Exit Hesi 700 + Bank 301 – 400 Exam
Questions and Answer
301.p4Anp4adultp4clientp4presentp4top4thep4clinicp4withp4largep4drainingp4ulcersp4onp4bothp4lo
werp4legsp4thatp4arep4characteristicsp4ofp4Kaposi‟sp4sarcomap4lesions.p4Thep4clientp4isp4ac
companiedp4byp4twop4familyp4members.p4Whichp4actionp4shouldp4thep4nursep4take?
a-p4Askp4familyp4memberp4top4wearp4glovesp4whenp4touchingp4thep4patient
b-p4Sendp4familyp4top4thep4waitingp4areap4whilep4thep4client‟sp4historyp4isp4taking
c-p4Obtainp4ap4bloodp4samplep4top4determinep4isp4thep4clientp4isp4HIVp4positive
d-p4Completep4thep4headp4top4toesp4assessmentp4top4identifyp4otherp4signp4ofp4HIVp4-
p4ANSWERS--b-
p4Sendp4familyp4top4thep4waitingp4areap4whilep4thep4client‟sp4historyp4isp4taking
Rationale:p4Top4protectp4thep4clientp4privacy,p4thep4familyp4memberp4shouldp4bep4askedp4t
op4waitp4outsidep4whilep4thep4client‟sp4historyp4isp4take.p4Glovesp4shouldp4bep4wornp4whenp
4touchingp4thep4client‟sp4bodyp4fluidsp4ifp4thep4clientp4isp4HIVp4positivep4andp4thesep4lesionp
4arep4actuallyp4Kaposip4sarcomap4lesion.p4HIVp4testingp4cannotp4legallyp4bep4donep4witho
utp4thep4clientp4explicitp4permission.p4Ap4furtherp4assessmentp4canp4bep4implementedp4aft
erp4thep4familyp4leftp4thep4room.
302.p4Anp4adultp4clientp4isp4exhibitp4thep4maniacp4stagep4ofp4bipolarp4disorderp4isp4admitted
p4top4thep4psychiatricp4unit.p4Thep4clientp4hasp4lostp410p4poundsp4inp4thep4lastp4twop4weeksp4
andp4hasp4nop4bathedp4inp4ap4weekp4"I‟mp4tryingp4top4startp4ap4newp4businessp4andp4"I‟mp4t
oop4busyp4top4eat".p4Thep4clientp4isp4orientedp4top4time,p4place,p4personp4butp4notp4situation
.p4Whichp4nursingp4problemp4hasp4thep4greatestp4priority?
a-p4Hygiene-self-carep4deficit
b-p4Imbalancep4nutritionp4
c-p4Disturbedp4sleepp4patternp4
d-p4Self-neglectp4-p4ANSWERS--b-p4Imbalancep4nutritionp4
Rationale:p4Thep4client‟sp4nutritionalp4statusp4hasp4thep4highestp4priorityp4atp4thisp4time,p4a
ndp4fingerp4foodsp4arep4oftenp4provided,p4sop4thep4clientp4whop4isp4onp4thep4maniacp4phase
p4ofp4bipolarp4diseasep4canp4receivep4adequatep4nutrition.p4Otherp4optionsp4arep4nursingp4
problemsp4thatp4shouldp4alsop4bep4addressesp4withp4thep4client‟sp4planp4ofp4care,p4butp4atp4
thisp4stagep4inp4thep4client‟sp4treatment,p4adequatep4nutritionp4isp4ap4priority
303.p4Thep4nursep4isp4preparingp4ap4dischargep4teachingp4planp4forp4ap4clientp4whop4hadp4a
p4liverp4transplant.p4Whichp4instructionp4isp4mostp4importantp4top4includep4inp4thisp4plan?
