HESI EXIT EXAM 2
A nurse on the psychiatric unit of the hospital has been assigned four clients for the
shift. The assignment includes an 84-year-old
... [Show More] client who is severely depressed, a 73-
year-old client who is being discharged, a 53-year-old client who was admitted for
lithium toxicity, and a 48-year-old client who has panic attacks. Which client should
the nurse evaluate first after receiving report?
1
84-year-old client
2
73-year-old client
Correct3
53-year-old client
4
48-year-old client
The 53-year-old client should be evaluated first because of the severity of adaptations
associated with lithium toxicity. A severely depressed client has a low energy level and is
not at the greatest risk at this time. A client who is stable enough to be discharged does not
need immediate attention. Clients with panic attacks usually seek immediate attention
when it is needed.
A young female client admitted to the trauma center after being sexually assaulted
continues to talk about the rape. Toward what goal should the primary nursing
intervention be directed?
1
Getting her involved with a rape therapy group
2
Remaining available and supportive to limit destructive anger
3
Exploring her feelings about men to promote future relationships
Correct4
Providing a safe environment that permits the ventilation of feelings
The client needs to be able to express her current feelings. Providing an environment in
which she feels safe will encourage this expression of feelings. It is too soon after the
assault to discuss this topic in a group. Although the nurse should be available and
supportive, feelings of anger are usually not the initial response. It is too soon after the
assault to discuss her feelings about men and future relationships.
A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how
much I love him, but I don't want to upset him." Which is the best response by the
nurse?
1
"You must keep up a strong appearance for him."
2
"I think he'd have difficulty dealing with that now."
3
"Don't you think he knows that without your telling him?"
Correct4
"Why don't you share your feelings with him while you can?"
It is difficult to work through a loss; however, encouraging the sharing of feelings helps
both parties to feel better about having to let go. The response "You must keep up a strong
appearance for him" impedes the work of acceptance of one's finality and the use of the
remaining time to the best advantage. There is no evidence to suggest that the client cannot
cope with these emotions; the response "I think he'd have difficulty dealing with that now"
denies that this is a time for closeness and honesty. The response "Don't you think he
knows that without your telling him?" is demeaning, closes off communication, and does
not foster the expression of feelings.
A nonviolent client on the psychiatric unit suddenly refuses to take the prescribed
antipsychotic medication. What should the nurse do?
Correct1
Honor the client's decision and document the behavior and all interventions
2
Use an authoritarian approach to induce the client to take the prescribed medication
3
Call the health care provider and request that the client be discharged against medical
advice
4
Start proceedings to have the client declared incompetent and seek a court order
permitting medication
A client has the right to refuse treatment and should not be forcibly medicated unless the
client is deemed dangerous to him- or herself or others. An authoritarian approach is not
therapeutic and may compromise the nurse-client relationship. Calling the health care
provider is premature; first the nurse should attempt therapeutic interventions to meet the
client's needs. Starting proceedings to have the client declared incompetent is appropriate
for a client who is considered to be dangerous to him- or herself or others, or incompetent
to evaluate necessary treatment.
STUDY TIP: When forming a study group, carefully select members for your group. Choose
students who have abilities and motivation similar to your own. Look for students who
have a different learning style than you. Exchange names, email addresses, and phone
numbers. Plan a schedule for when and how often you will meet. Plan an agenda for each
meeting. You may exchange lecture notes and discuss content for clarity or quiz one
another on the material. You could also create your own practice tests or make flash cards
that review key vocabulary terms.
Which psychotherapeutic theory uses hypnosis, dream interpretation, and free
association as methods to release repressed feelings?
1
Behaviorist model
Correct2
Psychoanalytical model
3
Psychobiological model
4
Social-interpersonal model
The psychoanalytical model studies the unconscious and uses the strategies of hypnosis,
dream interpretation, and free association to encourage the release of repressed feelings.
