Question

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

Answer 1

Correct Answers:

Have the child blow a cotton ball and have the parent catch it.

Rationale :

🎈Using a cotton ball and having the child blow it introduces a playful activity that mimics deep breathing and promotes cooperation during lung auscultation.

🧸This technique helps reduce anxiety in preschool-aged children by turning assessment into a game-like task.

👂It also allows the nurse to hear respiratory effort in a natural and relaxed way, increasing the accuracy of lung sound assessment.

🎯While other options provide distraction, they do not effectively engage the child in deep breathing, which is essential during auscultation.

📌Core Message

Using a play-based technique like blowing a cotton ball helps ensure cooperation and effective lung assessment in preschoolers.

Answer 2

Correct Answers:

Place the child in a quiet environment.

Rationale :

😶Placing a child with Kawasaki disease in a quiet environment helps reduce irritability and manage the inflammatory state.

🛏️This environment helps lower stimuli-related distress, which can exacerbate symptoms and delay healing.

🥣Although making a list of preferred foods is helpful, irritability and rest should be addressed first to promote intake.

🧴Applying lotion helps with peeling skin but is a comfort measure, not a primary intervention.

📌Core Message

For children with Kawasaki disease, reducing environmental stimuli helps manage irritability and systemic inflammation.

Answer 3

Correct Answers:

Auscultate heart and lungs while the infant is held.

Rationale :

👶Auscultating heart and lung sounds while the infant is calm and being held provides a more accurate assessment without inducing distress or cyanosis.

💓This method respects the infant’s emotional state and promotes a non-threatening evaluation of cardiac and respiratory function.

🧪A 12-lead ECG may be useful later but is not needed before a basic clinical assessment.

😭Inducing crying could provoke hypoxia, which is both dangerous and unnecessary.

📌Core Message

In post-op TOF infants, assess cardiopulmonary status while calm to avoid exacerbating symptoms.

Answer 4

Correct Answers:

Position the infant on the stomach occasionally when awake and active.

Rationale :

🔄Occasional supervised tummy time while the infant is awake helps prevent positional plagiocephaly and strengthens neck and upper body muscles.

🛌Putting infants to sleep on their backs is still essential for SIDS prevention, but tummy time when awake provides developmental and postural benefits.

🛑Using pillows in the crib or sleeping on the side increases the risk of asphyxiation and should be avoided.

🪑Propping infants in a sitting position for extended periods is not safe or developmentally appropriate at this age.

📌Core Message

Tummy time when awake prevents positional head flattening and supports motor development in infants.

Answer 5

Correct Answers:

Thyroxine (T4).

Rationale :

🧪Low levels of thyroxine (T4) are a hallmark sign of congenital hypothyroidism and must be promptly addressed to prevent developmental delays.

🧠T4 is essential for neurological and metabolic development, especially in the first few months of life.

📉LH, FSH, and GH levels are not primary indicators for diagnosing thyroid disorders in neonates.

⚠️Failure to treat low T4 can result in severe intellectual disability and growth failure.

📌Core Message

Low T4 levels are diagnostic of congenital hypothyroidism and must be addressed immediately to prevent irreversible harm.

Answer 6

Correct Answers:

Provide an activity room to spend time with other adolescents.

Rationale :

🧑‍🤝‍🧑Adolescents benefit from peer interaction, especially when coping with illness, which supports identity formation and reduces isolation.

🎨An activity room allows for safe engagement with same-age peers, fostering emotional and social resilience.

📵Limiting phone use may hinder their coping mechanisms in a tech-connected generation.

👨‍👩‍👧Family presence is helpful, but peers play a critical role in adolescent psychosocial development.

📌Core Message

Providing peer interaction opportunities supports the emotional and developmental needs of adolescents with chronic illness.

Answer 7

Correct Answers:

"The shunt will be replaced as your child grows to reduce pressure in the brain."

Rationale :

🧠VP shunts are permanent devices that often need to be revised or replaced as a child grows to maintain proper intracranial pressure.

