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"
i i i i i i i i i i
(4'5" [53 inches]). His twin sister is 5 inches taller than he is
i i i i i i i i i i i i i
(4'10" [58 inches]). Based on these findings, what conclusion
i i i i i i i i i
should the nurse reach?
i i i i
A.The boy is not growing as normally expected.
i i i i i i i
B.The girl is experiencing a period of unexpected growth.
i i i i i i i i
C.A normal growth spurt occurs in girls 1 to 2 years earlier
i i i i i i i i i i i
than boys.
i i
D.Male-female twins are not identical; therefore, their growth i i i i i i i
cannot be compared. ...ANS: C
i i i iiiii iii
Rationale:
Girls experience a growth spurt at 9.5 to 14.5 years of age and
i i i i i i i i i i i i
boys at 10.5 to 16 years of age (C). There are insufficient data
i i i i i i i i i i i i i
to support (A); growth trends must be assessed to reach such
i i i i i i i i i i i
a conclusion. (B) is not unexpected. The fact that the children
i i i i i i i i i i i
are twins has less to do with their growth than the fact that
i i i i i i i i i i i i i
they are male and female (D).
i i i i i i
A 45-year-old female client is admitted to the psychiatric unit
i i i i i i i i i
for evaluation. Her husband states that she has been reluctant
i i i i i i i i i i
to leave home for the last 6 months. The client has not gone to
i i i i i i i i i i i i i i
work for a month, has been terminated from her job, and has
i i i i i i i i i i i i
,not left the house since that time. This client is displaying
i i i i i i i i i i i
symptoms of which disorder?
i i i i
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
i i i i i i i i i i i i i i i
high places. (D) is an abnormal fear of death or bodies after
i i i i i i i i i i i i
death. A phobia is an unrealistic fear associated with severe
i i i i i i i i i i
anxiety.
i
A client at 32 weeks of gestation is hospitalized with
i i i i i i i i i
preeclampsia, and magnesium sulfate is prescribed to control
i i i i i i i i
the symptoms. Before the next dose of MgSO4 is given, which
i i i i i i i i i i i
assessment finding indicates that the patient is at risk for
i i i i i i i i i i
toxicity?
i
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
i i i i i i i i i i
that the medication is having a desired effect. The minimum
i i i i i i i i i i
urine output expected for a repeat dose of magnesium sulfate
i i i i i i i i i i
is 30 mL/hr, so 100 mL of urine in 4 hours can lead to poor
i i i i i i i i i i i i i i i
excretion of magnesium, with a possible cumulative effect (B).
i i i i i i i i i
A decreased respiratory rate (C) indicates that the drug is
i i i i i i i i i i
,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
i i i i i i i i i
i PIH client is 4 to 8 mg/dL (D).
i i i i i i i
A client comes to the obstetric clinic for her first prenatal visit
i i i i i i i i i i i
and complains of feeling nauseated every morning. The client
i i i i i i i i i
tells the nurse, "I'm having second thoughts about wanting to
i i i i i i i i i i
have this baby." Which response is best for the nurse to make?
i i i i i i i i i i i i
A."It's normal to feel ambivalent about a pregnancy when you
i i i i i i i i i
are not feeling well."
i i i i
B."I think you should discuss these feelings with your health
i i i i i i i i i
care provider."
i i
C."How does the father of your child feel about your having
i i i i i i i i i i
this baby?"
i i
D."Tell me about these second thoughts you are having about
i i i i i i i i i
this pregnancy." ...ANS: D
i i iiiii iii
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
i i i i i i i i i i i i
keeps the lines of communication open. (A) is not the best
i i i i i i i i i i i
response because it offers false reassurance. (B) dismisses the
i i i i i i i i i
client's feelings. The nurse should use communication skills
i i i i i i i i
that encourage this type of discussion, not shift responsibility
i i i i i i i i i
to the care provider. (C) may eventually be discussed, but it is
i i i i i i i i i i i i
not the most important information to obtain at this time.
