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 :

💠 Preschoolers respond best to play and imagination during procedures, which helps reduce fear.

💠 Blowing a cotton ball engages the child in breathing deeply, promoting better auscultation of lung sounds.

💠 This action also distracts the child, reducing anxiety and encouraging cooperation.

💠 Developmentally, this aligns with Piaget’s preoperational stage, where symbolic play is effective.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Place the child in a quiet environment.

Rationale :

🔷 Irritability is a hallmark of Kawasaki disease, especially in the subacute phase.

🔷 Reducing environmental stimuli helps manage this irritability and promote rest.

🔷 Restful surroundings can decrease stress on the cardiovascular system, a primary concern in this condition.

🔷 Comfort measures like a quiet room should be prioritized before addressing diet or skin care.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Auscultate heart and lungs while the infant is held.

Rationale :

🔶 Infants with cardiac issues like TOF may appear well while being held, masking signs of decompensation.

🔶 Performing assessments while being held ensures a baseline without exertion, which may trigger symptoms.

🔶 It helps in detecting subtle changes in respiratory and cardiac function.

🔶 Avoiding stress-induced crying prevents precipitating a "Tet spell" (cyanotic episode).

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

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

Rationale :

💎 "Tummy time" prevents positional plagiocephaly (flat head syndrome) by reducing pressure on the back of the head.

💎 It also promotes motor development such as head lifting and upper body strength.

💎 This should be done only while the infant is awake and supervised, not during sleep.

💎 Supine sleep is still recommended to prevent Sudden Infant Death Syndrome (SIDS).

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Thyroxine (T4).

Rationale :

✳️ Low levels of thyroxine (T4) are indicative of congenital hypothyroidism, a critical endocrine disorder.

✳️ Early detection and treatment are vital to prevent intellectual disability and developmental delay.

✳️ Other hormones listed (LH, GH, FSH) are not primary indicators of this condition.

✳️ T4 and TSH levels are typically used for diagnosis and screening in neonates.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Provide an activity room to spend time with other adolescents.

Rationale :

✔️ Adolescents value peer interaction, which supports their psychosocial development (Erikson’s Identity vs. Role Confusion stage).

✔️ An activity room facilitates peer bonding and decreases isolation during hospitalization.

✔️ It supports normalcy and independence while still maintaining safety.

✔️ Limiting phone use or excessive family presence may not meet developmental needs.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

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

Rationale :

🔴 A VP shunt does not get permanently removed; it must be adjusted or replaced as the child grows.

🔴 It continuously diverts excess cerebrospinal fluid to relieve intracranial pressure.

🔴 Removal is only considered in rare, resolved cases with close monitoring.

🔴 Education helps correct caregiver misconceptions about shunt function and maintenance.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Careful bathing and handling that avoids abdominal manipulation.

Rationale :

🟣 Wilms’ tumor (nephroblastoma) is highly vascular, and abdominal pressure can rupture the tumor, risking metastasis.

🟣 Nursing care must focus on gentle handling and avoiding palpation of the abdomen.

🟣 Educating caregivers about risk of hemorrhage or tumor seeding is essential.

🟣 Other interventions like antiemetics or pain assessment are secondary during pre-op.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Measure abdominal circumference.

Rationale :

⚪ Bilious vomiting in a newborn who has not passed meconium is a red flag for intestinal obstruction, such as Hirschsprung’s disease.

⚪ Measuring abdominal girth helps monitor for distension and worsening obstruction.

⚪ This assessment is non-invasive and gives critical baseline data.

⚪ Early identification helps prioritize further diagnostic steps like manometry or imaging.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

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

Rationale :

🟡 Coarctation of the aorta (narrowing) results in higher pressure proximal (upper body) and reduced perfusion distally.

🟡 Findings such as pounding brachial pulses and weak femoral pulses support this diagnosis.

🟡 The narrowed aortic lumen creates pressure gradients between upper and lower extremities.

🟡 This condition may require surgical correction and continued hemodynamic monitoring.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

RN-Hesi Medsurg Exam

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 provide

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?

Connect With Us

RN-Hesi Medsurg Exam

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 provide

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 provide

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?