,a-p4Limitp4intakep4fattyp4foodsp4forp4onep4monthp4afterp4surgery
b-p4Notifyp4thep4healthcarep4providerp4ifp4edemap4occurs
c-p4Increasep4activityp4andp4exercisep4gradually,p4asp4tolerated
d-p4Avoidp4crowdsp4forp4firstp4twop4monthsp4afterp4surgeryp4-p4ANSWERS--d-
p4Avoidp4crowdsp4forp4firstp4twop4monthsp4afterp4surgery
Rationale:p4Cyclosporinep4immunosuppressionp4therapyp4isp4vitalp4inp4thep4successp4ofp4l
iverp4transplantationp4andp4canp4increasep4thep4riskp4forp4infection,p4whichp4isp4criticalp4inp4
thep4firstp4twop4monthsp4afterp4surgery.p4Feverp4isp4often.
304.p4Photop4Questionp4-p4ANSWERS--
305.p4Ap4clientp4whop4hadp4ap4percutaneousp4transluminalp4coronaryp4angioplastyp4(PTC
A)p4twop4weeksp4agop4returnsp4top4thep4clinicp4forp4ap4followp4upp4visit.p4Thep4clientp4hasp4ap
4postoperativep4ejectionp4fractionp4ofp430%.p4Todayp4thep4clientp4hasp4lungsp4whichp4arep4
clear,p4+1p4pedalp4edema,p4andp4ap45-
poundp4weightp4gain.p4Whichp4interventionp4thep4nursep4implement?
a-p4Arrangep4transportp4forp4admissionp4top4thep4hospital
b-p4Insertp4salinep4lockp4forp4IVp4diureticp4therapy
c-p4Assessp4compliancep4withp4routinep4prescriptions
d-p4Instructp4thep4clientp4top4monitorp4dailyp4caloricp4intakep4-p4ANSWERS--c-
p4Assessp4compliancep4withp4routinep4prescriptions
Rationale:p4Fluidp4retentionp4mayp4bep4ap4signp4thatp4thep4clientp4isp4notp4takingp4thep4medi
cationp4asp4prescribedp4orp4thatp4thep4prescriptionsp4mayp4needp4adjustmentp4top4manage
p4cardiacp4functionp4post-PTCAp4(normalp4ejectionp4fractionp4rangep4isp450p4top475%)
306.p4Thep4RNp4isp4assignedp4top4carep4forp4fourp4surgicalp4clients.p4Afterp4receivingp4repo
rt,p4whichp4clientp4shouldp4thep4nursep4seep4first?p4Thep4clientp4whop4is
a-
p4Twop4daysp4postoperativep4bladderp4surgeryp4withp4continuousp4bladderp4irrigationp4inf
using
b-
p4Onep4dayp4postoperativep4laparoscopicp4cholecystectomyp4requestingp4painp4medicati
on
c-
p4Threep4daysp4postoperativep4colonp4resectionp4receivingp4transfusionp4ofp4packedp4RB
Cs
,d-
p4Preoperative,p4inp4buck‟sp4traction,p4andp4scheduledp4forp4hipp4arthroplastyp4withinp4thep
4nextp412p4hoursp4-p4ANSWERS--c-
p4Threep4daysp4postoperativep4colonp4resectionp4receivingp4transfusionp4ofp4packedp4RB
Cs
307.p4Thep4nursep4isp4preparingp4anp4olderp4clientp4forp4dischargep4followingp4cataractp4ex
traction.p4Whichp4instructionp4shouldp4bep4includingp4inp4thep4dischargep4teaching?