i i i i i i i i i i
A client exhibits symptoms of alcohol intoxication. The blood
i i i i i i i i
alcohol level is 200 mg (0.2%). Which measurement tool is
i i i i i i i i i i
best for the nurse to use during the initial assessment of this
i i i i i i i i i i i i
client?
i
, 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
i i i i i i i i i i i
useful in helping clients recognize their alcoholism. (B and D)
i i i i i i i i i i
are comprehensive assessments that should be completed
i i i i i i i
after the acute phase is resolved.
i i i i i i
A client in an acute psychiatric setting asks the nurse if their
i i i i i i i i i i i
conversations will remain confidential. How should the nurse
i i i i i i i i
respond?
i
A."The Health Insurance Portability and Accountability Act
i i i i i i i
(HIPAA) prevents me from repeating what you say."
i i i i i i i i
B."You can be assured that I will keep all of our conversations
i i i i i i i i i i i
confidential because it is important that you can trust me."
i i i i i i i i i i
C."For your safety and well-being, it may be necessary to share
i i i i i i i i i i
some of our conversations with the health care team."
i i i i i i i i i
D."I am legally required to document all of our conversations
i i i i i i i i i
in the electronic medical record." ...ANS: C
i i i i i iiiii iii
Rationale:
Some information, such as a suicide plan, must be shared with
i i i i i i i i i i
other team members for the client's safety and optimal
i i i i i i i i i
therapy (C). HIPAA does not prevent a member of the health
i i i i i i i i i i i
care team from repeating all conversations, particularly if
i i i i i i i i
safety is an issue (A). Ensuring a client that a conversation will
i i i i i i i i i i i i
remain confidential puts the nurse at risk, particularly if safety
i i i i i i i i i i
is an issue (B). Although pertinent information should be
i i i i i i i i i
NEW UPDATE |QUESTIONS WITH
CORRECT ANSWERS ALREADY
GRADED A+
A 12-year-old boy complains to the nurse that he is "short"
i i i i i i i i i i
(4'5" [53 inches]). His twin sister is 5 inches taller than he is
i i i i i i i i i i i i i
(4'10" [58 inches]). Based on these findings, what conclusion
i i i i i i i i i
should the nurse reach?
i i i i
A.The boy is not growing as normally expected.
i i i i i i i
B.The girl is experiencing a period of unexpected growth.
i i i i i i i i
C.A normal growth spurt occurs in girls 1 to 2 years earlier
i i i i i i i i i i i
than boys.
i i
D.Male-female twins are not identical; therefore, their growth i i i i i i i
cannot be compared. ...ANS: C
i i i iiiii iii
Rationale:
Girls experience a growth spurt at 9.5 to 14.5 years of age and
i i i i i i i i i i i i
boys at 10.5 to 16 years of age (C). There are insufficient data
i i i i i i i i i i i i i
to support (A); growth trends must be assessed to reach such
i i i i i i i i i i i
a conclusion. (B) is not unexpected. The fact that the children
i i i i i i i i i i i
are twins has less to do with their growth than the fact that
i i i i i i i i i i i i i
they are male and female (D).
i i i i i i
A 45-year-old female client is admitted to the psychiatric unit
i i i i i i i i i
for evaluation. Her husband states that she has been reluctant
i i i i i i i i i i
to leave home for the last 6 months. The client has not gone to
i i i i i i i i i i i i i i
work for a month, has been terminated from her job, and has
i i i i i i i i i i i i
,not left the house since that time. This client is displaying
i i i i i i i i i i i
symptoms of which disorder?
i i i i
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
i i i i i i i i i i i i i i i
high places. (D) is an abnormal fear of death or bodies after
i i i i i i i i i i i i
death. A phobia is an unrealistic fear associated with severe
i i i i i i i i i i
anxiety.
