NHESI LEVEL 2 (NSG 170) QUESTIONS
WITH VERIFIED ANSWERS
A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination
week at college. Which outcome is most important for the nurse to include in the plan of care?
A. Sleeping six to eight hours.
B. Achieve a sense of control.
C. Utilize problem solving skills.
D. Increased focus of attention. - B. Achieve a sense of control.
The experience of psychological discomfort may be as real as physical pain for the client and
should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of
control is a key need (B) before (A, C and D) are addressed.
A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO
after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is
best for the nurse to provide to this client?
A) I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight.
B) I will let you have one cracker, but that is all you can have for the rest of tonight.
C) What did the healthcare provider tell you about the test you are having tomorrow?
D) The test you are having tomorrow requires that you have nothing by mouth tonight. - D. "The test you
are having tomorrow requires that you have nothing by mouth tonight."
Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic
statement because the nurse is responding to the client's question and providing him the reason why.
A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is
contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if
other factors could be contributing to their difficulty. What information is best for the nurse to provide?
(Select all that apply.)
A.Marijuana cigarettes do not affect sperm count.
,B.Alcohol consumption can cause erectile dysfunction.
C.Low testosterone levels affect sperm production.
D.Cessation of smoking improves general health and fertility.
E.Obesity has no effect on sperm production. - B, C, D
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected
by low testosterone levels and obesity.
Which response by a client with a nursing diagnosis of Spiritual distress indicates to the nurse that a
desired outcome measure has been met?
A.Expresses concern about the meaning and importance of life.
B.Remains angry at God for the continuation of the illness.
C.Accepts that punishment from God is not related to illness.
D.Refuses to participate in religious rituals that have no meaning. - C.Accepts that punishment from God
is not related to illness
Acceptance that her illness is not God punishing her, indicates a desired outcome for some degree of
resolution of spiritual distress
A mother brings her 4-month-old infant to the clinic for a well-child checkup. She asks if she should go
back to work now or stay at home with the baby. How should the nurse respond to the mother?
A.Mothers can promote healthy bonding by staying at home during the child's first years.
B.Determine if other family relatives can stay at home with the baby.
C.Ask the mother to talk about the options she has been considering.
D.Returning to work when an infant is young helps the baby to adjust to other children. - C.Ask the
mother to talk about the options she has been considering.
It is common for mothers to feel ambivalent about returning to work and caring full time for children at
home. The nurse should assist the mother to explore her feelings on the subject while focusing on the
optimal, appropriate, safe, and available options for her child
A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to
have my tonsils and adenoids taken out?" Which response is best for the nurse to provide?
A. "It may hurt a little because of the incision made in your throat."
B. "It won't hurt because you're such a big boy."
,C. "It won't hurt because we put you to sleep."
D. "It may hurt but we'll give you medicine to help you feel better." - D. "It may hurt but we'll give you
medicine to help you feel better."
Answering questions simply and directly provides comfort for the preschool-age child and builds
confidence in the healthcare team.
A postoperative client has been receiving a continuous IV infusion of meperidine (Demerol) 35 mg/hr for
four days. The client has a PRN prescription for Demerol 100 mg PO q3h. The nurse notes that the client
has become increasingly restless, irritable and confused, stating that there are bugs all over the walls.
What action should the nurse take first?
A..Administer a PRN dose of the PO meperidine (Demerol).
B.Administer naloxone (Narcan) IV per PRN protocol.
C.Decrease the IV infusion rate of the meperidine (Demerol) per protocol.
D.Notify the healthcare provider of the client's confusion and hallucinations. - C.Decrease the IV infusion
rate of the meperidine (Demerol) per protocol.
The client is exhibiting symptoms of Demerol toxicity which is consistent with the large doses of Demerol
received over four days. Decreasing the infusion rate of the Demerol as per protocol is the most effective
action to immediately decrease the amount of serum Demerol. The next nursing action is for the nurse
to notify the healthcare provider.
A couple trying to cope with an infertility problem wants to know what can be done to preserve
emotional equilibrium. What is the best response for the nurse to provide?
A. "Tell your friends and family so that they can help you."
B. "Get involved with a support group. I will give you some names."
C. "Talk only to other friends who are infertile since only they can help."
D. "Start adoption proceedings immediately since obtaining an infant is very difficult." - B: "Get involved
with a support group. I will give you some names."
A support group provides a safe haven for the couple to share their feelings and experience, gain insight
from others dealing with the same experience, and assure the couple that they are not alone in their
situation.
A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and
has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse
document as health risk factors for the client? (Select all that apply.)
, A.Age.
B.Drug addiction.
C.History of abuse.
D.Pregnancy.