a-p4Dop4notp4readp4withoutp4directp4lightingp4forp46p4weeks
b-p4Avoidp4strainingp4atp4stool,p4bending,p4orp4liftingp4heavyp4objects
c-
p4Irrigatep4conjunctivap4withp4ophthalmicp4salinep4priorp4top4installingp4antibioticp4ointment
d-
p4Limitp4exposurep4top4sunlightp4duringp4thep4firstp42p4weeksp4whenp4thep4corneap4isp4heali
ngp4-p4ANSWERS--b-p4Avoidp4strainingp4atp4stool,p4bending,p4orp4liftingp4heavyp4objects
Rationale:p4afterp4cataractp4surgery,p4thep4clientp4shouldp4avoidp4activitiesp4whichp4increa
sep4pressurep4andp4placep4strainp4onp4thep4suturep4line
308.p4Thep4healthcarep4providerp4prescribesp4potassiump4chloridep425p4mEqp4inp4500p4ml
p4D5W p4top4infusep4overp46p4hours.p4Thep4availablep420p4mlp4vialp4ofp4potassiump4chloridep4
isp4labeledp4"10mEq/5ml".p4Howp4manyp4mlp4ofp4potassiump4chloridep4shouldp4thep4nurse
p4addp4thep4IVp4fluid?p4(enterp4numericalp4valuep4only.p4Ifp4roundingp4isp4required,p4roundp4t
op4thep4nearestp4tenth)p4-p4ANSWERS--12.5p4
Rationale:p4Usingp4thep4formulap4Dp4/p4Hp4Xp4Q:p425p4mEqp4/p410p4mEqp4xp45ml
꞊12.5ml
309.p4Atp440-
weekp4gestation,p4ap4laboringp4clientp4whop4isp4lyingp4isp4ap4supinep4positionp4tellsp4thep4nu
rsep4thatp4shep4hasp4finallyp4foundp4ap4comfortablep4position.p4Whatp4actionp4shouldp4thep4
nursep4take?
a-p4Encouragep4thep4clientp4top4turnp4onp4herp4leftp4side
b-p4Placep4ap4pillowp4underp4thep4client‟sp4headp4andp4knees
c-p4Explainp4top4thep4clientp4thatp4herp4positionp4isp4notp4safe
d-p4Placep4ap4wedgep4underp4thep4client‟sp4rightp4hipp4-p4ANSWERS--d-
p4Placep4ap4wedgep4underp4thep4client‟sp4rightp4hip
Rationale:p4Hypotensionp4fromp4pressurep4onp4thep4venap4cavap4isp4ap4riskp4forp4thep4full-
termp4client.p4Placingp4ap4wedgep4underp4thep4rightp4hipp4willp4relievep4pressurep4onp4thep4
venap4cava.p4Otherp4optionsp4willp4eitherp4notp4relievep4pressurep4onp4thep4venap4cavap4orp
4wouldp4notp4allowp4thep4clientp4thep4remainingp4herp4positionp4ofp4choice.
, 310.p4Ap4clientp4withp4ap4historyp4ofp4diabetesp4andp4coronaryp4arteryp4diseasep4isp4admitt
edp4withp4shortnessp4ofp4breath,p4anxiety,p4andp4confusion.p4Thep4client‟sp4bloodp4pressu
rep4isp480/60p4mmHg,p4heartp4ratep4120p4beats/minutep4withp4audiblep4thirdp4andp4fourthp4
heartp4sounds,p4andp4bibasilarp4crackles.p4Thep4client‟sp4averagep4urinaryp4outputp4isp45p4
ml/hour.p4Normalp4salinep4isp4infusingp4atp4124p4ml/hourp4withp4ap4secondaryp4infusionp4of
p4dopaminep4atp4mcg/kg/minutep4perp4infusionp4pump.p4Withp4interventionp4shouldp4thep4n
ursep4implement?
a-p4Irrigatep4thep4indwellingp4urinaryp4catheter
b-p4Preparep4thep4clientp4forp4externalp4pacing
c-p4Obtainp4capillaryp4bloodp4glucosep4measurement
d-p4Titratep4thep4dopaminep4infusionp4top4raisep4thep4BPp4-p4ANSWERS--d-
p4Titratep4thep4dopaminep4infusionp4top4raisep4thep4BP
Rationale:p4thep4clientp4isp4experiencingp4cardiogenicp4shockp4andp4requiresp4titrationp4pe
rp4protocolp4ofp4thep4vasoactivep4secondaryp4infusion,p4dopamine,p4top4increasep4thep4blo
odp4pressure.p4Lowp4hourlyp4urinep4outputp4isp4duep4top4shockp4andp4doesp4notp4indicatep4
ap4needp4forp4catheterp4irrigation.p4Pacingp4isp4notp4indicatedp4basedp4onp4thep4client‟sp4ca
pillaryp4bloodp4glucosep4shouldp4bep4monitoredp4butp4isp4notp4directlyp4indicatedp4atp4thisp4t
ime.
