2020 HESI exit v3
1. 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 -ANS Safety
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 -ANS They are able to think logically in organizing
facts
Rationale: Think logically in organizing facts
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 -ANS Place the child on the side
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 -ANS Lack of enjoyment in usual pleasures
. 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
A) Administer pain medication
B) Suction excessive tracheobronchial secretions
C) Assist client to turn, deep breathe and cough
D) Monitor oxygen saturation -ANS Suction excessive tracheobronchial secretions
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 -ANS Sense of impending doom
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 -ANS Explain that this behavior is expected
,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 -ANS Dependence
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 -ANS Sports and games with rules
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." -ANS Eat a balanced diet for your age
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." -ANS CD4 lymphocyte count is less than 200
, 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 -ANS Observe swallowing patterns
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 -ANS Anticipation of the birth
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 -ANS Increasing oral fluid intake to 3000 cc per day
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
1. 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 -ANS Safety
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 -ANS They are able to think logically in organizing
facts
Rationale: Think logically in organizing facts
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 -ANS Place the child on the side
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 -ANS Lack of enjoyment in usual pleasures
. 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
A) Administer pain medication
B) Suction excessive tracheobronchial secretions
C) Assist client to turn, deep breathe and cough
D) Monitor oxygen saturation -ANS Suction excessive tracheobronchial secretions
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 -ANS Sense of impending doom
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 -ANS Explain that this behavior is expected
,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 -ANS Dependence
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 -ANS Sports and games with rules
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." -ANS Eat a balanced diet for your age
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." -ANS CD4 lymphocyte count is less than 200
, 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 -ANS Observe swallowing patterns
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 -ANS Anticipation of the birth
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 -ANS Increasing oral fluid intake to 3000 cc per day
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
