Hesi Medical Surgical 1

Correct Answer: C. Normal.

Why this is the correct answer:

A concave curvature at the back of the neck is the natural cervical lordosis seen in children and adults. It represents the normal alignment of the cervical spine, which helps balance the head and distribute weight. By age 10, cervical lordosis is well established as part of spinal development. Therefore, this finding should be documented as a normal curvature and not mistaken for abnormality.

Why the other options are incorrect:

A. Minor deviation.

Labeling this curvature as a minor deviation would be inaccurate since it is not a deviation but a normal spinal alignment. Deviations suggest abnormality, which is not the case here.

B. Abnormal.

A concave cervical curve is not abnormal in a 10-year-old. An abnormal finding would be kyphosis or scoliosis, not the expected cervical lordosis.

D. Indicative of skeletal immaturity.

Skeletal immaturity refers to incomplete bone growth or epiphyseal plate status, not the presence of cervical lordosis. The curvature is part of normal spinal anatomy, not a marker of immaturity.

Correct Answer D: Instruct the client to stop taking the antibiotics.

Explanation of the correct answer:

The client is exhibiting signs of an allergic reaction to the antibiotic, including a rash, itchy skin, wheezing, and an elevated heart rate. These symptoms are consistent with an allergic reaction or anaphylaxis, which can occur with antibiotic use, particularly with drugs like penicillin or cephalosporins. The nurse should instruct the client to stop taking the antibiotic immediately and notify the healthcare provider to avoid further complications. If the reaction progresses to anaphylaxis, it can be life-threatening, so prompt action is necessary.

Why the other options are incorrect:

A. Apply a hypoallergenic cream to the rash:

Although a rash can occur with an allergic reaction, applying a hypoallergenic cream is not the priority intervention in this case. The rash, in combination with wheezing and an elevated heart rate, suggests a more serious systemic allergic reaction that could worsen. Stopping the antibiotic is the first priority before considering topical treatments.

B. Provide a mask for the client to wear:

While the client may need a mask if they are coughing or have a contagious condition like a respiratory infection, the symptoms described here are more consistent with an allergic reaction rather than an infectious disease. Providing a mask will not address the immediate concern of the allergic reaction.

C. Swab the throat for a rapid strep test:

The client has already been diagnosed with a Streptococcal throat infection and has been on antibiotics for three days. The symptoms described (rash, wheezing, elevated heart rate) are not related to the strep infection but to a possible allergic reaction to the prescribed antibiotic. Re-testing for strep is unnecessary at this point.

Correct Answer B: Complains of head pain.

Explanation of the correct answer:

Confusion in an older adult, especially after a fall and hip fracture, can be indicative of a serious complication such as a head injury, which may have occurred during the fall or from subsequent trauma. The complaint of head pain could suggest a concussion, subdural hematoma, or another intracranial injury that requires immediate attention. Head pain, particularly after a fall, warrants urgent evaluation to rule out potentially life-threatening conditions such as intracranial bleeding or increased intracranial pressure.

Why the other options are incorrect:

A. Concentrated urine output:

Concentrated urine output may suggest dehydration, especially in older adults, but it does not indicate a life-threatening situation that requires immediate intervention. While dehydration should be addressed, it is not as urgent as potential head trauma, which can have more severe and immediate consequences.

C. Serum glucose level 160 mg/dL (8.88 mmol/L):

A serum glucose level of 160 mg/dL is elevated, but it is not dangerously high and may not require immediate intervention unless the client has diabetes and is at risk for diabetic ketoacidosis or hyperosmolar hyperglycemic state. A blood glucose level of 160 mg/dL is not life-threatening on its own, and interventions such as adjusting insulin or diet can be addressed as part of routine care, rather than requiring immediate action.

D. Bruising on both arms:

Bruising on both arms, especially in the context of a recent fall and hip fracture, may be due to the injury itself or from the physical handling of the client. However, bruising alone is not immediately life-threatening and does not require urgent intervention unless accompanied by other signs of significant internal injury, such as swelling or severe pain. The priority here is to address the confusion and the possible head injury.

Correct Answer B. Change the client's position.

