EXIT HESI V5 EXAM VERIFIED
SOLUTIONS, SCORED A+
The .nurse .is .has .just .admitted .a .client .with .severe .depression. .From .which
.focus .should .the .nurse .identify .a .priority .nursing .diagnosis?
A) .Nutrition
B) .Elimination
C) .Activity
D) .Safety .- .CORRECT .ANSWER-D: .Safety
While .explaining .an .illness .to .a .10 .year-old, .what .should .the .nurse .keep .in
.mind .about .the .cognitive .development .at .this .age?
A) .They .are .able .to .make .simple .association .of .ideas
B) .They .are .able .to .think .logically .in .organizing .facts
C) .Interpretation .of .events .originate .from .their .own .perspective
D) .Conclusions .are .based .on .previous .experiences .- .CORRECT .ANSWER-B:
.Think .logically .in .organizing .facts
The .nurse .enters .the .room .as .a .3 .year-old .is .having .a .generalized .seizure.
.Which .intervention .should .the .nurse .do .first?
A) .Clear .the .area .of .any .hazards
B) .Place .the .child .on .the .side
C) .Restrain .the .child
D) .Give .the .prescribed .anticonvulsant .- .CORRECT .ANSWER-B: .Place .the .child
.on .the .side
The .nurse .is .reviewing .a .depressed .client's .history .from .an .earlier .admission.
.Documentation .of .anhedonia .is .noted. .The .nurse .understands .that .this .finding
.refers .to
A) .Reports .of .difficulty .falling .and .staying .asleep
B) .Expression .of .persistent .suicidal .thoughts
C) .Lack .of .enjoyment .in .usual .pleasures
D) .Reduced .senses .of .taste .and .smell .- .CORRECT .ANSWER-C: .Lack .of
.enjoyment .in .usual .pleasures
A .client .has .just .returned .to .the .medical-surgical .unit .following .a .segmental
.lung .resection. .After .assessing .the .client, .the .first .nursing .action .would .be .to
A) .Administer .pain .medication
B) .Suction .excessive .tracheobronchial .secretions
C) .Assist .client .to .turn, .deep .breathe .and .cough
D) .Monitor .oxygen .saturation .- .CORRECT .ANSWER-B) .Suction .excessive
.tracheobronchial .secretions
,While .assessing .a .client .in .an .outpatient .facility .with .a .panic .disorder, .the
.nurse .completes .a .thorough .health .history .and .physical .exam. .Which .finding .is
.most .significantfor .this .client?
A) .Compulsive .behavior
B) .Sense .of .impending .doom
C) .Fear .of .flying
D) .Predictable .episodes .- .CORRECT .ANSWER-B) .Sense .of .impending .doom
A .16 .month-old .child .has .just .been .admitted .to .the .hospital. .As .the .nurse
.assigned .to .this .child .enters .the .hospital .room .for .the .first .time, .the .toddler
.runs .to .the .mother, .clings
to .her .and .begins .to .cry. .What .would .be .the .initial .action .by .the .nurse?
A) .Arrange .to .change .client .care .assignments
B) .Explain .that .this .behavior .is .expected
C) .Discuss .the .appropriate .use .of ."time-out"
D) .Explain .that .the .child .needs .extra .attention .- .CORRECT .ANSWER-B) .Explain
.that .this .behavior .is .expected
A .15 .year-old .client .with .a .lengthy .confining .illness .is .at .risk .for .altered .growth
.and
development .of .which .task?
A) .Loss .of .control
B) .Insecurity
C) .Dependence
D) .Lack .of .trust .- .CORRECT .ANSWER-C) .Dependence
Which .playroom .activities .should .the .nurse .organize .for .a .small .group .of .7
.year-old .hospitalized .children?