i
A client at 32 weeks of gestation is hospitalized with
i i i i i i i i i
preeclampsia, and magnesium sulfate is prescribed to control
i i i i i i i i
the symptoms. Before the next dose of MgSO4 is given, which
i i i i i i i i i i i
assessment finding indicates that the patient is at risk for
i i i i i i i i i i
toxicity?
i
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
i i i i i i i i i i
that the medication is having a desired effect. The minimum
i i i i i i i i i i
urine output expected for a repeat dose of magnesium sulfate
i i i i i i i i i i
is 30 mL/hr, so 100 mL of urine in 4 hours can lead to poor
i i i i i i i i i i i i i i i
excretion of magnesium, with a possible cumulative effect (B).
i i i i i i i i i
A decreased respiratory rate (C) indicates that the drug is
i i i i i i i i i i
,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
i i i i i i i i i
i PIH client is 4 to 8 mg/dL (D).
i i i i i i i
A client comes to the obstetric clinic for her first prenatal visit
i i i i i i i i i i i
and complains of feeling nauseated every morning. The client
i i i i i i i i i
tells the nurse, "I'm having second thoughts about wanting to
i i i i i i i i i i
have this baby." Which response is best for the nurse to make?
i i i i i i i i i i i i
A."It's normal to feel ambivalent about a pregnancy when you
i i i i i i i i i
are not feeling well."
i i i i
B."I think you should discuss these feelings with your health
i i i i i i i i i
care provider."
i i
C."How does the father of your child feel about your having
i i i i i i i i i i
this baby?"
i i
D."Tell me about these second thoughts you are having about
i i i i i i i i i
this pregnancy." ...ANS: D
i i iiiii iii
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
i i i i i i i i i i i i
keeps the lines of communication open. (A) is not the best
i i i i i i i i i i i
response because it offers false reassurance. (B) dismisses the
i i i i i i i i i
client's feelings. The nurse should use communication skills
i i i i i i i i
that encourage this type of discussion, not shift responsibility
i i i i i i i i i
to the care provider. (C) may eventually be discussed, but it is
i i i i i i i i i i i i
not the most important information to obtain at this time.
i i i i i i i i i i
A client exhibits symptoms of alcohol intoxication. The blood
i i i i i i i i
alcohol level is 200 mg (0.2%). Which measurement tool is
i i i i i i i i i i
best for the nurse to use during the initial assessment of this
i i i i i i i i i i i i
client?
i
, 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
i i i i i i i i i i i
useful in helping clients recognize their alcoholism. (B and D)
i i i i i i i i i i
are comprehensive assessments that should be completed
i i i i i i i
after the acute phase is resolved.
i i i i i i
A client in an acute psychiatric setting asks the nurse if their
i i i i i i i i i i i
conversations will remain confidential. How should the nurse
i i i i i i i i
respond?
i
A."The Health Insurance Portability and Accountability Act
i i i i i i i
(HIPAA) prevents me from repeating what you say."
i i i i i i i i
B."You can be assured that I will keep all of our conversations
i i i i i i i i i i i
confidential because it is important that you can trust me."
i i i i i i i i i i
C."For your safety and well-being, it may be necessary to share
i i i i i i i i i i
some of our conversations with the health care team."
i i i i i i i i i
D."I am legally required to document all of our conversations
i i i i i i i i i
in the electronic medical record." ...ANS: C
i i i i i iiiii iii
Rationale:
Some information, such as a suicide plan, must be shared with
i i i i i i i i i i
other team members for the client's safety and optimal
i i i i i i i i i
therapy (C). HIPAA does not prevent a member of the health
i i i i i i i i i i i
care team from repeating all conversations, particularly if
i i i i i i i i
safety is an issue (A). Ensuring a client that a conversation will
i i i i i i i i i i i i
remain confidential puts the nurse at risk, particularly if safety
i i i i i i i i i i
is an issue (B). Although pertinent information should be
i i i i i i i i i