311.p4Thep4nursep4endsp4thep4assessmentp4ofp4ap4clientp4byp4performingp4ap4mentalp4statu
sp4exam.p4Whichp4statementp4correctlyp4describesp4thep4purposep4ofp4thep4mentalp4status
p4exam?
a-p4Determinep4thep4client‟sp4levelp4ofp4emotionalp4functioning‟p4
b-p4Assessp4functionalp4abilityp4ofp4thep4primaryp4supportp4system
c-p4Evaluatep4thep4client‟sp4mood,p4cognitionp4andp4orientation
d-p4Reviewp4thep4client‟sp4patternofadaptivep4copingp4skillp4-p4ANSWERS--c-
p4Evaluatep4thep4client‟sp4mood,p4cognitionp4andp4orientation
Rational:p4thep4mentalp4statusp4examp4assessesp4thep4clientp4forp4abnormalitiesp4inp4cogn
itivep4functioning;p4potentialp4thoughtp4processes,p4moodp4andp4reasoning,p4thep4otherp4o
ptionsp4listedp4arep4allp4componentsp4ofp4thep4client‟sp4psychosocialp4assessment.
312.p4Anp4olderp4adultp4residentp4ofp4ap4long-termp4carep4facilityp4hasp4ap45-
yearp4historyp4ofp4hypertension.p4Thep4clientp4hasp4ap4headachep4andp4ratep4thep4painp45p4
onp4ap4painp4scalep40p4top410.p4Thep4client‟sp4bloodp4pressurep4isp4currentlyp4142/89.p4Whi
chp4interventionsp4shouldp4thep4nursep4implement?p4(Selectp4allp4thatp4apply)
a-p4Administerp4ap4dailyp4dosep4ofp4lisinoprilp4asp4scheduled
b-p4Assessp4thep4clientp4forp4posturalp4hypotension
Questions and Answer
301.p4Anp4adultp4clientp4presentp4top4thep4clinicp4withp4largep4drainingp4ulcersp4onp4bothp4lo
werp4legsp4thatp4arep4characteristicsp4ofp4Kaposi‟sp4sarcomap4lesions.p4Thep4clientp4isp4ac
companiedp4byp4twop4familyp4members.p4Whichp4actionp4shouldp4thep4nursep4take?
a-p4Askp4familyp4memberp4top4wearp4glovesp4whenp4touchingp4thep4patient
b-p4Sendp4familyp4top4thep4waitingp4areap4whilep4thep4client‟sp4historyp4isp4taking
c-p4Obtainp4ap4bloodp4samplep4top4determinep4isp4thep4clientp4isp4HIVp4positive
d-p4Completep4thep4headp4top4toesp4assessmentp4top4identifyp4otherp4signp4ofp4HIVp4-
p4ANSWERS--b-
p4Sendp4familyp4top4thep4waitingp4areap4whilep4thep4client‟sp4historyp4isp4taking
Rationale:p4Top4protectp4thep4clientp4privacy,p4thep4familyp4memberp4shouldp4bep4askedp4t
op4waitp4outsidep4whilep4thep4client‟sp4historyp4isp4take.p4Glovesp4shouldp4bep4wornp4whenp
4touchingp4thep4client‟sp4bodyp4fluidsp4ifp4thep4clientp4isp4HIVp4positivep4andp4thesep4lesionp
4arep4actuallyp4Kaposip4sarcomap4lesion.p4HIVp4testingp4cannotp4legallyp4bep4donep4witho
utp4thep4clientp4explicitp4permission.p4Ap4furtherp4assessmentp4canp4bep4implementedp4aft
erp4thep4familyp4leftp4thep4room.