A) .Sports .and .games .with .rules
B) .Finger .paints .and .water .play
C) ."Dress-up" .clothes .and .props
D) .Chess .and .television .programs .- .CORRECT .ANSWER-A) .Sports .and .games
.with .rules
The .nurse .is .discussing .dietary .intake .with .an .adolescent .who .has .acne. .The
.most .appropriate .statement .for .the .nurse .is
A) ."Eat .a .balanced .diet .for .your .age."
B) ."Increase .your .intake .of .protein .and .Vitamin .A."
C) ."Decrease .fatty .foods .from .your .diet."
D) ."Do .not .use .caffeine .in .any .form, .including .chocolate." .- .CORRECT
.ANSWER-A) ."Eat .a .balanced .diet .for .your .age."
The .nurse .is .assigned .to .a .newly .delivered .woman .with .HIV/AIDS. .The .student
.asks .the .nurse .about .how .it .is .determined .that .a .person .has .AIDS .other .than .a
.positive .HIV .test. .The .nurse .responds
A) ."The .complaints .of .at .least .3 .common .findings."
B) ."The .absence .of .any .opportunistic .infection."
C) ."CD4 .lymphocyte .count .is .less .than .200."
, D) ."Developmental .delays .in .children." .- .CORRECT .ANSWER-C) ."CD4
.lymphocyte .count .is .less .than .200."
The .nurse .is .caring .for .a .child .who .has .just .returned .from .surgery .following .a
.tonsillectomy .and .adenoidectomy. .Which .action .by .the .nurse .is .appropriate?
A) .Offer .ice .cream .every .2 .hours
B) .Place .the .child .in .a .supine .position
C) .Allow .the .child .to .drink .through .a .straw
D) .Observe .swallowing .patterns .- .CORRECT .ANSWER-D: .Observe .swallowing
.patterns
A .23 .year-old .single .client .is .in .the .33rd .week .of .her .first .pregnancy. .She .tells
.the .nurse .that .she .has .everything .ready .for .the .baby .and .has .made .plans .for
.the .first .weeks .together .at .home. .Which .normal .emotional .reaction .does .the
.nurse .recognize?
A) .Acceptance .of .the .pregnancy
B) .Focus .on .fetal .development
C) .Anticipation .of .the .birth
D) .Ambivalence .about .pregnancy .- .CORRECT .ANSWER-C: .Anticipation .of .the
.birth
The .nurse .is .planning .care .for .a .client .with .pneumococcal .pneumonia. .Which
.of .the .following .would .be .most .effective .in .removing .respiratory .secretions?
A) .Administration .of .cough .suppressants
B) .Increasing .oral .fluid .intake .to .3000 .cc .per .day
C) .Maintaining .bed .rest .with .bathroom .privileges
D) .Performing .chest .physiotherapy .twice .a .day .- .CORRECT .ANSWER-B:
.Increasing .oral .fluid .intake .to .3000 .cc .per .day
15. .The .nurse .in .a .well-child .clinic .examines .many .children .on .a .daily .basis.
.Which .of .the .following .toddlers .requires .further .follow .up?
A) .A .13 .month-old .unable .to .walk
B) .A .20 .month-old .only .using .2 .and .3 .word .sentences
C) .A .24 .month-old .who .cries .during .examination
D) .A .30 .month-old .only .drinking .from .a .sip .cup .- .CORRECT .ANSWER-D: .A .30
.month-old .only .drinking .from .a .sip .cup
Which .of .the .following .would .be .the .best .strategy .for .the .nurse .to .use .when
.teaching .insulin .injection .techniques .to .a .newly .diagnosed .client .with
.diabetes?
A) .Give .written .pre .and .post .tests
B) .Ask .questions .during .practice
C) .Allow .another .diabetic .to .assist
D) .Observe .a .return .demonstration .- .CORRECT .ANSWER-D: .Observe .a .return
.demonstration
A .client .has .developed .thrombophlebitis .of .the .left .leg. .Which .nursing
.intervention .should .be .given .the .highest .priority?
