EXIT HESI Comprehensive B Evolve
Practice Questions
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. - ANS-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 - ANS-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 - ANS-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." - ANS-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
B.Addiction Severity Index
C.Glasgow Coma Scale
D.DSM multiaxial evaluation - ANS-C
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." -
ANS-C
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. - ANS-B
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. - ANS-C
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 - ANS-A
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 - ANS-C
Rationale:
Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia (C).
(A, B, and D) state incorrect information for symptoms of leukemia.
Practice Questions
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. - ANS-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 - ANS-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 - ANS-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." - ANS-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
B.Addiction Severity Index
C.Glasgow Coma Scale
D.DSM multiaxial evaluation - ANS-C
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." -
ANS-C
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. - ANS-B
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. - ANS-C
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 - ANS-A
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 - ANS-C
Rationale:
Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia (C).
(A, B, and D) state incorrect information for symptoms of leukemia.