The behaviorist model holds that the self and mental symptoms are learned behaviors that
persist because they are consciously rewarding to the individual; this model deals with
behaviors on a conscious level of awareness. The psychobiological model views emotional
and behavioral disturbances as stemming from a physical disease; abnormal behavior is
directly attributed to a disease process. This model deals with behaviors on a conscious
level of awareness. The social-interpersonal model affirms that crucial social processes are
involved in the development and resolution of disturbed behavior; this model deals with
behavior on a conscious level of awareness.
A depressed client has been taking Paroxetine (Paxil) 20 mg by
mouth once a day for 4 weeks. The practitioner concludes that there
is no clinical improvement in the client's condition and increases the
daily dose to 30 mg. The medication is supplied in an oral
suspension of 10 mg/5 mL. How many milliliters of Paxil solution
should the nurse instruct the client to take? Record your answer
using a whole number. __________ mL
Solve the problem with the use of ratio and proportion:
Desired 30 mg :: x mL
Have 10 mg 5 mL
10 x = 30 x 5
x = 150 ÷ 10
x = 15 mL
Test-Taking Tip: Do not fret over any one question for too long. If you are having trouble,
skip the question and go back to it when you have finished answering the other questions.
A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a
nurse, "I don't want her to know about the diagnosis." How should the nurse
respond?
1
"It's best for your child to know the diagnosis."
2
"Did you know that the cure rate for Hodgkin disease is high?"
3
"Would you like someone with Hodgkin disease to talk with you?"
Correct4
"Let's talk about how you're feeling about your child's diagnosis."
Initiating a conversation about the client's feelings does not prejudge the parent; it
encourages communication. Stating that it is best for the child to know the diagnosis
disregards the parent's feelings and cuts off further communication. Asking the client about
the cure rate may stop communication and does not recognize the parent's concerns.
Offering to have someone with Hodgkin disease speak to the client is premature and does
not recognize the parent's concerns.
A client who is to undergo dilation and curettage, and conization of the cervix for
cancer appears tense and anxious. What is the best approach for the nurse to
support the client emotionally?
1
Explaining that these procedures are considered minor surgery
Correct2
Asking whether something is troubling the client and whether she'd like to talk about it
3
Stating that the procedures are routine and asking what the client is really worried about
4
Explaining that everybody is fearful before the surgery even though there is little reason to
worry
Asking whether the client wants to talk about what's troubling her acknowledges that the
client is anxious and, by means of indirect questioning, helps facilitate communication.
Saying that these procedures are considered minor surgery denies the client's feelings. The
client has not indicated that she is upset, and she may be unaware of or unable to verbalize
the actual cause of the emotions. Saying that there is little reason to worry is false
reassurance and cuts off communication.
A client in the hyperactive phase of a mood disorder, bipolar type, is receiving
lithium. A nurse sees that the client's lithium blood level is 1.8 mEq/L. What is
the most appropriate nursing action?
1
Continuing the usual dose of lithium and noting any adverse reactions
2
Discontinuing the drug until the lithium serum level drops to 0.5 mEq/L
3
Asking the health care provider to increase the dose of lithium because the blood lithium
level is too low
Correct4
Holding the drug and notifying the health care provider (prescribing provider)
immediately because the blood lithium level may be toxic
The lithium level should be maintained between 0.5 and 1.5 mEq/L. The lithium level is
currently unsafe but does not need to drop to 0.5 mEq/L before being resumed. Continuing
the drug and asking the health care provider to prescribe a higher dosage are both unsafe
options.
An 18 year-old woman is brought to the emergency department by her two roommates after being
found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings
notes that the urinalysis is positive for flunitrazepam (Rohypnol). The nurse knows that
flunitrazepam is often used:
Correct1
As a date rape drug
2
To control symptoms of psychosis
3
To control symptoms of bipolar mania
Incorrect4
To treat hangover symptoms after excessive alcohol consumption
Rohypnol (flunitrazepam), illegal in the United States, has been used in date rapes; the victim is attacked
after consuming a drink spiked with the drug. Flunitrazepam is not used to treat psychosis, mania, or
hangover symptoms.
