EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE
QUESTIONS AND CORRECT ANSWERS
, A c12-year-old cboy ccomplains cto cthe cnurse cthat che cis c"short" c(4'5" c[53 cinches]). cHis ctwin
csister cis c5 cinches ctaller cthan che cis c(4'10" c[58 cinches]). cBased con cthese cfindings, cwhat
cconclusion cshould cthe cnurse creach?
A.The cboy cis cnot cgrowing cas cnormally cexpected.
B.The cgirl cis cexperiencing ca cperiod cof cunexpected cgrowth.
C.A cnormal cgrowth cspurt coccurs cin cgirls c1 cto c2 cyears cearlier cthan cboys.
ins care cnot cidentical; ctherefore, ctheir cgrowth ccannot cbe ccompared. c- cCORRECT cANSWER C
Rationale:
a cgrowth cspurt cat c9.5 cto c14.5 cyears cof cage cand cboys cat c10.5 cto c16 cyears cof cage c(C). cThere care cinsufficient
cdata cto csupport c(A); cgrowth ctrends cmust cbe cassessed cto creach csuch ca cconclusion. c(B) cis
cnot cunexpected. cThe cfact cthat cthe cchildren care ctwins chas cless cto cdo cwith ctheir cgrowth
cthan cthe cfact cthat cthey care cmale cand cfemale c(D).
A c45-year-old cfemale cclient cis cadmitted cto cthe cpsychiatric cunit cfor cevaluation. cHer chusband
cstates cthat cshe chas cbeen creluctant cto cleave chome cfor cthe clast c6 cmonths. cThe cclient chas cnot
cgone cto cwork cfor ca cmonth, chas cbeen cterminated cfrom cher cjob, cand chas cnot cleft cthe chouse
csince cthat ctime. cThis cclient cis cdisplaying csymptoms cof cwhich cdisorder?
B.Acrophobia cC.Agoraphobia
CORRECT cANSWER C
cRationale:
is cthe cfear cof ccrowds cor cof cbeing cin can copen cplace. c(A) cis cthe cfear cof cbeing cin cclosed cplaces. c(B) cis cthe
cfear cof chigh cplaces. c(D) cis can cabnormal cfear cof cdeath cor cbodies cafter cdeath. cA cphobia cis can
cunrealistic cfear cassociated cwith csevere canxiety.
A cclient cat c32 cweeks cof cgestation cis chospitalized cwith cpreeclampsia, cand cmagnesium csulfate cis
cprescribed cto ccontrol cthe csymptoms. cBefore cthe cnext cdose cof cMgSO4 cis cgiven, cwhich
cassessment cfinding cindicates cthat cthe cpatient cis cat crisk cfor ctoxicity?
A.Deep ctendon creflexes—decrease cto c2+
e coutput cin c4 chours cC.Respiratory crate cdecreases cto c16
cbreaths/min
um clevel, c7.5 cmg/dL c- cCORRECT cANSWER B
cRationale:
Magnesium csulfate, ca ccentral cnervous csystem c(CNS) cdepressant, chelps cprevent cseizures, cso c(A)
cis ca cpositive csign cthat cthe cmedication cis chaving ca cdesired ceffect. cThe cminimum curine coutput
cexpected cfor ca
,repeat cdose cof cmagnesium csulfate cis c30 cmL/hr, cso c100 cmL cof curine cin c4 chours ccan clead cto
cpoor cexcretion cof cmagnesium, cwith ca cpossible ccumulative ceffect c(B). cA cdecreased
crespiratory crate c(C) cindicates cthat cthe cdrug cis ceffective. cA crespiratory crate cbelow c12
cbreaths/min cindicates ctoxic ceffects. cThe ctherapeutic clevel cof cmagnesium csulfate cfor ca cPIH
cclient cis c4 cto c8 cmg/dL c(D).
A cclient ccomes cto cthe cobstetric cclinic cfor cher cfirst cprenatal cvisit cand ccomplains cof cfeeling
cnauseated cevery cmorning. cThe cclient ctells cthe cnurse, c"I'm chaving csecond cthoughts cabout
cwanting cto chave cthis cbaby." cWhich cresponse cis cbest cfor cthe cnurse cto cmake?