💁‍♂️Shunts do not get removed routinely unless there is an infection or mechanical issue, and most children do not outgrow the need.

❌Telling the parent it will be removed without replacement is misleading and may create false expectations.

🗣️Providing factual, gentle education builds trust and realistic understanding of the child’s long-term needs.

📌Core Message

VP shunts must often be replaced or revised as a child develops to manage hydrocephalus effectively.

Answer 8

Correct Answers:

Careful bathing and handling that avoids abdominal manipulation.

Rationale :

🙅Handling the abdomen gently and avoiding manipulation is critical in Wilms' tumor to prevent rupture and tumor seeding.

🛁Bathing should be done with care to avoid accidental pressure on the abdominal mass.

💊Pain and antiemetic medications are necessary, but they are not pre-op priorities for Wilms’ tumor management.

📉The prone position may place unnecessary pressure on the tumor site and should be avoided.

📌Core Message

For Wilms’ tumor, avoid abdominal manipulation to reduce the risk of tumor rupture and metastasis.

Answer 9

Correct Answers:

Measure abdominal circumference.

Rationale :

📏Measuring abdominal circumference helps identify distention, which may signal bowel obstruction or Hirschsprung’s disease in newborns.

🚼Failure to pass meconium and bilious vomiting are red flags that require immediate GI evaluation.

💉IV access and output monitoring are important but should follow focused physical assessment.

🧪Anorectal manometry is diagnostic but not the first nursing action in an emergent setting.

📌Core Message

In suspected bowel obstruction, begin with measuring abdominal girth to evaluate for distention and worsening pathology.

Answer 10

Correct Answers:

The lumen of the aorta reduces the volume of blood flow to the lower extremities.

Rationale :

💓Coarctation of the aorta narrows the aortic lumen, reducing blood flow to the lower extremities and increasing pressure in the upper body.

🩸This results in higher BP in the arms, bounding brachial pulses, and weaker femoral pulses.

🔄Aortic valve or pulmonary valve abnormalities would affect systemic or pulmonary circulation, but not this specific BP distribution pattern.

💔An atrial septal defect causes left-to-right shunting but doesn't explain the pulse discrepancy.

📌Core Message

Coarctation of the aorta causes reduced lower extremity perfusion and elevated upper body pressure, leading to pulse disparities.

HESI RN Med -Surg 2024 Exam-3

No.

1 :
The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

2 :
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

4 :
The mother of a one-month-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?

5 :
The nurse is caring for a one-month-old infant admitted for suspected congenital hypothyroidism. Which diagnostic test results should the nurse report to the healthcare provider?

6 :
An adolescent with a congenital heart defect is admitted for diagnostic testing with surgery scheduled in 3 days. Which intervention should the nurse implement to best support the client's psychosocial needs?

8 :
An infant who has a Wilms' tumor is admitted for surgery. Which intervention should the nurse implement during the preoperative period?

9 :
An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

HESI RN Med -Surg 2024 Exam-3

No.

1 : The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

2 : A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

4 : The mother of a one-month-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?

5 : The nurse is caring for a one-month-old infant admitted for suspected congenital hypothyroidism. Which diagnostic test results should the nurse report to the healthcare provider?

6 : An adolescent with a congenital heart defect is admitted for diagnostic testing with surgery scheduled in 3 days. Which intervention should the nurse implement to best support the client's psychosocial needs?

8 : An infant who has a Wilms' tumor is admitted for surgery. Which intervention should the nurse implement during the preoperative period?

9 : An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

1 :
The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

2 :
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

4 :
The mother of a one-month-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?

5 :
The nurse is caring for a one-month-old infant admitted for suspected congenital hypothyroidism. Which diagnostic test results should the nurse report to the healthcare provider?

6 :
An adolescent with a congenital heart defect is admitted for diagnostic testing with surgery scheduled in 3 days. Which intervention should the nurse implement to best support the client's psychosocial needs?

8 :
An infant who has a Wilms' tumor is admitted for surgery. Which intervention should the nurse implement during the preoperative period?

9 :
An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?