A) .Elevate .leg .on .2 .pillows
SOLUTIONS, SCORED A+
The .nurse .is .has .just .admitted .a .client .with .severe .depression. .From .which
.focus .should .the .nurse .identify .a .priority .nursing .diagnosis?
A) .Nutrition
B) .Elimination
C) .Activity
D) .Safety .- .CORRECT .ANSWER-D: .Safety
While .explaining .an .illness .to .a .10 .year-old, .what .should .the .nurse .keep .in
.mind .about .the .cognitive .development .at .this .age?
A) .They .are .able .to .make .simple .association .of .ideas
B) .They .are .able .to .think .logically .in .organizing .facts
C) .Interpretation .of .events .originate .from .their .own .perspective
D) .Conclusions .are .based .on .previous .experiences .- .CORRECT .ANSWER-B:
.Think .logically .in .organizing .facts
The .nurse .enters .the .room .as .a .3 .year-old .is .having .a .generalized .seizure.
.Which .intervention .should .the .nurse .do .first?
A) .Clear .the .area .of .any .hazards
B) .Place .the .child .on .the .side
C) .Restrain .the .child
D) .Give .the .prescribed .anticonvulsant .- .CORRECT .ANSWER-B: .Place .the .child
.on .the .side
The .nurse .is .reviewing .a .depressed .client's .history .from .an .earlier .admission.
.Documentation .of .anhedonia .is .noted. .The .nurse .understands .that .this .finding
.refers .to
A) .Reports .of .difficulty .falling .and .staying .asleep
B) .Expression .of .persistent .suicidal .thoughts
C) .Lack .of .enjoyment .in .usual .pleasures
D) .Reduced .senses .of .taste .and .smell .- .CORRECT .ANSWER-C: .Lack .of
.enjoyment .in .usual .pleasures
A .client .has .just .returned .to .the .medical-surgical .unit .following .a .segmental
.lung .resection. .After .assessing .the .client, .the .first .nursing .action .would .be .to
A) .Administer .pain .medication
B) .Suction .excessive .tracheobronchial .secretions
C) .Assist .client .to .turn, .deep .breathe .and .cough
D) .Monitor .oxygen .saturation .- .CORRECT .ANSWER-B) .Suction .excessive
.tracheobronchial .secretions
,While .assessing .a .client .in .an .outpatient .facility .with .a .panic .disorder, .the
.nurse .completes .a .thorough .health .history .and .physical .exam. .Which .finding .is
.most .significantfor .this .client?
A) .Compulsive .behavior
B) .Sense .of .impending .doom
C) .Fear .of .flying
D) .Predictable .episodes .- .CORRECT .ANSWER-B) .Sense .of .impending .doom
A .16 .month-old .child .has .just .been .admitted .to .the .hospital. .As .the .nurse
.assigned .to .this .child .enters .the .hospital .room .for .the .first .time, .the .toddler
.runs .to .the .mother, .clings
to .her .and .begins .to .cry. .What .would .be .the .initial .action .by .the .nurse?
A) .Arrange .to .change .client .care .assignments
B) .Explain .that .this .behavior .is .expected
C) .Discuss .the .appropriate .use .of ."time-out"
D) .Explain .that .the .child .needs .extra .attention .- .CORRECT .ANSWER-B) .Explain
.that .this .behavior .is .expected
A .15 .year-old .client .with .a .lengthy .confining .illness .is .at .risk .for .altered .growth
.and
development .of .which .task?
A) .Loss .of .control
B) .Insecurity
C) .Dependence
D) .Lack .of .trust .- .CORRECT .ANSWER-C) .Dependence
Which .playroom .activities .should .the .nurse .organize .for .a .small .group .of .7
.year-old .hospitalized .children?
