKI)

Question 38

According to Erikson, to meet the psychosocial needs of a 5-year-old child in relation to a diagnosis of diabetes, which of the following should the nurse implement? Allow the client to eat according to preference and instruct the parents to give insulin as needed to maintain blood glucose levels. Explain to the parents the reasons why their child must have rigid dietary restrictions. Check the client's blood glucose levels 4 times a day and at bedtime. Allow the client to check blood glucose levels independently whenever possible.

Answer 38

Allow the client to check blood glucose levels independently whenever possible.

Question 39

Type 1 diabetes mellitus is an auto-immune disease caused by the destruction of __________________________. The client is unable to make insulin and will require insulin injections for the rest of their life.

Answer 39

insulin-producing pancreatic β cells

Question 40

Considering the potential problem of hypoglycemia, what nursing intervention has the highest priority? Refer the parents to a nutritionist. Discuss implications in the school setting. Recommend frequent hand washings. Emphasize the importance of frequent blood glucose monitoring.

Answer 40

Emphasize the importance of frequent blood glucose monitoring.

Question 41

The nurse recognizes that epidural hematomas have which characteristic? Rapid brain decompression. Distinct, classic clinical signs. Periods of impaired consciousness. Usually caused by skull fracture.

Answer 41

Rapid brain decompression.

Question 42

To prepare the client's parents for her CT scan, which explanation by the nurse is accurate? “Your daughter will only be gone a short while. You may wait for her here.” “A nurse from the ED will remain with your daughter to monitor her constantly.” “Your daughter will be given a sedative to assure that she holds still.” “Your daughter will be asked to swallow a small amount of contrast material.”

Answer 42

“A nurse from the ED will remain with your daughter to monitor her constantly.”

Question 43

The nurse recognizes that signs of increased intracranial pressure (ICP) in infants differs from signs in older children. Which symptom is most characteristic of ICP in infants? Forceful vomiting. Blurred vision. Headache. Separated cranial sutures.

Answer 43

Separated cranial sutures.

Question 44

While conducting the client's neurological assessment, the nurse notes possible damage to cranial nerve III as evidenced by which of the following symptoms? Facial asymmetry. Ptosis and dilated pupils. Difficulty swallowing. Altered gag reflex.

Answer 44

Ptosis and dilated pupils.

Question 45

The brother's heart rate changes from 80 to 65 bpm, his pupils are less reactive to light, and his response to pain is diminished. Which conclusion regarding this assessment is accurate? Early signs of increased intracranial pressure. Late signs of increased intracranial pressure. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH). Impending brainstem herniation.

Answer 45

Late signs of increased intracranial pressure.

Question 46

Which clinical manifestations should the nurse expect to assess in an infant diagnosed with a ventricular septal defect (VSD)? Normal S1 and S2 heart sounds with no audible murmur or palpable thrill. Tachypnea and grunting with intercostal and subcostal retractions. Extreme pallor and porcelain-like skin. Excessive bruising, lymphadenopathy, and poor skin turgor.

Answer 46

Tachypnea and grunting with intercostal and subcostal retractions.

Question 47

Heart failure (HF) in a pediatric client is most often manifested by which symptoms? Frequent feedings with irritability and poor suckling. An active and happy baby that does not sleep very much. Cyanosis of the fingers, toes, and gums. Frequent nosebleeds.

Answer 47

Frequent feedings with irritability and poor suckling.