302.p4Anp4adultp4clientp4isp4exhibitp4thep4maniacp4stagep4ofp4bipolarp4disorderp4isp4admitted
p4top4thep4psychiatricp4unit.p4Thep4clientp4hasp4lostp410p4poundsp4inp4thep4lastp4twop4weeksp4
andp4hasp4nop4bathedp4inp4ap4weekp4"I‟mp4tryingp4top4startp4ap4newp4businessp4andp4"I‟mp4t
oop4busyp4top4eat".p4Thep4clientp4isp4orientedp4top4time,p4place,p4personp4butp4notp4situation
.p4Whichp4nursingp4problemp4hasp4thep4greatestp4priority?
a-p4Hygiene-self-carep4deficit
b-p4Imbalancep4nutritionp4
c-p4Disturbedp4sleepp4patternp4
d-p4Self-neglectp4-p4ANSWERS--b-p4Imbalancep4nutritionp4
Rationale:p4Thep4client‟sp4nutritionalp4statusp4hasp4thep4highestp4priorityp4atp4thisp4time,p4a
ndp4fingerp4foodsp4arep4oftenp4provided,p4sop4thep4clientp4whop4isp4onp4thep4maniacp4phase
p4ofp4bipolarp4diseasep4canp4receivep4adequatep4nutrition.p4Otherp4optionsp4arep4nursingp4
problemsp4thatp4shouldp4alsop4bep4addressesp4withp4thep4client‟sp4planp4ofp4care,p4butp4atp4
thisp4stagep4inp4thep4client‟sp4treatment,p4adequatep4nutritionp4isp4ap4priority
303.p4Thep4nursep4isp4preparingp4ap4dischargep4teachingp4planp4forp4ap4clientp4whop4hadp4a
p4liverp4transplant.p4Whichp4instructionp4isp4mostp4importantp4top4includep4inp4thisp4plan?
,a-p4Limitp4intakep4fattyp4foodsp4forp4onep4monthp4afterp4surgery
b-p4Notifyp4thep4healthcarep4providerp4ifp4edemap4occurs
c-p4Increasep4activityp4andp4exercisep4gradually,p4asp4tolerated
d-p4Avoidp4crowdsp4forp4firstp4twop4monthsp4afterp4surgeryp4-p4ANSWERS--d-
p4Avoidp4crowdsp4forp4firstp4twop4monthsp4afterp4surgery
Rationale:p4Cyclosporinep4immunosuppressionp4therapyp4isp4vitalp4inp4thep4successp4ofp4l
iverp4transplantationp4andp4canp4increasep4thep4riskp4forp4infection,p4whichp4isp4criticalp4inp4
thep4firstp4twop4monthsp4afterp4surgery.p4Feverp4isp4often.
304.p4Photop4Questionp4-p4ANSWERS--
305.p4Ap4clientp4whop4hadp4ap4percutaneousp4transluminalp4coronaryp4angioplastyp4(PTC
A)p4twop4weeksp4agop4returnsp4top4thep4clinicp4forp4ap4followp4upp4visit.p4Thep4clientp4hasp4ap
4postoperativep4ejectionp4fractionp4ofp430%.p4Todayp4thep4clientp4hasp4lungsp4whichp4arep4
clear,p4+1p4pedalp4edema,p4andp4ap45-
poundp4weightp4gain.p4Whichp4interventionp4thep4nursep4implement?