A) .Sports .and .games .with .rules
B) .Finger .paints .and .water .play
C) ."Dress-up" .clothes .and .props
D) .Chess .and .television .programs .- .CORRECT .ANSWER-A) .Sports .and .games
.with .rules
The .nurse .is .discussing .dietary .intake .with .an .adolescent .who .has .acne. .The
.most .appropriate .statement .for .the .nurse .is
A) ."Eat .a .balanced .diet .for .your .age."
B) ."Increase .your .intake .of .protein .and .Vitamin .A."
C) ."Decrease .fatty .foods .from .your .diet."
D) ."Do .not .use .caffeine .in .any .form, .including .chocolate." .- .CORRECT
.ANSWER-A) ."Eat .a .balanced .diet .for .your .age."
The .nurse .is .assigned .to .a .newly .delivered .woman .with .HIV/AIDS. .The .student
.asks .the .nurse .about .how .it .is .determined .that .a .person .has .AIDS .other .than .a
.positive .HIV .test. .The .nurse .responds
A) ."The .complaints .of .at .least .3 .common .findings."
B) ."The .absence .of .any .opportunistic .infection."
C) ."CD4 .lymphocyte .count .is .less .than .200."
, D) ."Developmental .delays .in .children." .- .CORRECT .ANSWER-C) ."CD4
.lymphocyte .count .is .less .than .200."
The .nurse .is .caring .for .a .child .who .has .just .returned .from .surgery .following .a
.tonsillectomy .and .adenoidectomy. .Which .action .by .the .nurse .is .appropriate?
A) .Offer .ice .cream .every .2 .hours
B) .Place .the .child .in .a .supine .position
C) .Allow .the .child .to .drink .through .a .straw
D) .Observe .swallowing .patterns .- .CORRECT .ANSWER-D: .Observe .swallowing
.patterns
A .23 .year-old .single .client .is .in .the .33rd .week .of .her .first .pregnancy. .She .tells
.the .nurse .that .she .has .everything .ready .for .the .baby .and .has .made .plans .for
.the .first .weeks .together .at .home. .Which .normal .emotional .reaction .does .the
.nurse .recognize?
A) .Acceptance .of .the .pregnancy
B) .Focus .on .fetal .development
C) .Anticipation .of .the .birth
D) .Ambivalence .about .pregnancy .- .CORRECT .ANSWER-C: .Anticipation .of .the
.birth
The .nurse .is .planning .care .for .a .client .with .pneumococcal .pneumonia. .Which
.of .the .following .would .be .most .effective .in .removing .respiratory .secretions?
A) .Administration .of .cough .suppressants
B) .Increasing .oral .fluid .intake .to .3000 .cc .per .day
C) .Maintaining .bed .rest .with .bathroom .privileges
D) .Performing .chest .physiotherapy .twice .a .day .- .CORRECT .ANSWER-B:
.Increasing .oral .fluid .intake .to .3000 .cc .per .day
15. .The .nurse .in .a .well-child .clinic .examines .many .children .on .a .daily .basis.
.Which .of .the .following .toddlers .requires .further .follow .up?
A) .A .13 .month-old .unable .to .walk
B) .A .20 .month-old .only .using .2 .and .3 .word .sentences
C) .A .24 .month-old .who .cries .during .examination
D) .A .30 .month-old .only .drinking .from .a .sip .cup .- .CORRECT .ANSWER-D: .A .30
.month-old .only .drinking .from .a .sip .cup
Which .of .the .following .would .be .the .best .strategy .for .the .nurse .to .use .when
.teaching .insulin .injection .techniques .to .a .newly .diagnosed .client .with
.diabetes?
A) .Give .written .pre .and .post .tests
B) .Ask .questions .during .practice
C) .Allow .another .diabetic .to .assist
D) .Observe .a .return .demonstration .- .CORRECT .ANSWER-D: .Observe .a .return
.demonstration
A .client .has .developed .thrombophlebitis .of .the .left .leg. .Which .nursing
.intervention .should .be .given .the .highest .priority?
A) .Elevate .leg .on .2 .pillows
