EXIT HESI COMPREHENSIVE B EVOLVE
PRACTICE QUESTIONS AND ANSWERS LATEST
VERSION 2024 VERIFIED RATIONALE GRADED
A+
A 12-year-old boy complains to the nurse that he is "short" (4'5" [53 inches]). His twin sister is 5 inches
taller than he is (4'10" [58 inches]). Based on these findings, what conclusion should the nurse reach?
A.The boy is not growing as normally expected.
B.The girl is experiencing a period of unexpected growth.
C.A normal growth spurt occurs in girls 1 to 2 years earlier than boys.
D.Male-female twins are not identical; therefore, their growth cannot be compared. - ansC
Rationale:
Girls experience a growth spurt at 9.5 to 14.5 years of age and boys at 10.5 to 16 years of age (C). There
are insufficient data to support (A); growth trends must be assessed to reach such a conclusion. (B) is not
unexpected. The fact that the children are twins has less to do with their growth than the fact that they
are male and female (D).
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she
has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, has
been terminated from her job, and has not left the house since that time. This client is displaying
symptoms of which disorder?
A.Claustrophobia
B.Acrophobia
C.Agoraphobia
D.Necrophobia - ansC
Rationale:
Agoraphobia (C) is the fear of crowds or of being in an open place. (A) is the fear of being in closed
places. (B) is the fear of high places. (D) is an abnormal fear of death or bodies after death. A phobia is
an unrealistic fear associated with severe anxiety.
A client at 32 weeks of gestation is hospitalized with preeclampsia, and magnesium sulfate is prescribed
to control the symptoms. Before the next dose of MgSO4 is given, which assessment finding indicates
that the patient is at risk for toxicity?
A.Deep tendon reflexes—decrease to 2+
, EXIT HESI COMPREHENSIVE B EVOLVE
PRACTICE QUESTIONS AND ANSWERS LATEST
VERSION 2024 VERIFIED RATIONALE GRADED
A+
B.100 mL of urine output in 4 hours
C.Respiratory rate decreases to 16 breaths/min
D.Serum magnesium level, 7.5 mg/dL - ansB
Rationale:
Magnesium sulfate, a central nervous system (CNS) depressant, helps prevent seizures, so (A) is a
positive sign that the medication is having a desired effect. The minimum urine output expected for a
repeat dose of magnesium sulfate is 30 mL/hr, so 100 mL of urine in 4 hours can lead to poor excretion
of magnesium, with a possible cumulative effect (B). A decreased respiratory rate (C) indicates that the
drug is effective. A respiratory rate below 12 breaths/min indicates toxic effects. The therapeutic level of
magnesium sulfate for a PIH client is 4 to 8 mg/dL (D).
A client comes to the obstetric clinic for her first prenatal visit and complains of feeling nauseated every
morning. The client tells the nurse, "I'm having second thoughts about wanting to have this baby." Which
response is best for the nurse to make?
A."It's normal to feel ambivalent about a pregnancy when you are not feeling well."
B."I think you should discuss these feelings with your health care provider."
C."How does the father of your child feel about your having this baby?"
D."Tell me about these second thoughts you are having about this pregnancy." - ansD
Rationale:
Although ambivalence is normal during the first trimester, (D) is the best nursing response at this time. It
is reflective and keeps the lines of communication open. (A) is not the best response because it offers
false reassurance. (B) dismisses the client's feelings. The nurse should use communication skills that
encourage this type of discussion, not shift responsibility to the care provider. (C) may eventually be
discussed, but it is not the most important information to obtain at this time.
A client exhibits symptoms of alcohol intoxication. The blood alcohol level is 200 mg (0.2%). Which
measurement tool is best for the nurse to use during the initial assessment of this client?
A.CAGE questionnaire for alcoholism
B.Addiction Severity Index
, EXIT HESI COMPREHENSIVE B EVOLVE
PRACTICE QUESTIONS AND ANSWERS LATEST
VERSION 2024 VERIFIED RATIONALE GRADED
A+
C.Glasgow Coma Scale
D.DSM multiaxial evaluation - ansC
Rationale:
Evaluation of level of consciousness, which is the purpose of the Glasgow Coma Scale (C), has the highest
priority. (A) is useful in helping clients recognize their alcoholism. (B and D) are comprehensive
assessments that should be completed after the acute phase is resolved.
A client in an acute psychiatric setting asks the nurse if their conversations will remain confidential. How
should the nurse respond?
A."The Health Insurance Portability and Accountability Act (HIPAA) prevents me from repeating what
you say."
B."You can be assured that I will keep all of our conversations confidential because it is important that
you can trust me."
C."For your safety and well-being, it may be necessary to share some of our conversations with the
health care team."
D."I am legally required to document all of our conversations in the electronic medical record." - ansC
Rationale:
Some information, such as a suicide plan, must be shared with other team members for the client's
safety and optimal therapy (C). HIPAA does not prevent a member of the health care team from
repeating all conversations, particularly if safety is an issue (A). Ensuring a client that a conversation will
remain confidential puts the nurse at risk, particularly if safety is an issue (B). Although pertinent
information should be documented, the nurse is not legally required to document all conversations with
a client (D).
A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action should the
nurse take first?
A.Administer an antianxiety medication PRN.
B.Assess the client's vital signs.
C.Notify the primary health care provider.
, EXIT HESI COMPREHENSIVE B EVOLVE
PRACTICE QUESTIONS AND ANSWERS LATEST
VERSION 2024 VERIFIED RATIONALE GRADED
A+
D.Determine coping mechanisms used in the past. - ansB
Rationale:
Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is important that
the nurse assess the patient and rule out physiologic causes (B). Nonpharmacologic measures should be
taken first (A). (C and D) may be considered but are not as high priority as the initial physiologic
assessment.
A client is admitted to a mental health unit because of mild depression. When asked, he denies suicidal
ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on
aspirin 5 years earlier. Which intervention is most important for the nurse to implement?
A.Orient the client to activities on the unit.
B.Document suicide precautions on the shift report.
C.Assign the client to a semiprivate room.
D.Obtain a verbal no-suicide contract with the client. - ansC
Rationale:
It is most important to prevent the risk of self-harm from social isolation, so the client should be
assigned to a semiprivate room (C). (A) does not have the priority of (C). (B and D) can be implemented if
the client admits suicidal ideation. However, based on the fact that this client is mildly depressed and
that he attempted suicide 5 years ago using a method that is usually nonlethal (aspirin overdose), it is
most important to prevent social isolation.
A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation is
most significant?
A.Heart palpitations
B.Leg cramps
C.Nausea
D.Tetany - ansA
Rationale:
PRACTICE QUESTIONS AND ANSWERS LATEST
VERSION 2024 VERIFIED RATIONALE GRADED
A+
A 12-year-old boy complains to the nurse that he is "short" (4'5" [53 inches]). His twin sister is 5 inches
taller than he is (4'10" [58 inches]). Based on these findings, what conclusion should the nurse reach?
A.The boy is not growing as normally expected.
B.The girl is experiencing a period of unexpected growth.
C.A normal growth spurt occurs in girls 1 to 2 years earlier than boys.
D.Male-female twins are not identical; therefore, their growth cannot be compared. - ansC
Rationale:
Girls experience a growth spurt at 9.5 to 14.5 years of age and boys at 10.5 to 16 years of age (C). There
are insufficient data to support (A); growth trends must be assessed to reach such a conclusion. (B) is not
unexpected. The fact that the children are twins has less to do with their growth than the fact that they
are male and female (D).
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she
has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, has
been terminated from her job, and has not left the house since that time. This client is displaying
symptoms of which disorder?
A.Claustrophobia
B.Acrophobia
C.Agoraphobia
D.Necrophobia - ansC
Rationale:
Agoraphobia (C) is the fear of crowds or of being in an open place. (A) is the fear of being in closed
places. (B) is the fear of high places. (D) is an abnormal fear of death or bodies after death. A phobia is
an unrealistic fear associated with severe anxiety.
A client at 32 weeks of gestation is hospitalized with preeclampsia, and magnesium sulfate is prescribed
to control the symptoms. Before the next dose of MgSO4 is given, which assessment finding indicates
that the patient is at risk for toxicity?
A.Deep tendon reflexes—decrease to 2+
, EXIT HESI COMPREHENSIVE B EVOLVE
PRACTICE QUESTIONS AND ANSWERS LATEST
VERSION 2024 VERIFIED RATIONALE GRADED
A+
B.100 mL of urine output in 4 hours
C.Respiratory rate decreases to 16 breaths/min
D.Serum magnesium level, 7.5 mg/dL - ansB
Rationale:
Magnesium sulfate, a central nervous system (CNS) depressant, helps prevent seizures, so (A) is a
positive sign that the medication is having a desired effect. The minimum urine output expected for a
repeat dose of magnesium sulfate is 30 mL/hr, so 100 mL of urine in 4 hours can lead to poor excretion
of magnesium, with a possible cumulative effect (B). A decreased respiratory rate (C) indicates that the
drug is effective. A respiratory rate below 12 breaths/min indicates toxic effects. The therapeutic level of
magnesium sulfate for a PIH client is 4 to 8 mg/dL (D).