Test-Taking Tip: Watch for grammatical inconsistencies. If one or more of the options is not grammatically
consistent with the stem, the alert test taker can identify it as a probable incorrect option. When the stem is in
the form of an incomplete sentence, each option should complete the sentence in a grammatically correct
way.
4.
In the second stage of labor the nurse should plan to discourage a client from holding her breath
longer than 6 seconds while pushing with each contraction. What complication does this prevent?
Correct1
Fetal hypoxia
2
Perineal lacerations
3
Carpopedal spasms
Incorrect4
Maternal hypertension
Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which
could lead to fetal hypoxia. Perineal lacerations occur with rapid, uncontrolled expulsion of the fetus.
Carpopedal spasms and maternal hypertension are not caused by prolonged holding of the breath.
A nurse is aware that after the administration of alprazolam (Xanax) is started, it is important to
observe the client for side effects. What is the nurse's initial action?
1
Measuring the client's urine output
2
Examining the client's pupils daily
Correct3
Checking the client's blood pressure
Incorrect4
Monitoring the abdomen for distention
Orthostatic hypotension is a common side effect of alprazolam (Xanax) that occurs early in therapy. Central
nervous system depression is not an early side effect, but it may occur after prolonged use. An alteration in
urine output is not a common side effect, but it may occur after prolonged use. Distention is not a common
side effect, but distention from constipation may occur after prolonged use.
Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing
the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those
in one or two of the options. Example: If the item relates to and identifies stroke rehabilitation as its focus and
only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this
choice as the correct response.
A 6-year-old child is found to have type 1 diabetes. In light of the child's cognitive developmental
level, which explanation of the illness is most appropriate?
1
"Diabetes is caused by not having any insulin in your body."
Incorrect2
"Diabetes will require you to take insulin shots for the rest of your life."
3
"You'll learn how to give yourself insulin now that you have diabetes."
Correct4
"Taking insulin for your diabetes is like getting new batteries for your superhero toys."
The child is in Piaget's stage of preoperational thought, which is manifested by magical thinking; therefore
teaching should also employ magical thinking. "Diabetes is caused by not having any insulin in your body" is
too technical and does not take into account the child's preoperational stage of development. This statement
is appropriate for an adolescent in the formal operational stage of cognitive development. "Diabetes will
require you to take insulin shots for the rest of your life" is too direct and does not consider the child's
cognitive developmental stage of preoperational thought. This statement is appropriate for an adolescent in
the formal operational stage of cognitive development. Also, the use of the word "shots" may precipitate
anxiety. "You will be taught how to give yourself insulin now that you have diabetes" is too direct and does
not consider the child's cognitive developmental stage of preoperational thought. This statement is
appropriate for an adolescent in the formal operational stage of cognitive development.
1.
A client is scheduled for amniocentesis. What should the nurse do before the procedure?
1
Give the client the prescribed sedative
Correct2
Remind the client to empty her bladder
3
Prepare the client for an intravenous infusion
4
Encourage the client to drink three glasses of water
An empty bladder reduces the risk of bladder puncture during the procedure. Sedation is not necessary. An
intravenous line is not necessary. The client is encouraged to drink three glasses of water before a sonogram,
not an amniocentesis.
A woman has just received the news that she is pregnant. She is ambivalent about the pregnancy
because she had planned to go back to work when her youngest child started school next year.
What developmental task of pregnancy must the woman accomplish in the first trimester of
pregnancy?
1
Recognize her ambivalence
Correct2
Accept that she is pregnant
3
Prepare for the birth of the baby
4
Recognize the fetus as an individual separate from the mother
The developmental task of the first trimester is accepting the reality of the pregnancy. Ambivalence is a
normal emotion associated with early pregnancy. It is not a developmental task. Preparing for the birth is a
developmental task of the third trimester. Recognizing the fetus as a separate individual from the mother is a
developmental task of the second trimester.
Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary
circumstances and that the action can be carried out in the given situation.
A married male client with three children has lost his job and states that he feels useless. He is
tearful, upset, and embarrassed. What is an appropriate objective of care for this client?
1
Limiting tearfulness
Correct2
Increasing self-esteem
3
Controlling feelings of sadness
4
Promoting acceptance by others
The loss of a job can precipitate negative feelings about the self and decrease self-esteem. Feelings should be
expressed, not limited; attempting to decrease a client's crying often ends up worsening it. Crying is not
necessarily an expression of sadness; other feelings are involved. The focus should be on the client's selfacceptance,
not acceptance by others.
Test-Taking Tip: Do not read too much into the question or worry that it is a "trick." If you have nursing
experience, ask yourself how a classmate who is inexperienced would answer this question from only the
information provided in the textbooks or given in the lectures.
A health care provider prescribes oxazepam (Serax) for a client who is beginning to experience
withdrawal symptoms while undergoing detoxification. What are the primary reasons that
oxazepam is given during detoxification?
1
Prevents injury and protects the client when seizures occur
2
Enables the client to sleep and eat better during periods of agitation
3
Encourages the client to cooperate with and accept treatment for alcoholism
Correct4
Reduces the anxiety-tremor state and prevents more serious withdrawal symptoms
Oxazepam (Serax) potentiates the actions of γ-aminobutyric acid, especially in the limbic system and ,
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risk for seizures but does not prevent injury or protect the client during a seizure. Enabling the client to sleep
and eat better during periods of agitation is not the purpose of the drug. The ability of the client to accept
treatment depends on the client's readiness to accept the reality of the problem.
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A nurse is aware that a co-worker's mother died 16 months ago. The co-worker cries every time
someone says the word "mother" and when the mother's name is mentioned. What does the nurse
conclude about this behavior?
1
It is an expected response.
2
Most people cry when their mother dies.
Correct3
The co-worker may need help with grieving.
4
The co-worker was extremely attached to the mother.
Crying is a release, but the individual should have developed effective coping mechanisms by this time. The
co-worker may need help with the grieving process. Excessive crying 16 months after the death of a loved one
is not an expected response. People express grief in a variety of ways, not necessarily by crying. Concluding
that the co-worker was extremely attached to the mother is an assumption and is not a valid conclusion.
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7.
What prenatal teaching is applicable for a client who is between 13 and 24 weeks' gestation?
1
Infant care, travel to the hospital, and signs of labor
Correct2
Growth of the fetus, personal hygiene, and nutritional guidance
3
Interventions for nausea and vomiting, urinary frequency, and anticipated care
4
Danger signs of preeclampsia, relaxation breathing techniques, and signs of labor
Awareness of the fetus as an individual and the body changes of pregnancy lead the client seek information
about fetal growth, body changes, and nutrition . Interventions for nausea and vomiting, urinary
frequency, and anticipated care are appropriate for the first trimester. Information on infant care, travel to
the hospital, signs of labor, signs of preeclampsia, and relaxation breathing techniques is appropriate in the
last trimester.
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8.
When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having
contractions for 3 hours, and I think my water broke." What will the nurse do to confirm that the
membranes have ruptured?
1
Take the client's oral temperature
Correct2
Test the leaking fluid with nitrazine paper
3
Obtain a clean-catch urine specimen
4
Inspect the perineum for leaking fluid
Nitrazine paper will turn dark blue if amniotic fluid is present; it remains the same color in the presence of
urine. Temperature assessment is not specific to ruptured membranes at this time; vital signs are part of the
initial assessment. Although this may be done as part of the initial assessment; a urine test is unrelated to
leakage of amniotic fluid. Inspecting the vagina for leaking fluid will not confirm rupture of the membranes.
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