MDA 224 2018 HESI EXIT V4
1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which
nursing intervention is appropriate
... [Show More] for this child?
A) Make certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort
D) Release the traction for 15-20 minutes every 6 hours PRN.
The correct answer is A: Make certain the child is maintained in correct body alignment.
2. 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?
A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven
The correct answer is A: Height and weight percentiles vary widely
3. 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?
A) Teach the parents how to perform cardiopulmonary resuscitation
B) Recommend that the parents give in when he holds his breath to prevent anoxia
C) Advise the parents to ignore breath holding because breathing will begin as a reflex
D) Instruct the parents on how to reason with the child about possible harmful effects
The correct answer is C: Advise the parents to ignore breath holding because breathing
will begin as a reflex
4. The nurse is assessing a client in the emergency room. Which statement suggests that
the problem is acute angina?
A) "My pain is deep in my chest behind my sternum."
B) "When I sit up the pain gets worse."
C) "As I take a deep breath the pain gets worse."
D) "The pain is right here in my stomach area."
The correct answer is A: "My pain is deep in my chest behind my sternum."
.
5. The nurse is assessing the mental status of a client admitted with possible organic brain
disorder. Which of these questions will best assess the function of the client's recentmemory?
A) "Name the year." "What season is this?" (pause for answer after each question)
B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now
continue to subtract 7 from the new number."
C) "I am going to say the names of three things and I want you to repeat them after me:
blue, ball, pen."
D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of
it?"
The correct answer is C: "I am going to say the names of three things and I want you to
repeat them after me: blue, ball, pen."
6. In planning care for a 6 month-old infant, what must the nurse provide to assist in the
development of trust?
A) Food
B) Warmth
C) Security
D) Comfort
The correct answer is C: Security
7. A nurse has just received a medication order which is not legible. Which statement best
reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean."
B) "Would you please clarify what you have written so I am sure I am reading it
correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if you would
be more careful."
D) "Please print in the future so I do not have to spend extra time attempting to read your
writing."
The correct answer is B) "Would you please clarify what you have written so I am sure I
am
reading it correctly?"
8. What is the most important consideration when teaching parents how to reduce risks in
the home?
A) Age and knowledge level of the parents
B) Proximity to emergency services
C) Number of children in the home
D) Age of children in the home
The correct answer is D: Age of children in the home9. 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
A) Administer a placebo
B) Encourage increased fluid intake
C) Administer the prescribed analgesia
D) Recommend relaxation exercises for pain control
The correct answer is C: Administer the prescribed analgesia
10. While caring for a toddler with croup, which initial sign of croup requires the nurse's
immediate attention?
A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions
The correct answer is A: Respiratory rate of 30
11. 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?
A) Lethargy
B) Heat intolerance
C) Diarrhea
D) Skin eruptions
The correct answer is A: Lethargy
12. 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?
A) "Do not worry. Epilepsy can be treated with medications."
B) "The seizure may or may not mean your child has epilepsy."
C) "Since this was the first convulsion, it may not happen again."
D) "Long term treatment will prevent future seizures."
The correct answer is B: "The seizure may or may not mean your child has epilepsy."
13. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What
nursing diagnosis best applies?
A) Risk for injury
B) Risk for knowledge deficitC) Altered thought process
D) Disturbance in self-esteem
The correct answer is A: Risk for injury
14. 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?
A) Mouth
B) Nasal passages
C) Back of throat
D) Bronchials
The correct answer is B: Nasal passages
15. The nurse is providing instructions for a client with pneumonia. What is the most
important information to convey to the client?
A) "Take at least 2 weeks off from work."
B) "You will need another chest x-ray in 6 weeks."
C) "Take your temperature every day."
D) "Complete all of the antibiotic even if your findings decrease."
The correct answer is D: "Complete all of the antibiotic even if your findings decrease."
16. When counseling a 6 year old who is experiencing enuresis, what must the nurse
understand about the pathophysiological basis of this disorder?
A) Has no clear etiology
B) May be associated with sleep phobia
C) Has a definite genetic link
D) Is a sign of willful misbehavior
The correct answer is A: Has no clear etiology
17. 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?
A) Reprimand the child and give a 15 minute "time out"
B) Maintain a permissive attitude for this behavior
C) Use patience and a sense of humor to deal with this behavior
D) Assert authority over the child through limit setting
The correct answer is C: Use patience and a sense of humor to deal with this behavior
18. 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?
A) Chewable aspirin is the preferred analgesicB) Topical cortisone ointment relieves itching
C) Papules, vesicles, and crusts will be present at one time
D) The illness is only contagious prior to lesion eruption
The correct answer is C: Papules, vesicles, and crusts will be present at one time
19. 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?
