HESI CRITICAL CARE ACTUAL EXAM LATEST
VERSION 2024-2025 WITH REAL 100+
QUESTIONS AND WELL VERIFIED CORRECT
AND DETAILED ANSWERS [GRADED A+] //HESI
... [Show More]
CRITICAL CARE BRAND NEW EXAM//
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The nurse is assessing an older client and determines that the client's left upper
eyelid droops, covering more of the iris than the right eyelid. Which description
should the nurse use to document this finding?
A. A nystagmus on the left.
B. Exophthalmos on the right.
C. Ptosis on the left eyelid.
D. Astigmatism on the right. - ANSWER-Ptosis on the left eyelid
Rationale: Ptosis is the term to describe an eyelid droop that covers a large portion
of the iris (A), which
may result from oculomotor nerve or eyelid muscle disorder. (B) is characterized
by rapid,
rhythmic movement of both eyes. (C) is a distortion of the lens of the eye, causing
decreased
visual acuity. (D) is a term used to describe a protrusion of the eyeballs that occurs
with
hyperthyroidism.
The nurse is assessing a child's weight and height during a clinic visit prior to
starting school. The nurse plots the child's weight on the growth chart and notes
that the child's weight is in the 95th percentile for the child's height. What action
should the nurse take?
A. Question the type and quantity of foods eaten in a typical day.
B. Encourage giving two additional snacks each day to the child.
C. Recommend a daily intake of at least four glasses of whole milk.
D. Assess for signs of poor nutrition, such as a pale appearance - ANSWER-A.
Question the type and quantity of foods eaten in a typical day.
RATIONALE:
The child is overweight for height, so assessment of the child's daily diet (C)
should be
determined. The child does not need (A or B), both of which will increase the
child's weight.
Poor nutrition (D) is commonly seen in underweight children, not overweight.
A male client is angry and is leaving the hospital against medical advice (AMA).
The client demands to take his chart with him and states the chart is "his" and he
doesn’t' want any more contact with the hospital. How should the nurse respond?
A. This hospital does not need to keep it if you are leaving and not returning here.
B. Because you are leaving against medical advice, you may not have your chart.
C. The information in your chart is confidential and cannot leave this facility
legally.
D. The chart is the property of the hospital but I will see that a copy is made for
you. - ANSWER-D. The chart is the property of the hospital but I will see that a
copy is made for you.
RATIONALE:
The chart is the property of the facility, but the client has a legal right to the
information in it, even if he is leaving AMA, so a copy of the record (D) should be
provided. The client does not lose his legal rights to his medical record if he leaves
AMA (A). The medical record is, but the hospital protects the client's privacy by
not allowing unauthorized access to the record, so the hospital may provide the
client with a copy (B). The hospital must maintain records of the care provided and
should not release the original record (C)
When engaging in planned change on the unit, what should the nurse-manager
establish first?
A. Resources needed for the change are available.
B. Staff members are aware of the need for change.
C. Goals for achieving the change are established.
D. Options for accomplishing the change are explored. - ANSWER-B. Staff
members are aware of the need for change.
RATIONALE:
The first step in planned change involves establishing a relationship with those
involved in the change process and instilling knowledge and awareness of the need
for change (D). The nurse manager should next implement (C), and then (A and
B). [Show Less]