a-p4Arrangep4transportp4forp4admissionp4top4thep4hospital
b-p4Insertp4salinep4lockp4forp4IVp4diureticp4therapy
c-p4Assessp4compliancep4withp4routinep4prescriptions
d-p4Instructp4thep4clientp4top4monitorp4dailyp4caloricp4intakep4-p4ANSWERS--c-
p4Assessp4compliancep4withp4routinep4prescriptions
Rationale:p4Fluidp4retentionp4mayp4bep4ap4signp4thatp4thep4clientp4isp4notp4takingp4thep4medi
cationp4asp4prescribedp4orp4thatp4thep4prescriptionsp4mayp4needp4adjustmentp4top4manage
p4cardiacp4functionp4post-PTCAp4(normalp4ejectionp4fractionp4rangep4isp450p4top475%)
306.p4Thep4RNp4isp4assignedp4top4carep4forp4fourp4surgicalp4clients.p4Afterp4receivingp4repo
rt,p4whichp4clientp4shouldp4thep4nursep4seep4first?p4Thep4clientp4whop4is
a-
p4Twop4daysp4postoperativep4bladderp4surgeryp4withp4continuousp4bladderp4irrigationp4inf
using
b-
p4Onep4dayp4postoperativep4laparoscopicp4cholecystectomyp4requestingp4painp4medicati
on
c-
p4Threep4daysp4postoperativep4colonp4resectionp4receivingp4transfusionp4ofp4packedp4RB
Cs
,d-
p4Preoperative,p4inp4buck‟sp4traction,p4andp4scheduledp4forp4hipp4arthroplastyp4withinp4thep
4nextp412p4hoursp4-p4ANSWERS--c-
p4Threep4daysp4postoperativep4colonp4resectionp4receivingp4transfusionp4ofp4packedp4RB
Cs
307.p4Thep4nursep4isp4preparingp4anp4olderp4clientp4forp4dischargep4followingp4cataractp4ex
traction.p4Whichp4instructionp4shouldp4bep4includingp4inp4thep4dischargep4teaching?
a-p4Dop4notp4readp4withoutp4directp4lightingp4forp46p4weeks
b-p4Avoidp4strainingp4atp4stool,p4bending,p4orp4liftingp4heavyp4objects
c-
p4Irrigatep4conjunctivap4withp4ophthalmicp4salinep4priorp4top4installingp4antibioticp4ointment
d-
p4Limitp4exposurep4top4sunlightp4duringp4thep4firstp42p4weeksp4whenp4thep4corneap4isp4heali
ngp4-p4ANSWERS--b-p4Avoidp4strainingp4atp4stool,p4bending,p4orp4liftingp4heavyp4objects
Rationale:p4afterp4cataractp4surgery,p4thep4clientp4shouldp4avoidp4activitiesp4whichp4increa
sep4pressurep4andp4placep4strainp4onp4thep4suturep4line
308.p4Thep4healthcarep4providerp4prescribesp4potassiump4chloridep425p4mEqp4inp4500p4ml
p4D5W p4top4infusep4overp46p4hours.p4Thep4availablep420p4mlp4vialp4ofp4potassiump4chloridep4
isp4labeledp4"10mEq/5ml".p4Howp4manyp4mlp4ofp4potassiump4chloridep4shouldp4thep4nurse
p4addp4thep4IVp4fluid?p4(enterp4numericalp4valuep4only.p4Ifp4roundingp4isp4required,p4roundp4t
op4thep4nearestp4tenth)p4-p4ANSWERS--12.5p4
Rationale:p4Usingp4thep4formulap4Dp4/p4Hp4Xp4Q:p425p4mEqp4/p410p4mEqp4xp45ml
꞊12.5ml
309.p4Atp440-
weekp4gestation,p4ap4laboringp4clientp4whop4isp4lyingp4isp4ap4supinep4positionp4tellsp4thep4nu
rsep4thatp4shep4hasp4finallyp4foundp4ap4comfortablep4position.p4Whatp4actionp4shouldp4thep4
nursep4take?
a-p4Encouragep4thep4clientp4top4turnp4onp4herp4leftp4side
b-p4Placep4ap4pillowp4underp4thep4client‟sp4headp4andp4knees
c-p4Explainp4top4thep4clientp4thatp4herp4positionp4isp4notp4safe
d-p4Placep4ap4wedgep4underp4thep4client‟sp4rightp4hipp4-p4ANSWERS--d-
p4Placep4ap4wedgep4underp4thep4client‟sp4rightp4hip
Rationale:p4Hypotensionp4fromp4pressurep4onp4thep4venap4cavap4isp4ap4riskp4forp4thep4full-
termp4client.p4Placingp4ap4wedgep4underp4thep4rightp4hipp4willp4relievep4pressurep4onp4thep4
venap4cava.p4Otherp4optionsp4willp4eitherp4notp4relievep4pressurep4onp4thep4venap4cavap4orp
4wouldp4notp4allowp4thep4clientp4thep4remainingp4herp4positionp4ofp4choice.