A) Take the client's vital signs
B) Place the client in a sitting position with legs dangling
C) Contact the health care provider
D) Administer the PRN anti anxiety agent
The correct answer is B: Place the client in a sitting position with legs dangling
20. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the
parents to
A) Dress the child warmly to avoid chilling
B) Keep the child away from other children for the duration of the rash
C) Clean the affected areas with tepid water and detergent
D) Wrap the child's hand in mittens or socks to prevent scratching
The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching
21. 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?
A) "A recovering person has to be very careful not to lose control, therefore, confine your
drinking just at family gatherings."
B) "At your next AA meeting discuss the possibility of limited drinking with your
sponsor."
C) "A recovering person needs to get in touch with their feelings. Do you want a drink?"
D) "A recovering person cannot return to drinking without starting the addiction process
over."
The correct answer is D: "The recovering person cannot return to drinking without
starting the addiction process over."
22. In taking the history of a pregnant woman, which of the following would the nurse
recognize as the primary contraindication for breast feeding?
A) Age 40 years
B) Lactose intoleranceC) Family history of breast cancer
D) Uses cocaine on weekends
The correct answer is D: Uses cocaine on weekends
23. 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) Potassium
B) Arterial blood gasses
C) Blood urea nitrogen
D) Thiocyanate
The correct answer is D: Thiocyanate
24. 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) With acceptance and views the victim’s comment as an indication that their marriage
is in trouble
B) With fear of rejection causing increased rage toward the victim
C) With a new commitment to seek counseling to assist with their marital problems
D) With relief, and welcomes the separation as a means to have some personal time
The correct answer is B: With fear of rejection causing increased rage toward the victim
25. 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) Discuss with the mother sharing parenting responsibilities
B) Set time aside to get the mother to express her feelings and concerns
C) Arrange for the parents to attend infant care classes
D) Talk with the father and help him accept the wife's decision
The correct answer is B: Set time aside to get the mother to express her feelings and
concerns
26. A client with emphysema visits the clinic. While teaching about proper nutrition, the
nurse should emphasize that the client
A) Eat foods high in sodium increases sputum liquefaction
B) Use oxygen during meals improves gas exchange
C) Perform exercise after respiratory therapy enhances appetite
D) Cleanse the mouth of dried secretions reduces risk of infectionThe correct answer is B: Use oxygen during meals improves gas exchange
27. Which of these parents’ comment for a newborn would most likely reveal an initial
finding of a suspected pyloric stenosis?
A) I noticed a little lump a little above the belly button.
B) The baby seems hungry all the time.
C) Mild vomiting that progressed to vomiting shooting across the room.
D) Irritation and spitting up immediately after feedings.
The correct answer is C: Mild emesis progressing to projectile vomiting
28. The nurse is assessing a child for clinical manifestations of iron deficiency anemia.
Which factor would the nurse recognize as cause for the findings?
A) Decreased cardiac output
B) Tissue hypoxia
C) Cerebral edema
D) Reduced oxygen saturation
The correct answer is B: Tissue hypoxia
29. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic
enzymes along with a diet
A) High in carbohydrates and proteins
B) Low in carbohydrates and proteins
C) High in carbohydrates, low in proteins
D) Low in carbohydrates, high in proteins
The correct answer is A: High in carbohydrates and proteins
30. 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) Increased 10% in height
B) 2 deciduous teeth
C) Tripled the birth weight
D) Head > chest circumference
The correct answer is C: Tripled the birth weight
31. A Hispanic client in the postpartum period refuses the hospital food because it is
"cold." The best initial action by the nurse is to
A) Have the unlicensed assistive personnel (UAP) reheat the food if the client wishesB) Ask the client what foods are acceptable or bad
C) Encourage her to eat for healing and strength
D) Schedule the dietitian to meet with the client as soon as possible
The correct answer is B: Ask the client what foods are acceptable
32. 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?
A) Cooing
B) Imitation of sounds
C) Throaty sounds
D) Laughter
The correct answer is B: Imitation of Sounds
33. The nurse should recognize that physical dependence is accompanied by what
findings when alcohol consumption is first reduced or ended?
A) Seizures
B) Withdrawal
C) Craving
D) Marked tolerance
The correct answer is B: Withdrawal
34. Immediately following an acute battering incident in a violent relationship, the
batterer may respond to the partner’s injuries by
A) Seeking medical help for the victim's injuries
B) Minimizing the episode and underestimating the victim’s injuries
C) Contacting a close friend and asking for help
D) Being very remorseful and assisting the victim with medical care
The correct answer is B: Minimizing the episode and underestimating the victim’s
injuries
35. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following
is the best approach by the nurse?
A) "Do you want to take this pretty red medicine?"
B) "You will feel better if you take your medicine."
C) "This is your medicine, and you must take it all right now."
D) "Would you like to take your medicine from a spoon or a cup?"
