EXIT HESI COMPREHENSIVE B EVOLVE NEW UPDATE |QUESTIONS WITH CORRECT ANSWERS ALREADY GRADED A+

EXIT HESI COMPREHENSIVE B EVOLVE
NEW UPDATE |QUESTIONS WITH
CORRECT ANSWERS ALREADY
GRADED A+


A 12-year-old boy complains to the nurse that he is "short"
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(4'5" [53 inches]). His twin sister is 5 inches taller than he is
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(4'10" [58 inches]). Based on these findings, what conclusion
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should the nurse reach?
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A.The boy is not growing as normally expected.
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B.The girl is experiencing a period of unexpected growth.
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C.A normal growth spurt occurs in girls 1 to 2 years earlier
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than boys.
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D.Male-female twins are not identical; therefore, their growth i i i i i i i



cannot be compared. ...ANS: C
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Rationale:
Girls experience a growth spurt at 9.5 to 14.5 years of age and
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boys at 10.5 to 16 years of age (C). There are insufficient data
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to support (A); growth trends must be assessed to reach such
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a conclusion. (B) is not unexpected. The fact that the children
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are twins has less to do with their growth than the fact that
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they are male and female (D).
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A 45-year-old female client is admitted to the psychiatric unit
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for evaluation. Her husband states that she has been reluctant
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to leave home for the last 6 months. The client has not gone to
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work for a month, has been terminated from her job, and has
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,not left the house since that time. This client is displaying
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symptoms of which disorder?
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A.Claustrophobia
B.Acrophobia
C.Agoraphobia
D.Necrophobia ...ANS: C iiiii iii



Rationale:
Agoraphobia (C) is the fear of crowds or of being in an open i i i i i i i i i i i i



place. (A) is the fear of being in closed places. (B) is the fear of
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high places. (D) is an abnormal fear of death or bodies after
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death. A phobia is an unrealistic fear associated with severe
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anxiety.
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A client at 32 weeks of gestation is hospitalized with
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preeclampsia, and magnesium sulfate is prescribed to control
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the symptoms. Before the next dose of MgSO4 is given, which
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assessment finding indicates that the patient is at risk for
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toxicity?
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A.Deep tendon reflexes—decrease to 2+ i i i i



B.100 mL of urine output in 4 hours i i i i i i i



C.Respiratory rate decreases to 16 breaths/min i i i i i



D.Serum magnesium level, 7.5 mg/dL ...ANS: B i i i i iiiii iii



Rationale:
Magnesium sulfate, a central nervous system (CNS) i i i i i i



depressant, helps prevent seizures, so (A) is a positive sign
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that the medication is having a desired effect. The minimum
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urine output expected for a repeat dose of magnesium sulfate
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is 30 mL/hr, so 100 mL of urine in 4 hours can lead to poor
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excretion of magnesium, with a possible cumulative effect (B).
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A decreased respiratory rate (C) indicates that the drug is
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,i effective. A respiratory rate below 12 breaths/min indicates i i i i i i i



i toxic effects. The therapeutic level of magnesium sulfate for a
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i PIH client is 4 to 8 mg/dL (D).
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A client comes to the obstetric clinic for her first prenatal visit
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and complains of feeling nauseated every morning. The client
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tells the nurse, "I'm having second thoughts about wanting to
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have this baby." Which response is best for the nurse to make?
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A."It's normal to feel ambivalent about a pregnancy when you
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are not feeling well."
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B."I think you should discuss these feelings with your health
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care provider."
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C."How does the father of your child feel about your having
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this baby?"
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D."Tell me about these second thoughts you are having about
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this pregnancy." ...ANS: D
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Rationale:
Although ambivalence is normal during the first trimester, (D) i i i i i i i i



is the best nursing response at this time. It is reflective and
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keeps the lines of communication open. (A) is not the best
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response because it offers false reassurance. (B) dismisses the
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client's feelings. The nurse should use communication skills
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that encourage this type of discussion, not shift responsibility
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to the care provider. (C) may eventually be discussed, but it is
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not the most important information to obtain at this time.
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A client exhibits symptoms of alcohol intoxication. The blood
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alcohol level is 200 mg (0.2%). Which measurement tool is
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best for the nurse to use during the initial assessment of this
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client?
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, A.CAGE questionnaire for alcoholism i i i



B.Addiction Severity Index i i



C.Glasgow Coma Scale i i



D.DSM multiaxial evaluation ...ANS: C i i iiiii iii



Rationale:
Evaluation of level of consciousness, which is the purpose of i i i i i i i i i



the Glasgow Coma Scale (C), has the highest priority. (A) is
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useful in helping clients recognize their alcoholism. (B and D)
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are comprehensive assessments that should be completed
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after the acute phase is resolved.
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A client in an acute psychiatric setting asks the nurse if their
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conversations will remain confidential. How should the nurse
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respond?
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A."The Health Insurance Portability and Accountability Act
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(HIPAA) prevents me from repeating what you say."
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B."You can be assured that I will keep all of our conversations
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confidential because it is important that you can trust me."
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C."For your safety and well-being, it may be necessary to share
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some of our conversations with the health care team."
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D."I am legally required to document all of our conversations
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in the electronic medical record." ...ANS: C
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Rationale:
Some information, such as a suicide plan, must be shared with
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other team members for the client's safety and optimal
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therapy (C). HIPAA does not prevent a member of the health
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care team from repeating all conversations, particularly if
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safety is an issue (A). Ensuring a client that a conversation will
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remain confidential puts the nurse at risk, particularly if safety
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is an issue (B). Although pertinent information should be
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