Question

A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

Answer 1

Correct Answers:

Double vision.

Rationale :

🔷 Double vision (diplopia) is a significant neurological sign and may indicate phenytoin toxicity, especially if serum levels are elevated.

🔷 Phenytoin has a narrow therapeutic range (10–20 mcg/mL), and early signs of toxicity include ataxia, diplopia, slurred speech, and nystagmus.

🔷 Immediate intervention is essential to prevent seizures or central nervous system complications.

🔷 Puffy gums may indicate gingival hyperplasia (a known side effect), but this is not urgent.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Encourage continued maintenance of the walking routine.

Rationale :

🔷 Regular, low-impact physical activity such as walking helps maintain joint mobility and muscle strength in osteoarthritis.

🔷 It also promotes circulation and weight control, which reduces joint stress.

🔷 Advising the client to continue walking supports autonomy, quality of life, and joint function.

🔷 Restricting activity may lead to joint stiffness and deconditioning.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Notify the healthcare provider of the client's medication history.

Rationale :

🔷 Heparin increases the risk of perioperative bleeding, especially in clients with open wounds or fractures.

🔷 The surgeon needs this information to assess bleeding risk and determine perioperative anticoagulation management.

🔷 Other tasks like signing consent or monitoring bruising are important but secondary to notifying the provider.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Lower back pain and hypotension.

Rationale :

🔷 These are signs of an acute hemolytic transfusion reaction, particularly due to ABO incompatibility.

🔷 Hemolysis leads to renal involvement (causing back pain), hypotension, fever, and chills.

🔷 Immediate action includes stopping the transfusion and initiating emergency treatment.

🔷 Rash or joint changes are signs of delayed reactions, not acute emergencies.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Lower back pain and hypotension.

Rationale :

🔷 Same explanation as above — these are hallmark signs of an acute ABO incompatibility hemolytic reaction.

🔷 This requires immediate intervention to prevent acute renal failure and shock.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Lumbar puncture.

Rationale :

🔷 A lumbar puncture (spinal tap) is the diagnostic gold standard for confirming bacterial meningitis.

🔷 It allows analysis of cerebrospinal fluid (CSF) for elevated WBCs, protein, and decreased glucose.

🔷 Other options (e.g., CT, MRI) may be used to rule out abscess or increased ICP, but CSF analysis confirms the diagnosis.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Lumbar puncture

Rationale :

🔷 Confirming bacterial meningitis depends on analysis of the CSF, obtained by lumbar puncture.

🔷 Rapid diagnosis is essential to begin empiric antibiotics and reduce morbidity.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Family members can assist with regular foot exams.

Rationale :

🔷 Clients with peripheral neuropathy have reduced sensation and may not detect early signs of injury or infection.

🔷 Daily foot exams are critical, and family assistance ensures timely detection of wounds.

🔷 Walking barefoot or using heating pads is risky due to burn or trauma risk.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Check fingerstick glucose level.
Assess skin temperature and moisture.
Measure pulse and blood pressure.

Rationale :

🔷 A. Check fingerstick glucose level

✔️ Hypoglycemia or hyperglycemia must be ruled out, especially with symptoms like weakness and jitteriness.

🔷 B. Assess skin temperature and moisture

✔️ Diaphoresis and clammy skin suggest hypoglycemia.

🔷 E. Measure pulse and blood pressure

✔️ Autonomic symptoms must be monitored; vital signs confirm physiological status.

❌ C. Administer PRN insulin—never given without confirming blood glucose.

❌ D. Documenting anxiety—May miss critical diagnosis of hypoglycemia.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Eat a diet that is high in protein and vitamins A and C.
Keep legs elevated when sitting or lying down.
Inspect ankles daily for areas of darkening skin.

Rationale :

🔷 A. Eat a diet high in protein and vitamins A and C

✔️ Promotes wound healing and collagen formation.

🔷 C. Keep legs elevated when sitting or lying down

✔️ Enhances venous return and reduces edema.

🔷 D. Inspect ankles daily for areas of darkening skin

✔️ Early detection of stasis dermatitis or ulcer recurrence.

❌ B. Maintain bed rest—prolonged immobility impairs circulation.

❌ E. Cold compresses—Not appropriate for venous ulcers; may worsen perfusion.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

RN-Hesi Medical Surgical Exam I

No.

1 :
A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

2 :
A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?

4 :
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

5 :
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

6 :
The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider?

7 :
A nurse is caring for a patient who has been admitted to the hospital with a suspected diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the patient for?

8 :
A nurse is educating a patient with type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?

9 :
An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The patient reports feeling very weak and jittery. What actions should the nurse take? (Select all that apply.).

10 :
The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

Connect With Us

RN-Hesi Medical Surgical Exam I

No.

1 : A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

2 : A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?

4 : A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

5 : A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

6 : The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider?

7 : A nurse is caring for a patient who has been admitted to the hospital with a suspected diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the patient for?

8 : A nurse is educating a patient with type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?

9 : An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The patient reports feeling very weak and jittery. What actions should the nurse take? (Select all that apply.).

10 : The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

1 :
A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

2 :
A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?

4 :
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

5 :
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

6 :
The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider?

7 :
A nurse is caring for a patient who has been admitted to the hospital with a suspected diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the patient for?

8 :
A nurse is educating a patient with type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?

9 :
An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The patient reports feeling very weak and jittery. What actions should the nurse take? (Select all that apply.).

10 :
The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)