The correct answer is D: "Would you like to take your medicine from a spoon or a cup?"36. In planning care for a child diagnosed with minimal change nephrotic syndrome, the
nurse should understand the relationship between edema formation and
A) Increased retention of albumin in the vascular system
B) Decreased colloidal osmotic pressure in the capillaries
C) Fluid shift from interstitial spaces into the vascular space
D) Reduced tubular reabsorption of sodium and water
The correct answer is B: Decreased colloidal osmotic pressure in the capillaries
37. 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) Septicemia
B) Dehydration
C) Hypokalemia
D) Hypercalcemia
The correct answer is B: Dehydration
38. 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
A) Recreational and social needs
B) Feelings of anger
C) Life’s stressors
D) Issues of guilt and disappointment
The correct answer is C: Life’s stressors
39. 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
A.M. What is the frequency of the contractions?
A) 14 minutes
B) 10 minutes
C) 15 minutes
D) Nine minutes
The correct answer is C: 15 minutes
40. The nurse is performing an assessment on a child with severe airway obstruction.
Which finding would the nurse anticipate finding?
A) Retractions in the intercostal tissues of the thoraxB) Chest pain aggravated by respiratory movement
C) Cyanosis and mottling of the skin
D) Rapid, shallow respirations
The correct answer is A: Retractions in the soft tissues of the thorax
41. During the evaluation phase for a client, the nurse should focus on
A) All finding of physical and psychosocial stressors of the client and in the family
B) The client's status, progress toward goal achievement, and ongoing re-evaluation
C) Setting short and long-term goals to insure continuity of care from hospital to home
D) Select interventions that are measurable and achievable within selected timeframes
The correct answer is B: The client''s status, progress toward goal achievement, and
ongoing re evaluation
42. 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
A) Observe the child's behavior on at least 2 occasions
B) Consult with the teacher about how to control impulsivity
C) Compile a history of behavior patterns and developmental accomplishments
D) Compare the child's behavior with classic signs and symptoms
The correct answer is C: Compile a history of behavior patterns and developmental
accomplishments
43. 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) Measure head circumference
B) Place in airborne isolation
C) Provide passive range of motion
D) Provide an over-the-crib protective top
The correct answer is A: Measure head circumference
44. 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?
A) Blood urea nitrogen
B) Acid phosphatase
C) BilirubinD) Sedimentation rate
The correct answer is C: Bilirubin
45. The nurse is discussing nutritional requirements with the parents of an 18 month-old
child. Which of these statements about milk consumption is correct?
A) May drink as much milk as desired
B) Can have milk mixed with other foods
C) Will benefit from fat-free cow's milk
D) Should be limited to 3-4 cups of milk daily
The correct answer is D: Should be limited to three to four cups of milk daily
46. 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) Neologisms
B) Dissociation
* C) Flight of ideas
D) Word salad
The correct answer is C: Flight of ideas
47. 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) Jumping rope
B) Tying shoelaces
C) Riding a tricycle
D) Playing hopscotch
The correct answer is C: Riding a tricycle
48. 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
A) A transparent film dressing
B) Wet dressing with debridement granules
C) Wet to dry with hydrogen peroxide
D) Moist saline dressing
The correct answer is D: Moist saline dressing49. 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) Leave the room and return five minutes later and give the medicine
B) Explain to the child that the medicine must be taken now
C) Give the medication to the father and ask him to give it
D) Mix the medication with ice cream or applesauce
The correct answer is A: Leave the room and return five minutes later and give the
medicine
50. 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?
A) "I understand that a glass of wine with dinner is healthy."
B) "Beer is not really hard alcohol, so I guess I can drink some."
C) "If I drink, my baby may be harmed before I know I am pregnant."
D) "Drinking with meals reduces the effects of alcohol."
The correct answer is C: "If I drink, my baby may be harmed before I know I am
pregnant."
51. 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) Review the medications the client is receiving
B) Increase the formula infusion rate
C) Increase the amount of water used to flush the tube
D) Attach a rectal bag to protect the skin
The correct answer is A: Review the medications the client is receiving
52. 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?
A) "My partner's breathing rate is usually below 12."
B) "I find the mood swings and the change from a calm person to being angry all the time
hard to deal with."
C) "It seems our sex life is non existant over the past 6 months."
D) "In the morning and evening I hear complaints that reading is next to impossible from
blurred print."
The correct answer is B: "I find the mood swings and the change from a calm person tobeing angry all the time hard to deal with."
53. 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?
A) It measures a child’s intelligence.
B) It assesses a child's development.
C) It evaluates psychological responses.
D) It helps to determine problems.
The correct answer is B: It assesses a child''s development.
54. 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?
A) Introduce the child to all staff the day before surgery
B) Explain the surgery 1 week prior to the procedure
C) Arrange a tour of the operating and recovery rooms
D) Encourage the child to bring a favorite toy to the hospital
The correct answer is B: Explain the surgery 1 week prior to the procedure [Show Less]