E.Homelessness.
n F.Unmarried. n- nA, nB, nC, nD, nE
Health nrisk nfactors nfor nthis nclient ninclude nage, ndrug naddiction, npregnancy, nhistory nof nabuse nand
nhomelessness. nEach nfactor nshould nbe nconsidered nindividually. nThe nclient, nas nan nadolescent nmother,
nis nat nhigh nrisk nfor nnutritional ndeficits, nanemia, ngestational ndiabetes nand nhypertension, nwhich nalso
nimpact nthe nfetus' nrisk nfor nsmall nfor ngestational nage, nfetal nanomalies, nand nfetal ndemise.
Which nnursing nintervention nshould nthe nnurse nimplement nwith nparents nwho nexperience na nfetal
ndemise nand nexpress nthe nwish nnot nto nsee nthe nbaby?
n A.Tell nthem nthere nis nnothing nto nfear. n
n B. nInsist nthat nthey nhold ninfant nso nthey ncan ngrieve. n
n C.Respect ntheir nwishes nand nrelease nthe nbody nto nthe nmorgue. n
D.Keep nthe nbody navailable nfor na nfew nhours nin ncase nthey nchange ntheir nminds. n- nD.Keep nthe nbody
n
available nfor na nfew nhours nin ncase nthey nchange ntheir nminds. n
n
Grieving nparents nshould nbe nencouraged nto nhold ntheir ninfant nafter ndeath nto nfacilitate nclosure. nIf
nparents nare nhesitant nabout nseeing nor nholding ntheir ndead ninfant, nthe nfetus nshould nbe navailable nfor
na nfew nhours nin nthe nevent nthey nchange ntheir nmind nafter nthe ninitial nshock. nThe nother nactions nare
nnot nindicated.
A nclient nis ntold nthat nher ninfant nwill nbe nstillborn. nWhat nis nthe nmost nimportant naction nfor nthe nnurse
nto nimplement nafter nthe nbirth? n
n A.Ask nthe nfamily nif nthey nwould nlike nto nsee nand nhold nthe ninfant nafter nbirth. n
n B.Inquire nif nthe nparents nwant na npicture ntaken nafter nthe ninfant nis nborn. n
n C.Discuss nwith nthe nparents nwhich nfuneral nhome nshould nbe nnotified. n
n D.Find nout nif nthe nclient nhas na nspecial noutfit nfor nthe ninfant nafter nthe nbirth. n- nA.Ask nthe nfamily nif
nthey nwould nlike nto nsee nand nhold nthe ninfant nafter nbirth.
WITH VERIFIED ANSWERS
A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination
week at college. Which outcome is most important for the nurse to include in the plan of care?
A. Sleeping six to eight hours.
B. Achieve a sense of control.
C. Utilize problem solving skills.
D. Increased focus of attention. - B. Achieve a sense of control.
The experience of psychological discomfort may be as real as physical pain for the client and
should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of
control is a key need (B) before (A, C and D) are addressed.
A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO
after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is
best for the nurse to provide to this client?
A) I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight.
B) I will let you have one cracker, but that is all you can have for the rest of tonight.
C) What did the healthcare provider tell you about the test you are having tomorrow?
D) The test you are having tomorrow requires that you have nothing by mouth tonight. - D. "The test you
are having tomorrow requires that you have nothing by mouth tonight."
Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic
statement because the nurse is responding to the client's question and providing him the reason why.
A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is
contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if
other factors could be contributing to their difficulty. What information is best for the nurse to provide?
(Select all that apply.)
A.Marijuana cigarettes do not affect sperm count.
,B.Alcohol consumption can cause erectile dysfunction.
C.Low testosterone levels affect sperm production.
D.Cessation of smoking improves general health and fertility.
E.Obesity has no effect on sperm production. - B, C, D
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected
by low testosterone levels and obesity.
Which response by a client with a nursing diagnosis of Spiritual distress indicates to the nurse that a
desired outcome measure has been met?
A.Expresses concern about the meaning and importance of life.
B.Remains angry at God for the continuation of the illness.
C.Accepts that punishment from God is not related to illness.
D.Refuses to participate in religious rituals that have no meaning. - C.Accepts that punishment from God
is not related to illness
Acceptance that her illness is not God punishing her, indicates a desired outcome for some degree of
resolution of spiritual distress
A mother brings her 4-month-old infant to the clinic for a well-child checkup. She asks if she should go
back to work now or stay at home with the baby. How should the nurse respond to the mother?
A.Mothers can promote healthy bonding by staying at home during the child's first years.
B.Determine if other family relatives can stay at home with the baby.
C.Ask the mother to talk about the options she has been considering.
D.Returning to work when an infant is young helps the baby to adjust to other children. - C.Ask the
mother to talk about the options she has been considering.
