EXIT HESI Comprehensive B Evolve
Exam Prep Questions Solved 100%
Correct (Rationale)
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 - ANSWER-C
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+
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 - ANSWER-B
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." -
ANSWER-D
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
C.Glasgow Coma Scale
D.DSM multiaxial evaluation - ANSWER-C
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." - ANSWER-C
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.
D.Determine coping mechanisms used in the past. - ANSWER-B
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. - ANSWER-C
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 - ANSWER-A
Rationale:
Hypokalemia can cause heart palpitations, which are indicative of a dysrhythmia that
could progress to a medical emergency (A). (B and C) are also of concern but are not
as life threatening. (D) is a symptom of hypocalcemia.
A client is admitted with a diagnosis of leukemia. This condition is manifested by which
of the following?
A.Fever, elevated white blood count, elevated platelets
B.Fatigue, weight loss and anorexia, elevated red blood cells
C.Hyperplasia of the gums, elevated white blood count, weakness
D.Hypocellular bone marrow aspirate, fever, decreased hemoglobin level - ANSWER-C
Rationale:
Hyperplastic gums, weakness, and elevated white blood count are classic signs of
leukemia (C). (A, B, and D) state incorrect information for symptoms of leukemia.
A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test
results indicate that the medication is producing the desired effect?
A.Increased hemoglobin and hematocrit levels
B.Increased serum calcium level
Exam Prep Questions Solved 100%
Correct (Rationale)
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 - ANSWER-C
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+
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 - ANSWER-B
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." -
ANSWER-D
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
C.Glasgow Coma Scale
D.DSM multiaxial evaluation - ANSWER-C
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." - ANSWER-C
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.
D.Determine coping mechanisms used in the past. - ANSWER-B
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. - ANSWER-C
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 - ANSWER-A
Rationale:
Hypokalemia can cause heart palpitations, which are indicative of a dysrhythmia that
could progress to a medical emergency (A). (B and C) are also of concern but are not
as life threatening. (D) is a symptom of hypocalcemia.
A client is admitted with a diagnosis of leukemia. This condition is manifested by which
of the following?
A.Fever, elevated white blood count, elevated platelets
B.Fatigue, weight loss and anorexia, elevated red blood cells
C.Hyperplasia of the gums, elevated white blood count, weakness
D.Hypocellular bone marrow aspirate, fever, decreased hemoglobin level - ANSWER-C
Rationale:
Hyperplastic gums, weakness, and elevated white blood count are classic signs of
leukemia (C). (A, B, and D) state incorrect information for symptoms of leukemia.
A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test
results indicate that the medication is producing the desired effect?
A.Increased hemoglobin and hematocrit levels
B.Increased serum calcium level