Why this is the correct answer:

B. Change the client’s position.

Variable decelerations are usually caused by umbilical cord compression. The first and most effective nursing action is to reposition the client (e.g., side-to-side or knee-chest) to relieve pressure on the cord and improve blood flow to the fetus. This intervention is rapid, noninvasive, and directly targets the cause of the deceleration.

Why the other options are incorrect:

A. Administer oxygen via facemask.

Oxygen may be provided if the decelerations persist after position changes, but it is not the immediate first action. The priority is to relieve cord compression before supplementing oxygen.

C. Turn off the oxytocin infusion.

Stopping oxytocin is appropriate if there are recurrent decelerations linked to uterine tachysystole, but with a single variable deceleration, repositioning is the first step. Oxytocin adjustment is considered only if repositioning and other measures fail.

D. Assess cervical dilatation.

Assessing dilation may provide information about labor progress but does not address the urgent cause of the deceleration. Immediate corrective action (position change) takes precedence over assessment.

Correct Answer C: Insert a nasogastric tube (NGT) and attach to low intermittent suction.

Explanation of the correct answer:

The client’s symptoms of vomiting dark brown emesis, severe abdominal pain, and a history of adenocarcinoma of the small intestine suggest a potential bowel obstruction or gastrointestinal perforation. The dark brown emesis indicates the possibility of gastric contents mixed with bile or old blood, which could be a sign of a more severe issue like bowel obstruction. In such cases, inserting an NGT and attaching it to low intermittent suction is critical to decompress the stomach, prevent further vomiting, and reduce the risk of aspiration. This also helps to relieve pressure on the intestines and prevents further complications.

Why the other options are incorrect:

A. Send the client to x-ray for a flat plate of the abdomen:

While an abdominal x-ray can help assess for bowel obstruction, the priority action for this client is to relieve the immediate symptoms and prevent complications like aspiration or worsening of the obstruction. Inserting an NGT to decompress the stomach takes precedence over diagnostic imaging at this moment, as it addresses the urgent need to manage the client’s symptoms and prevent further harm.

B. Give a prescribed analgesic for temperature above 101° F (38.3° C):

While the client may need pain management, the focus initially should be on assessing and addressing the potential bowel obstruction, which is the underlying cause of the client’s symptoms. Analgesics can be administered after the more urgent interventions are performed, but the first priority is to relieve the abdominal pressure and prevent further complications.

D. Place an indwelling urinary catheter and attach a bedside drainage unit:

Placing a urinary catheter is not indicated based on the current symptoms. The primary concern is related to the gastrointestinal tract, and placing an NGT to decompress the stomach should be the nurse's priority. The insertion of a urinary catheter is unnecessary unless there is concern about urinary retention or monitoring output due to other issues, which is not indicated here.

Correct Answer D. Give the mother positive feedback about the way she administered the medication.

Why this is the correct answer:

D. Give the mother positive feedback about the way she administered the medication.

Ferrous sulfate is best absorbed in the presence of vitamin C, and orange juice is an excellent source. Giving the drops with orange juice maximizes absorption and supports effective treatment of iron deficiency anemia. The mother demonstrated correct administration, so the nurse should provide positive reinforcement to encourage continuation of this effective practice.

Why the other options are incorrect:

A. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.

There is no requirement to keep the infant NPO after giving iron. The focus is on administering iron with vitamin C to enhance absorption and avoiding giving it with milk.

B. Tell the mother to follow the iron drops with infant formula instead of orange juice.

Formula (especially cow’s milk–based) inhibits iron absorption due to calcium content. This would decrease the effectiveness of the iron supplement.

C. Suggest placing the iron drops in the orange juice and then feeding the infant.

This may seem reasonable, but mixing the iron in juice can stain the teeth and reduce assurance of a full dose being consumed. Giving the iron directly and then following with juice is the correct method.

Correct Answer B: Put a night light on in the room.

Explanation of the correct answer:

B. Put a night light on in the room:

Clients with dementia are often prone to confusion and agitation, especially during the evening, a phenomenon known as "sundowning." This can be exacerbated by environmental factors, such as low lighting, which may contribute to hallucinations or misperceptions. By placing a night light in the room, the nurse helps to reduce the risk of shadows or darkness that could contribute to the client's confusion and fear of someone standing in the room. This simple environmental modification can provide comfort and help the client feel more secure.

Why the other options are incorrect:

A. Give an anxiolytic at bedtime:

While anxiolytics can be helpful in managing anxiety, medications should be used cautiously in older adults, especially those with dementia, due to the risk of increased sedation, confusion, or other adverse effects. Pharmacologic interventions should not be the first approach unless necessary, and non-pharmacologic strategies (like adjusting the environment) are generally preferred for managing agitation in dementia.

C. Reassure her that she is alone:

While reassurance might seem helpful, it can sometimes be counterproductive in clients with dementia, especially if they are experiencing hallucinations or confusion. Telling the client they are alone may not align with their reality, and it could potentially increase agitation if the client does not understand or believe the reassurance. Instead, providing environmental adjustments like a night light can help the client feel safer without challenging their perception directly.

D. Provide soft music at bedside:

While soft music can have a calming effect, it is not as directly relevant to addressing the client's confusion and agitation related to their perception of someone being in the room. Environmental factors, such as lighting, may have a more immediate impact on reducing misperceptions in this situation.

Correct Answer A: Obtain a blood pressure reading before client gets out of bed.

Why this is the correct answer:

The older adult male has hypertension (with an average blood pressure of 180/98 mm Hg) and is about to start taking antihypertensive medication. One of the major concerns when initiating antihypertensive therapy in older adults is the risk of orthostatic hypotension, a condition where the blood pressure drops significantly when moving from a sitting or lying position to standing. This can lead to dizziness, falls, and injuries. Therefore, it is important to monitor the blood pressure before the client gets out of bed to identify any potential drop in blood pressure and ensure the client is not at risk for orthostatic hypotension. This intervention will help assess the effect of the medication and guide safe mobility.

Why the other options are incorrect:

B. Provide client with dietary teaching regarding a cardiac diet.

While teaching the client about a cardiac diet is important for managing hypertension in the long term, it is not the most immediate concern. The client’s blood pressure is significantly elevated, and the priority is to monitor for potential side effects of the antihypertensive medication, such as orthostatic hypotension, and ensure that the client can safely mobilize. Dietary changes are important but are not the priority at this stage.

C. Measure and record the client's urinary output every day.

Monitoring urinary output is important, especially if the client is on diuretic therapy, as it can help identify any fluid imbalance or renal function issues. However, this is not the priority in the initial stages of antihypertensive treatment. The more immediate concern is ensuring that the client’s blood pressure is stable and that they do not experience complications related to the medication, such as orthostatic hypotension.

D. Obtain client's vital signs every 4 hours when awake.

While it is important to monitor the client’s vital signs frequently, especially after starting a new medication, obtaining vital signs every 4 hours may be excessive and not necessary unless specifically ordered. More frequent blood pressure monitoring is warranted, especially in the context of initiating an antihypertensive regimen. However, the key focus should be monitoring the blood pressure before the client gets out of bed to assess for any orthostatic changes in pressure.

Correct Answer A. The diaper area shows severe skin breakdown.

Why this is the correct answer:

A. The diaper area shows severe skin breakdown.

Severe diaper rash indicates a physical problem that can cause significant discomfort and pain. For a 3-month-old, this pain may explain why the infant wakes frequently at night and cannot settle. Addressing this skin breakdown is critical not only to relieve discomfort and restore sleep but also to prevent complications such as infection. Immediate intervention to treat the diaper area is essential in planning care.

Why the other options are incorrect:

B. The mother is a single parent and lives with her parents.

Although social factors influence caregiving, this does not directly explain the infant’s sleep disturbance. The most pressing issue is the infant’s physical discomfort, which needs immediate treatment before addressing family structure.

C. The infant's formula has been changed twice.

Frequent formula changes may cause mild gastrointestinal upset, but this is less urgent than severe skin breakdown. Formula changes should be reviewed, but they are not the most significant factor contributing to disrupted sleep in this situation.

D. The mother reports the baby is irritable during feedings.

Feeding irritability is concerning and warrants follow-up, but it is not as urgent as severe skin breakdown. Pain from skin irritation is more likely to cause immediate and ongoing distress, leading to poor sleep, making option A the priority.