A client comes to the obstetric clinic for her first prenatal visit and complains of feeling nauseated every
morning. The client tells the nurse, "I'm having second thoughts about wanting to have this baby." Which
response is best for the nurse to make?
A."It's normal to feel ambivalent about a pregnancy when you are not feeling well."
B."I think you should discuss these feelings with your health care provider."
C."How does the father of your child feel about your having this baby?"
D."Tell me about these second thoughts you are having about this pregnancy." - ansD
Rationale:
Although ambivalence is normal during the first trimester, (D) is the best nursing response at this time. It
is reflective and keeps the lines of communication open. (A) is not the best response because it offers
false reassurance. (B) dismisses the client's feelings. The nurse should use communication skills that
encourage this type of discussion, not shift responsibility to the care provider. (C) may eventually be
discussed, but it is not the most important information to obtain at this time.
A client exhibits symptoms of alcohol intoxication. The blood alcohol level is 200 mg (0.2%). Which
measurement tool is best for the nurse to use during the initial assessment of this client?
A.CAGE questionnaire for alcoholism
B.Addiction Severity Index
, EXIT HESI COMPREHENSIVE B EVOLVE
PRACTICE QUESTIONS AND ANSWERS LATEST
VERSION 2024 VERIFIED RATIONALE GRADED
A+
C.Glasgow Coma Scale
D.DSM multiaxial evaluation - ansC
Rationale:
Evaluation of level of consciousness, which is the purpose of the Glasgow Coma Scale (C), has the highest
priority. (A) is useful in helping clients recognize their alcoholism. (B and D) are comprehensive
assessments that should be completed after the acute phase is resolved.
A client in an acute psychiatric setting asks the nurse if their conversations will remain confidential. How
should the nurse respond?
A."The Health Insurance Portability and Accountability Act (HIPAA) prevents me from repeating what
you say."
B."You can be assured that I will keep all of our conversations confidential because it is important that
you can trust me."
C."For your safety and well-being, it may be necessary to share some of our conversations with the
health care team."
D."I am legally required to document all of our conversations in the electronic medical record." - ansC
Rationale:
Some information, such as a suicide plan, must be shared with other team members for the client's
safety and optimal therapy (C). HIPAA does not prevent a member of the health care team from
repeating all conversations, particularly if safety is an issue (A). Ensuring a client that a conversation will
remain confidential puts the nurse at risk, particularly if safety is an issue (B). Although pertinent
information should be documented, the nurse is not legally required to document all conversations with
a client (D).
A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action should the
nurse take first?
A.Administer an antianxiety medication PRN.
B.Assess the client's vital signs.
C.Notify the primary health care provider.
, EXIT HESI COMPREHENSIVE B EVOLVE
PRACTICE QUESTIONS AND ANSWERS LATEST
VERSION 2024 VERIFIED RATIONALE GRADED
A+
D.Determine coping mechanisms used in the past. - ansB
Rationale:
Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is important that
the nurse assess the patient and rule out physiologic causes (B). Nonpharmacologic measures should be
taken first (A). (C and D) may be considered but are not as high priority as the initial physiologic
assessment.
A client is admitted to a mental health unit because of mild depression. When asked, he denies suicidal
ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on
aspirin 5 years earlier. Which intervention is most important for the nurse to implement?
A.Orient the client to activities on the unit.
B.Document suicide precautions on the shift report.
C.Assign the client to a semiprivate room.
D.Obtain a verbal no-suicide contract with the client. - ansC
Rationale:
It is most important to prevent the risk of self-harm from social isolation, so the client should be
assigned to a semiprivate room (C). (A) does not have the priority of (C). (B and D) can be implemented if
the client admits suicidal ideation. However, based on the fact that this client is mildly depressed and
that he attempted suicide 5 years ago using a method that is usually nonlethal (aspirin overdose), it is
most important to prevent social isolation.
A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation is
most significant?
A.Heart palpitations
B.Leg cramps
C.Nausea
D.Tetany - ansA
Rationale:
