HESI EXIT V2 ACTUAL EXAM UPDATE. COMPLETE QUESTION AND ANSWERS.

HESI EXIT V2 ACTUAL EXAM UPDATE. COMPLETE QUESTION AND ANSWERS. 1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? Ans: Be sure the traction weights touch the end of the bed. 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? Ans: 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? Ans: 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? Ans: "My pain is deep in my chest behind my sternum." . 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 recent memory? Ans: "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? Ans: Security A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? Ans: "Would you please clarify what you have written so I am sure I am reading it correctly?" What is the most important consideration when teaching parents how to reduce risks in the home? Ans: Age of children 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 Ans: Administer the prescribed analgesia While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? Ans: Respiratory rate of 42 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? Ans: Lethargy 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? Ans: "The seizure may or may not mean your child has epilepsy." Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? Ans: Risk for injury 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? Ans: Nasal passages The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client? Ans: "Complete all of the antibiotic even if your findings decrease." When counseling a 6 year old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder? Ans: Has no clear etiology 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? Ans: Use patience and a sense of humor to deal with 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? Ans: Papules, vesicles, and crusts will be present at one time 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? Ans: Place the client in a sitting position with legs dangling The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to Ans: Wrap the child's hand in mittens or socks to prevent scratching 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 recovering person cannot return to drinking without starting the addiction process over." In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding? Ans: Uses cocaine on weekends 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? Ans: Thiocyanate A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond? Ans: With fear of rejection causing increased rage toward the victim 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? Ans: Set time aside to get the mother to express her feelings and concerns A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client Ans: Use oxygen during meals improves gas exchange Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? Ans: Mild vomiting that progressed to vomiting shooting across the room. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? Ans: Tissue hypoxia The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet Ans: High in carbohydrates and proteins In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? Ans: Tripled the birth weight A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to Ans: Ask the client what foods are acceptable or bad 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? Ans: Imitation of sounds The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? Ans: Withdrawal Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by Ans: Minimizing the episode and underestimating the victim’s injuries The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse? Ans: "Would you like to take your medicine from a spoon or a cup?" In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and Ans: Decreased colloidal osmotic pressure in the capillaries 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 Dehydration 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 Ans: Life’s stressors 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? Ans: 15 minutes The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding? Ans: Retractions in the intercostal tissues of the thorax During the evaluation phase for a client, the nurse should focus on Ans: The client's status, progress toward goal achievement, and ongoing re-evaluation 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 Ans: Compile a history of behavior patterns and developmental accomplishments 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? Ans: Measure head circumference 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? Ans: Bilirubin The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? Ans: Should be limited to 3-4 cups of milk daily 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 Ans: Flight of ideas 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? Ans: Riding a tricycle 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 Ans: Moist saline dressing 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? Ans: Leave the room and return five minutes later and give the medicine 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? Ans: "If I drink, my baby may be harmed before I know I am pregnant." The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should Ans: Review the medications the client is receiving 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? Ans: "I find the mood swings and the change from a calm person to being angry all the time hard to deal with." 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? Ans: It assesses a child's development. 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? Ans: Explain the surgery 1 week prior to the procedure The nurse, assisting in applying a cast to a client with a broken arm, knows that Ans: The wet cast should be handled with the palms of hands 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? Ans: Assessing the client's learning style 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? Ans: All lesions crusted 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? Ans: I can switch to a bottle if I need to take a break from breast feeding. 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? Ans: Medication compliance 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? Ans: Place client on a pressure reducing support surface A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning? Ans: 20 month-old who has just learned to climb stairs 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? Ans: All the pants have become tight around the waist. What is the most important aspect to include when developing a home care plan for a client with severe arthritis? Ans: Maintaining and preserving function 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? Ans: Age of the child A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants? Ans: Provides antibodies Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects Ans: Red reflex test 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? Ans: Occlusive moist dressing 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? Ans: Large wooden puzzle 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 Ans: Yin, the negative force that represents darkness, cold, and emptiness 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? Ans: "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." Which type of accidental poisoning would the nurse expect to occur in children under age 6? Ans: Oral ingestion 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? Ans: Ping-pong The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? Ans: Distended neck veins Which nursing action is a priority as the plan of care is developed for a 7 year- old child hospitalized for acute glomerulonephritis? Ans: Note patterns of increased blood pressure The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? Ans: Confine the percussion to the rib cage area 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 Ans: headed for relapse 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 Ans: Psychomotor retardation or agitation 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? Ans: "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety." 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? Ans: Sit without support 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? Ans: Obesity 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 Ans: Give the client simple information about what she will be doing 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? Ans: "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do." 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? Ans: Lung remodeling and permanent changes in lung function 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? Ans: Continue with the present formula Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice? Ans: When the client threatens self-harm and harm to others 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? Ans: Precautions with position changes 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? Ans: Activity intolerance caused by fatigue related to chronic tissue hypoxia The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure? Ans: In both arms 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?