, 310.p4Ap4clientp4withp4ap4historyp4ofp4diabetesp4andp4coronaryp4arteryp4diseasep4isp4admitt
edp4withp4shortnessp4ofp4breath,p4anxiety,p4andp4confusion.p4Thep4client‟sp4bloodp4pressu
rep4isp480/60p4mmHg,p4heartp4ratep4120p4beats/minutep4withp4audiblep4thirdp4andp4fourthp4
heartp4sounds,p4andp4bibasilarp4crackles.p4Thep4client‟sp4averagep4urinaryp4outputp4isp45p4
ml/hour.p4Normalp4salinep4isp4infusingp4atp4124p4ml/hourp4withp4ap4secondaryp4infusionp4of
p4dopaminep4atp4mcg/kg/minutep4perp4infusionp4pump.p4Withp4interventionp4shouldp4thep4n
ursep4implement?
a-p4Irrigatep4thep4indwellingp4urinaryp4catheter
b-p4Preparep4thep4clientp4forp4externalp4pacing
c-p4Obtainp4capillaryp4bloodp4glucosep4measurement
d-p4Titratep4thep4dopaminep4infusionp4top4raisep4thep4BPp4-p4ANSWERS--d-
p4Titratep4thep4dopaminep4infusionp4top4raisep4thep4BP
Rationale:p4thep4clientp4isp4experiencingp4cardiogenicp4shockp4andp4requiresp4titrationp4pe
rp4protocolp4ofp4thep4vasoactivep4secondaryp4infusion,p4dopamine,p4top4increasep4thep4blo
odp4pressure.p4Lowp4hourlyp4urinep4outputp4isp4duep4top4shockp4andp4doesp4notp4indicatep4
ap4needp4forp4catheterp4irrigation.p4Pacingp4isp4notp4indicatedp4basedp4onp4thep4client‟sp4ca
pillaryp4bloodp4glucosep4shouldp4bep4monitoredp4butp4isp4notp4directlyp4indicatedp4atp4thisp4t
ime.
311.p4Thep4nursep4endsp4thep4assessmentp4ofp4ap4clientp4byp4performingp4ap4mentalp4statu
sp4exam.p4Whichp4statementp4correctlyp4describesp4thep4purposep4ofp4thep4mentalp4status
p4exam?
a-p4Determinep4thep4client‟sp4levelp4ofp4emotionalp4functioning‟p4
b-p4Assessp4functionalp4abilityp4ofp4thep4primaryp4supportp4system
c-p4Evaluatep4thep4client‟sp4mood,p4cognitionp4andp4orientation
d-p4Reviewp4thep4client‟sp4patternofadaptivep4copingp4skillp4-p4ANSWERS--c-
p4Evaluatep4thep4client‟sp4mood,p4cognitionp4andp4orientation
Rational:p4thep4mentalp4statusp4examp4assessesp4thep4clientp4forp4abnormalitiesp4inp4cogn
itivep4functioning;p4potentialp4thoughtp4processes,p4moodp4andp4reasoning,p4thep4otherp4o
ptionsp4listedp4arep4allp4componentsp4ofp4thep4client‟sp4psychosocialp4assessment.
312.p4Anp4olderp4adultp4residentp4ofp4ap4long-termp4carep4facilityp4hasp4ap45-
yearp4historyp4ofp4hypertension.p4Thep4clientp4hasp4ap4headachep4andp4ratep4thep4painp45p4
onp4ap4painp4scalep40p4top410.p4Thep4client‟sp4bloodp4pressurep4isp4currentlyp4142/89.p4Whi
chp4interventionsp4shouldp4thep4nursep4implement?p4(Selectp4allp4thatp4apply)
a-p4Administerp4ap4dailyp4dosep4ofp4lisinoprilp4asp4scheduled
b-p4Assessp4thep4clientp4forp4posturalp4hypotension
