RN mix hesi 3 Allround Questions and Answers
Revised and Approved
A 1-year-old infant is in the pediatric unit for management of AIDS. One of the medications that
has been prescribed for the child is zidovudine. What clinical finding indicates to the nurse that
the infant is experiencing life-threatening zidovudine toxicity?
Multiple choice question
Fatigue and lethargy
Increased urine output
Progressive weight loss
Bruises on the limbs and trunk - CORRECT ANSWER ✔✔ -Bruises on the limbs and trunk
Zidovudine can cause life-threatening blood dyscrasias, including thrombocytopenia. With
zidovudine toxicity the infant will demonstrate agitation, restlessness, and insomnia, not fatigue
and lethargy. Urine output is unrelated to zidovudine toxicity; decreased urine output may be
,related to decreased fluid intake, vomiting, and diaphoresis associated with the illness. Weight
loss is usually a response to the illness rather than to the therapy.
A 16-year-old high school student who has anorexia nervosa tells the school nurse that she thinks
she is pregnant even though she has had intercourse only once, more than a year ago. What is the
most appropriate inference for the nurse to make about the student?
Multiple choice question
Using magical thinking
Submitting to peer pressure
Lying about the last time she had intercourse
Lacking knowledge that anorexia can cause amenorrhea - CORRECT ANSWER ✔✔ -Lacking
knowledge that anorexia can cause amenorrhea
The loss of body fat from anorexia can cause amenorrhea; the client needs information. No data
are available to support the fact that the client is using magical thinking, which is characterized
by the belief that thinking or wishing something can cause it to occur; in light of the client's
diagnosis of anorexia, this is not the first conclusion. Submitting to peer pressure is not related to
,this type of concern. Although the nurse should question the timeline again, the client's
nutritional status should be explored first.
A 3-year-old child is admitted to the pediatric unit with a diagnosis of nephrotic syndrome. The
child has ascites, oliguria, respirations of 40 breaths/min, and a recent weight gain of 10 lb (4.5
kg). What nursing intervention may help ease the child's respiratory difficulty?
Multiple choice question
Providing six small meals daily
Maintaining a well-ventilated room
Ensuring bed rest in the low Fowler position
Administering oxygen at 2 L/min by way of nasal cannula - CORRECT ANSWER ✔✔ -The low
Fowler position decreases pressure on the diaphragm from the abdominal organs and the ascites,
thereby increasing respiratory excursion. Frequent feedings may lead to fatigue and quickened
respiration, which will further distress the child. Placing the child in a well-ventilated room will
not alleviate the cause of the respiratory problem, which is pressure on the diaphragm from the
, ascites. Oxygen therapy is not necessary; the dyspnea results from pressure on the diaphragm,
not lack of oxygen.
A 30-year-old female client asks the nurse to change her room, stating that she hates her
roommate and can't stand to be in the same room with her. Just as she finishes speaking, her
roommate enters and the client tells her she missed her and has been all over the unit looking for
her. What does the nurse recognize the client to be using?
Multiple choice question
Projection
Sublimation
Reaction formation
Passive aggression - CORRECT ANSWER ✔✔ -Reaction formation
The client's expressed feelings are opposite the client's behavior and are an acceptable substitute
for repressed antisocial feelings when facing the roommate. The client's feelings are expressed to
the nurse, not projected or attributed to others. The client has expressed real feelings to the nurse
Revised and Approved
A 1-year-old infant is in the pediatric unit for management of AIDS. One of the medications that
has been prescribed for the child is zidovudine. What clinical finding indicates to the nurse that
the infant is experiencing life-threatening zidovudine toxicity?
Multiple choice question
Fatigue and lethargy
Increased urine output
Progressive weight loss
Bruises on the limbs and trunk - CORRECT ANSWER ✔✔ -Bruises on the limbs and trunk
Zidovudine can cause life-threatening blood dyscrasias, including thrombocytopenia. With
zidovudine toxicity the infant will demonstrate agitation, restlessness, and insomnia, not fatigue
and lethargy. Urine output is unrelated to zidovudine toxicity; decreased urine output may be
,related to decreased fluid intake, vomiting, and diaphoresis associated with the illness. Weight
loss is usually a response to the illness rather than to the therapy.
A 16-year-old high school student who has anorexia nervosa tells the school nurse that she thinks
she is pregnant even though she has had intercourse only once, more than a year ago. What is the
most appropriate inference for the nurse to make about the student?
Multiple choice question
Using magical thinking
Submitting to peer pressure
Lying about the last time she had intercourse
Lacking knowledge that anorexia can cause amenorrhea - CORRECT ANSWER ✔✔ -Lacking
knowledge that anorexia can cause amenorrhea
The loss of body fat from anorexia can cause amenorrhea; the client needs information. No data
are available to support the fact that the client is using magical thinking, which is characterized
by the belief that thinking or wishing something can cause it to occur; in light of the client's
diagnosis of anorexia, this is not the first conclusion. Submitting to peer pressure is not related to
,this type of concern. Although the nurse should question the timeline again, the client's
nutritional status should be explored first.
A 3-year-old child is admitted to the pediatric unit with a diagnosis of nephrotic syndrome. The
child has ascites, oliguria, respirations of 40 breaths/min, and a recent weight gain of 10 lb (4.5
kg). What nursing intervention may help ease the child's respiratory difficulty?
Multiple choice question
Providing six small meals daily
Maintaining a well-ventilated room
Ensuring bed rest in the low Fowler position
Administering oxygen at 2 L/min by way of nasal cannula - CORRECT ANSWER ✔✔ -The low
Fowler position decreases pressure on the diaphragm from the abdominal organs and the ascites,
thereby increasing respiratory excursion. Frequent feedings may lead to fatigue and quickened
respiration, which will further distress the child. Placing the child in a well-ventilated room will
not alleviate the cause of the respiratory problem, which is pressure on the diaphragm from the
, ascites. Oxygen therapy is not necessary; the dyspnea results from pressure on the diaphragm,
not lack of oxygen.
A 30-year-old female client asks the nurse to change her room, stating that she hates her
roommate and can't stand to be in the same room with her. Just as she finishes speaking, her
roommate enters and the client tells her she missed her and has been all over the unit looking for
her. What does the nurse recognize the client to be using?
Multiple choice question
Projection
Sublimation
Reaction formation
Passive aggression - CORRECT ANSWER ✔✔ -Reaction formation
The client's expressed feelings are opposite the client's behavior and are an acceptable substitute
for repressed antisocial feelings when facing the roommate. The client's feelings are expressed to
the nurse, not projected or attributed to others. The client has expressed real feelings to the nurse
