Hesi Exit V5 COMPLETE 160 QUESTION AND ANSWERS

Hesi Exit V5 COMPLETE 160 QUESTION AND ANSWERS1. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? A) Nutrition B) Elimination C) Activity D) Safety The correct answer is D: Safety 2. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? A) They are able to make simple association of ideas B) They are able to think logically in organizing facts C) Interpretation of events originate from their own perspective D) Conclusions are based on previous experiences The correct answer is B: Think logically in organizing facts 3. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first? A) Clear the area of any hazards B) Place the child on the side C) Restrain the child D) Give the prescribed anticonvulsant The correct answer is B: Place the child on the side 4. The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to A) Reports of difficulty falling and staying asleep B) Expression of persistent suicidal thoughts C) Lack of enjoyment in usual pleasures D) Reduced senses of taste and smell The correct answer is C: Lack of enjoyment in usual pleasures 5. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to 1 | P a g eA) Administer pain medication B) Suction excessive tracheobronchial secretions C) Assist client to turn, deep breathe and cough D) Monitor oxygen saturation The correct answer is B: Suction excessive tracheobronchial secretions 6. While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client? A) Compulsive behavior B) Sense of impending doom C) Fear of flying D) Predictable episodes The correct answer is B: Sense of impending doom 7. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse? A) Arrange to change client care assignments B) Explain that this behavior is expected C) Discuss the appropriate use of "time-out" D) Explain that the child needs extra attention The correct answer is B: Explain that this behavior is expected 8. A 15 year-old client with a lengthy confining illness is at risk for altered growth and development of which task? A) Loss of control B) Insecurity C) Dependence D) Lack of trust The correct answer is C: Dependence 9. Which playroom activities should the nurse organize for a small group of 7 year- old hospitalized children? A) Sports and games with rules B) Finger paints and water play C) "Dress-up" clothes and props D) Chess and television programs 2 | P a g eThe correct answer is A: Sports and games with rules 10. The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is A) "Eat a balanced diet for your age." B) "Increase your intake of protein and Vitamin A." C) "Decrease fatty foods from your diet." D) "Do not use caffeine in any form, including chocolate." The correct answer is A: "Eat a balanced diet for your age." 11. The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds A) "The complaints of at least 3 common findings." B) "The absence of any opportunistic infection." C) "CD4 lymphocyte count is less than 200." D) "Developmental delays in children." The correct answer is C: "CD4 lymphocyte count is less than 200." 12. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate? A) Offer ice cream every 2 hours B) Place the child in a supine position C) Allow the child to drink through a straw D) Observe swallowing patterns The correct answer is D: Observe swallowing patterns 13. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? A) Acceptance of the pregnancy B) Focus on fetal development C) Anticipation of the birth D) Ambivalence about pregnancy 3 | P a g eThe correct answer is C: Anticipation of the birth 14. The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions? A) Administration of cough suppressants B) Increasing oral fluid intake to 3000 cc per day C) Maintaining bed rest with bathroom privileges D) Performing chest physiotherapy twice a day The correct answer is B: Increasing oral fluid intake to 3000 cc per day 15. The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up? A) A 13 month-old unable to walk B) A 20 month-old only using 2 and 3 word sentences C) A 24 month-old who cries during examination D) A 30 month-old only drinking from a sip cup The correct answer is D: A 30 month-old only drinking from a sip cup 16. Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes? A) Give written pre and post tests B) Ask questions during practice C) Allow another diabetic to assist D) Observe a return demonstration The correct answer is D: Observe a return demonstration 17. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority? A) Elevate leg on 2 pillows B) Apply support stockings C) Apply warm compresses D) Maintain complete bed rest The correct answer is A: Elevate leg on 2 pillows 18. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to 4 | P a g ethis nurse is which child? A) Congenital cardiac defects B) An acute febrile illness C) Prolonged hypoxemia D) Severe multiple trauma The correct answer is C: Prolonged hypoxemia 19. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to A) A social worker from the local hospital B) An occupational therapist from the community center C) A physical therapist from the rehabilitation agency D) Another client with diabetes mellitus and takes insulin The correct answer is B: An occupational therapist from the community center 20. A priority goal of involuntary hospitalization of the severely mentally ill client is A) Re-orientation to reality B) Elimination of symptoms C) Protection from harm to self or others The correct answer is C: Protection from self harm and harm to others 21. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend A) Isometric B) Range of motion C) Aerobic D) Isotonic The correct answer is A: Isometric 22. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report A) Loss of consciousness B) Feeding problems 5 | P a g eC) Poor weight gain D) Fatigue with crying The correct answer is A: Loss of consciousness 23. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would A) Instruct the client to maintain a regular diet the day prior to the examination B) Restrict the client's fluid intake 4 hours prior to the examination C) Administer a laxative to the client the evening before the examination D) Inform the client that only 1 x-ray of his abdomen is necessary The correct answer is C: Administer a laxative to the client the evening before the examination 24. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? A) Altered tissue perfusion B) Risk for fluid volume deficit C) High risk for hemorrhage D) Risk for infection The correct answer is D: Risk for infection 25. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that A) Circumcision is delayed so the foreskin can be used for the surgical repair B) This procedure is contraindicated because of the permanent defect C) There is no medical indication for performing a circumcision on any child D) The procedure should be performed as soon as the infant is stable The correct answer is A: Circumcision is delayed so the foreskin can be used for the surgical repair 26. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? A) Confusion B) Loss of half of visual field C) Shallow respirations D) Tonic-clonic seizures The correct answer is C: Shallow respirations 6 | P a g e27. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings? A) These side effects are common and should subside in a few days B) The client is probably having an allergic reaction and should discontinue the drug C) Taking the lithium on an empty stomach should decrease these symptoms D) Decreasing dietary intake of sodium and fluids should minimize the side effects The correct answer is A: These side effects are common and should subside in a few days 28. A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse? A) Ask the client if he has noticed any bleeding or dark stools B) Tell the client to call 911 and go to the emergency department immediately C) Schedule a repeat Hemoglobin and Hematocrit in 1 month D) Tell the client to schedule an appointment with a hematologist The correct answer is A: Ask the client if he