Exit Hesi Comprehensive B
Evolve Practice Questions /
Hesi Pn Exit Exam Test Bank
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. - ✔✔✔ANSWER-C
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 - ✔✔✔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
Evolve Practice Questions /
Hesi Pn Exit Exam Test Bank
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. - ✔✔✔ANSWER-C
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 - ✔✔✔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
