EXIT HESI Comprehensive B Evolve Practice Questions and Answers
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+
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
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.
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:
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 - ansC
Rationale:
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+
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
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.
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:
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 - ansC
Rationale:
