HESI RN Comprehensive Exam 1
1. A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby
... [Show More] sucks for a few minutes?" Which information should the nurse provide?
A. This feeling occurs during feeding with a breast infection.
B. This sensation occurs as breast milk moves to the nipple.
C. The baby does not have good latch-on.
D. The infant is not positioned correctly.
2. A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first?
A. Check the client's blood pressure.
B. Teach her to elevate her feet when sitting.
C. Obtain a 24-hour diet history to evaluate for the intake of salty foods.
D. Assess the fetal heart rate.
3. A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement?
A. Teach the client testicular self- examination (TSE).
B. Assess for the presence of blood in the urine.
B. This sensation occurs as breast milk moves to the nipple.
Rationale:
When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation in their nipples (B) when let- down occurs. (A, C, and D) provide inaccurate information.
A. Check the client's blood pressure. Rationale:
The blood pressure (A) should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and have chronic hypertension are at increased risk.
Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. (B, C, and D) can be done if the blood pressure is normal.
C. Ask about scrotal pain or blood in the semen.
Rationale:
Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or an indwelling urethral urinary catheter
4. A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client?
A. As women age, they often become rounder in the middle because they do not exercise properly.
B. Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur with aging.
C. With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation.
D. Because there is no evidence of a diseased colon, there is no need to worry about abdominal size.
C. With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation.
Rationale:
With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and constipation are age-related changes. (D) dismisses the client's concerns and does not help her understand the changes that she is experiencing.
integrity (D). The nurse uses Erikson stages of development over the life span to assess an older client's adjustment to aging and plans teaching strategies to assist the clients attain integrity versus despair. (A, B, and C) are normal developmental tasks of older adults. [Show Less]