It is common for mothers to feel ambivalent about returning to work and caring full time for children at
home. The nurse should assist the mother to explore her feelings on the subject while focusing on the
optimal, appropriate, safe, and available options for her child
A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to
have my tonsils and adenoids taken out?" Which response is best for the nurse to provide?
A. "It may hurt a little because of the incision made in your throat."
B. "It won't hurt because you're such a big boy."
,C. "It won't hurt because we put you to sleep."
D. "It may hurt but we'll give you medicine to help you feel better." - D. "It may hurt but we'll give you
medicine to help you feel better."
Answering questions simply and directly provides comfort for the preschool-age child and builds
confidence in the healthcare team.
A postoperative client has been receiving a continuous IV infusion of meperidine (Demerol) 35 mg/hr for
four days. The client has a PRN prescription for Demerol 100 mg PO q3h. The nurse notes that the client
has become increasingly restless, irritable and confused, stating that there are bugs all over the walls.
What action should the nurse take first?
A..Administer a PRN dose of the PO meperidine (Demerol).
B.Administer naloxone (Narcan) IV per PRN protocol.
C.Decrease the IV infusion rate of the meperidine (Demerol) per protocol.
D.Notify the healthcare provider of the client's confusion and hallucinations. - C.Decrease the IV infusion
rate of the meperidine (Demerol) per protocol.
The client is exhibiting symptoms of Demerol toxicity which is consistent with the large doses of Demerol
received over four days. Decreasing the infusion rate of the Demerol as per protocol is the most effective
action to immediately decrease the amount of serum Demerol. The next nursing action is for the nurse
to notify the healthcare provider.
A couple trying to cope with an infertility problem wants to know what can be done to preserve
emotional equilibrium. What is the best response for the nurse to provide?
A. "Tell your friends and family so that they can help you."
B. "Get involved with a support group. I will give you some names."
C. "Talk only to other friends who are infertile since only they can help."
D. "Start adoption proceedings immediately since obtaining an infant is very difficult." - B: "Get involved
with a support group. I will give you some names."
A support group provides a safe haven for the couple to share their feelings and experience, gain insight
from others dealing with the same experience, and assure the couple that they are not alone in their
situation.
A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and
has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse
document as health risk factors for the client? (Select all that apply.)
, A.Age.
B.Drug addiction.
C.History of abuse.
D.Pregnancy.
E.Homelessness.
n F.Unmarried. n- nA, nB, nC, nD, nE
Health nrisk nfactors nfor nthis nclient ninclude nage, ndrug naddiction, npregnancy, nhistory nof nabuse nand
nhomelessness. nEach nfactor nshould nbe nconsidered nindividually. nThe nclient, nas nan nadolescent nmother,
nis nat nhigh nrisk nfor nnutritional ndeficits, nanemia, ngestational ndiabetes nand nhypertension, nwhich nalso
nimpact nthe nfetus' nrisk nfor nsmall nfor ngestational nage, nfetal nanomalies, nand nfetal ndemise.
Which nnursing nintervention nshould nthe nnurse nimplement nwith nparents nwho nexperience na nfetal
ndemise nand nexpress nthe nwish nnot nto nsee nthe nbaby?
n A.Tell nthem nthere nis nnothing nto nfear. n
n B. nInsist nthat nthey nhold ninfant nso nthey ncan ngrieve. n
n C.Respect ntheir nwishes nand nrelease nthe nbody nto nthe nmorgue. n
D.Keep nthe nbody navailable nfor na nfew nhours nin ncase nthey nchange ntheir nminds. n- nD.Keep nthe nbody
n
available nfor na nfew nhours nin ncase nthey nchange ntheir nminds. n
n
Grieving nparents nshould nbe nencouraged nto nhold ntheir ninfant nafter ndeath nto nfacilitate nclosure. nIf
nparents nare nhesitant nabout nseeing nor nholding ntheir ndead ninfant, nthe nfetus nshould nbe navailable nfor
na nfew nhours nin nthe nevent nthey nchange ntheir nmind nafter nthe ninitial nshock. nThe nother nactions nare
nnot nindicated.
A nclient nis ntold nthat nher ninfant nwill nbe nstillborn. nWhat nis nthe nmost nimportant naction nfor nthe nnurse
nto nimplement nafter nthe nbirth? n
n A.Ask nthe nfamily nif nthey nwould nlike nto nsee nand nhold nthe ninfant nafter nbirth. n
n B.Inquire nif nthe nparents nwant na npicture ntaken nafter nthe ninfant nis nborn. n
n C.Discuss nwith nthe nparents nwhich nfuneral nhome nshould nbe nnotified. n
n D.Find nout nif nthe nclient nhas na nspecial noutfit nfor nthe ninfant nafter nthe nbirth. n- nA.Ask nthe nfamily nif
nthey nwould nlike nto nsee nand nhold nthe ninfant nafter nbirth.
