HESI EXIT Exam V4 – Question and Answers
The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is ap... [Show More] propriate for this child?
The nurse is assessing a healthy child at the 2 year check-up. Which of the following should the nurse report immediately to the health care provider?
The parents of a 2-year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?
The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina?
The nurse is assessing the mental status of a client admitted with a possible organic brain disorder. Which of these questions will best assess the function of the client’s recent memory?
In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?
A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
What is the most important consideration when teaching parents how to reduce risks in the home?
A 35-year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should
While caring for a toddler with croup, which initial sign of croup requires the nurse’s immediate attention?
A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings?
The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse?
Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies?
The nurse is caring for a 10 month-old infant who is has oxygen via mask. It is important for the nurse to maintain patency of which of these areas?
The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client?
When counseling a 6 year old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder?
The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?
The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse?
The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to
A recovering alcoholic asked the nurse, “Will it be ok for me to just drink at special family gatherings?” Which initial response by the nurse would be best?
In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?
A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication?
A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?
A postpartum mother is unwilling to allow the father to participate in the newborn’s care, although he is interested in doing so. She states, “I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers.” The nurse’s initial intervention should be what focus?
A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client
Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings?
The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet
In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?
A Hispanic client in the postpartum period refuses the hospital food because it is “cold.” The best initial action by the nurse is to
The father of an 8 month-old infant asks the nurse if his infant’s vocalizations are normal for his age. Which of the following would the nurse expect at this age?
The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?
Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by
The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and
An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of
A client who has been drinking for five years states that he drinks when he gets upset about “things” such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with
The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15
The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding?
During the evaluation phase for a client, the nurse should focus on
The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should
Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?
A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?
The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?
The nurse is talking with a client. The client abruptly says to the nurse, “The moon is full. Astronauts walk on the moon. Walking is a good health habit.” The client’s behavior most likely indicates
A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?
A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
The nurse enters a 2 year-old child’s hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, “No!”. What would be the most appropriate next action?
A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?
The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should
A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated?
The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?
The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child’s reaction to impending surgery. Which nursing intervention would be best to prepare the child?
The nurse, assisting in applying a cast to a client with a broken arm, knows that
Based on principles of teaching and learning, what is the best initial approach to pre- op teaching for a client scheduled for coronary artery bypass?
A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?
The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?
The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?
A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?
During an examination of a 2 year-old child with a tentative diagnosis of Wilm’s tumor, the nurse would be most concerned about which statement by the mother?
What is the most important aspect to include when developing a home care plan for a client with severe arthritis?
A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent?
A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants?
Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects?
A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?
A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?
A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the
A 2 year-old child has just been diagnosed with cystic fibrosis. The child’s father asks the nurse “What is our major concern now, and what will we have to deal with in the future?” Which of the following is the best response?
Which type of accidental poisoning would the nurse expect to occur in children under age 6?
A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?
The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?
The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?
A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to “see old buddies.” The nurse understands that the client’s behavior is a warning sign to indicate that the client may be
A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for
A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client?
At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?
The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group?
At the geriatric day care program a client is crying and repeating “I want to go home. Call my daddy to come for me.” The nurse should
A victim of domestic violence states to the nurse, “If only I could change and be how my companion wants me to be, I know things would be different.” Which would be the best response by the nurse?
A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn’t really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?
A mother wants to switch her 9 month-old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?
The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?
The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?
The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?
Post-procedure nursing interventions for electroconvulsive therapy include
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
The mother of a 15 month-old child asks the nurse to explain her child’s lab results and how they show her child has iron deficiency anemia. The nurse’s best response is
In a child with suspected coarctation of the aorta, the nurse would expect to find
At the day treatment center a client diagnosed with Schizophrenia – Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client’s behavior most likely indicates
A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0- to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to
When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection?
First-time parents bring their 5 day-old infant to the pediatrician’s office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings?
A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect in assessing this client?
Clients taking which of the following drugs are at risk for depression?
When a client is having a general tonic clonic seizure, the nurse should
101 After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, “My husband told me to get treatment or he would divorce me. I don’t believe I really need treatment but I don’t want my husband to leave me.” Which response by the nurse would assist the client?
A neonate born 12 hours ago to a methadone-maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passes loose, watery stool. Which of these is a nursing priority?
The nurse is caring for a post-myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to
The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is
The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the health care provider?
A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement?
The nurse walks into a client’s room and finds the client lying still and silent on the floor. The nurse should first
The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to
The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these demonstrates the normal pathway?
When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?
A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: “The manager makes all decisions and rarely asks for our input.” The best description of the nurse manager’s management style is
A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse “I’ve made some decisions about my life.” What should be the nurse’s initial response?
The nurse caring for a 14-year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, what must the nurse understand about adolescents with hemophilia?
When an autistic client begins to eat with her hands, the nurse can best handle the problem by
In assessing the healing of a client’s wound during a home visit, which of the following is the best indicator of good healing?
Which therapeutic communication skill is most likely to encourage a depressed client to vent feelings?
In order to enhance a client’s response to medication for chest pain from acute angina, the nurse should emphasize
The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?
Clients with mitral stenosis would likely manifest findings associated with congestion in the
The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?
What is the best way for the nurse to accomplish a health history on a 14-year-old client?
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
While planning care for a preschool-aged child, the nurse understands developmental needs. Which of the following would be of the most concern to the nurse?
A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important to emphasize to the client?
While teaching a client about their medications, the client asks how long it will take before the effects of lithium take place. What is the best response of the nurse?
The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include
Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called
The nurse asks a client with a history of alcoholism about the client’s drinking behavior. The client states “I didn’t hurt anyone. I just like to have a good time, and drinking helps me to relax.” The client is using which defense mechanism?
One reason that domestic violence remains extensively undetected is
A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 20-40 mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug administration, what should the nurse do next?
The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when
The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization?
Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the health care provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse?
When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority?
The nurse is caring for a newborn who has just been diagnosed with hypospadias. After discussing the defect with the parents, the nurse should expect that
The nurse is assessing a client on admission to a community mental health center. The client discloses that she has been thinking about ending her life. The nurse’s best response would be
The nursing care plan for a client with decreased adrenal function should include
The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)?
The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?
During the use of an interpreter to teach a client about a procedure to do in the home the nurse should take which approach?
A client is in the third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby’s father. Which of the following nursing interventions is a priority?
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
A nurse who is evaluating a mentally retarded 2-year-old in a clinic should stress which goal when talking to the child’s mother?
The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist the client with nutrition needs, the nurse should
The nurse is assessing a 2-year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis?
The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
Upon examining the mouth of a 3-year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings?
The nurse is reassigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice?
Which of these is an example of a variation in the newborn resulting from the presence of maternal hormones?
A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?
A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to
A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)?
The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is
The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that
The nurse is performing physical assessments on adolescents. When would the nurse anticipate that females experience growth spurts? [Show Less]