HESI RN
HESI Medical Surgical Test Bank
1. Which of the following is a characteristic symptom of multiple sclerosis (MS)?
- A. Muscle atrophy.
- B. Severe pain.
- C. Vision problems.
- D. Hearing loss.
Correct answer: C
Rationale: Vision problems are a characteristic symptom of multiple sclerosis (MS) due to demyelination of the optic nerve. This can lead to issues such as optic neuritis, blurred vision, double vision, or even total vision loss. Muscle atrophy (Choice A) is not a primary symptom of MS but can occur as a secondary effect of decreased mobility. Severe pain (Choice B) is not a typical symptom of MS, though some individuals may experience pain related to muscle spasms or other factors. Hearing loss (Choice D) is not commonly associated with MS unless there is an unrelated concurrent condition affecting the auditory system.
2. What is the most common symptom of hypoglycemia that the nurse should teach the diabetic client to recognize?
- A. Nervousness
- B. Anorexia
- C. Kussmaul's respirations
- D. Bradycardia
Correct answer: A
Rationale: Nervousness is the most common symptom of hypoglycemia. It is often accompanied by other signs such as weakness, perspiration, confusion, and palpitations. Anorexia (lack of appetite) is not a typical symptom of hypoglycemia; it is more commonly associated with hyperglycemia. Kussmaul's respirations are a deep and labored breathing pattern seen in diabetic ketoacidosis, not hypoglycemia. Bradycardia (slow heart rate) is not a typical symptom of hypoglycemia; tachycardia (fast heart rate) is more commonly associated with hypoglycemia due to the release of catecholamines in response to low blood sugar.
3. A client is to have a transsphenoidal hypophysectomy to remove a large, invasive pituitary tumor. The nurse should instruct the client that the surgery will be performed through an incision in the:
- A. Back of the mouth.
- B. Nose.
- C. Sinus channel below the right eye.
- D. Upper gingival mucosa in the space between the upper gums and lip.
Correct answer: D
Rationale: The correct answer is D: Upper gingival mucosa in the space between the upper gums and lip. A transsphenoidal hypophysectomy involves accessing the pituitary gland through an incision in the upper gingival mucosa, providing direct access to the pituitary gland without external scars. Choices A, B, and C are incorrect because the surgery is not performed through the back of the mouth, the nose, or the sinus channel below the right eye. It is crucial for the client to understand the specific location of the incision to ensure accurate preoperative education and expectations.
4. An adult who was recently diagnosed with glaucoma tells the nurse, 'it feels like I am driving through a tunnel.' The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?
- A. Maintain prescribed eye drop regimen
- B. Avoid frequent eye pressure measurements
- C. Wear prescription glasses
- D. Eat a diet high in carotene
Correct answer: A
Rationale: The correct answer is A: Maintain prescribed eye drop regimen. In glaucoma, maintaining the prescribed eye drop regimen is crucial for controlling intraocular pressure, which helps in preventing vision loss. Consistent use of eye drops as directed can slow down the progression of the disease and preserve vision. Choice B is incorrect because avoiding frequent eye pressure measurements does not address the primary treatment for glaucoma. Choice C is incorrect as wearing prescription glasses may be helpful for vision correction but does not directly address the management of glaucoma. Choice D is incorrect because while a diet high in carotene may promote overall eye health, it is not the most important instruction for managing glaucoma.
5. A client with chronic renal failure is receiving epoetin alfa (Epogen) to treat anemia. The nurse should assess the client for which of the following side effects?
- A. Hypertension.
- B. Hypotension.
- C. Infection.
- D. Edema.
Correct answer: A
Rationale: The correct answer is A: Hypertension. Epoetin alfa (Epogen) is a medication used to treat anemia in clients with chronic renal failure. One common side effect of this medication is hypertension. Epoetin alfa stimulates red blood cell production, which can lead to an increase in blood pressure. Therefore, the nurse should closely monitor the client for signs and symptoms of hypertension while on this medication. Choices B, C, and D are incorrect. Hypotension is not typically associated with epoetin alfa administration. Infection is not a direct side effect of epoetin alfa. Edema is also not a common side effect of this medication.
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