A."It's cnormal cto cfeel cambivalent cabout ca cpregnancy cwhen cyou care cnot cfeeling cwell."
B."I cthink cyou cshould cdiscuss cthese cfeelings cwith cyour chealth ccare cprovider."
C."How cdoes cthe cfather cof cyour cchild cfeel cabout cyour chaving cthis cbaby?"
D."Tell cme cabout cthese csecond cthoughts cyou care chaving cabout cthis cpregnancy." c- cCORRECT
cANSWER cD
Rationale:
Although cambivalence cis cnormal cduring cthe cfirst ctrimester, c(D) cis cthe cbest cnursing cresponse
cat cthis ctime. cIt cis creflective cand ckeeps cthe clines cof ccommunication copen. c(A) cis cnot cthe cbest
cresponse cbecause cit coffers cfalse creassurance. c(B) cdismisses cthe cclient's cfeelings. cThe cnurse
cshould cuse ccommunication cskills cthat cencourage cthis ctype cof cdiscussion, cnot cshift
cresponsibility cto cthe ccare cprovider. c(C) cmay ceventually cbe cdiscussed, cbut cit cis cnot cthe cmost
cimportant cinformation cto cobtain cat cthis ctime.
A cclient cexhibits csymptoms cof calcohol cintoxication. cThe cblood calcohol clevel cis c200 cmg c(0.2%).
cWhich cmeasurement ctool cis cbest cfor cthe cnurse cto cuse cduring cthe cinitial cassessment cof cthis
cclient?
A.CAGE cquestionnaire cfor
calcoholism cB.Addiction cSeverity
cIndex cC.Glasgow cComa cScale
D.DSM cmultiaxial cevaluation c- cCORRECT cANSWER c C
cRationale:
Evaluation cof clevel cof cconsciousness, cwhich cis cthe cpurpose cof cthe cGlasgow cComa cScale c(C),
chas cthe chighest cpriority. c(A) cis cuseful cin chelping cclients crecognize ctheir calcoholism. c(B cand cD)
care ccomprehensive cassessments cthat cshould cbe ccompleted cafter cthe cacute cphase cis cresolved.
A cclient cin can cacute cpsychiatric csetting casks cthe cnurse cif ctheir cconversations cwill cremain
cconfidential. cHow cshould cthe cnurse crespond?
A."The cHealth cInsurance cPortability cand cAccountability cAct c(HIPAA) cprevents cme cfrom
crepeating cwhat cyou csay."
B."You ccan cbe cassured cthat cI cwill ckeep call cof cour cconversations cconfidential cbecause cit cis
cimportant cthat cyou ccan ctrust cme."
C."For cyour csafety cand cwell-being, cit cmay cbe cnecessary cto cshare csome cof cour cconversations
cwith cthe chealth ccare cteam."
, D."I cam clegally crequired cto cdocument call cof cour cconversations cin cthe celectronic cmedical
crecord." c- cCORRECT cANSWER c C
Rationale:
Some cinformation, csuch cas ca csuicide cplan, cmust cbe cshared cwith cother cteam cmembers cfor cthe
cclient's csafety cand coptimal ctherapy c(C). cHIPAA cdoes cnot cprevent ca cmember cof cthe chealth
ccare cteam cfrom crepeating call cconversations, cparticularly cif csafety cis can cissue c(A). cEnsuring ca
cclient cthat ca cconversation cwill cremain cconfidential cputs cthe cnurse cat crisk, cparticularly cif csafety
cis can cissue c(B). cAlthough cpertinent cinformation cshould cbe cdocumented, cthe cnurse cis cnot
clegally crequired cto cdocument call cconversations cwith ca cclient c(D).
A cclient cin cthe cpsychiatric csetting cwith can canxiety cdisorder creports cchest cpain. cWhich caction
cshould cthe cnurse ctake cfirst?
A.Administer can cantianxiety cmedication cPRN.
B.Assess cthe cclient's cvital csigns.
C.Notify cthe cprimary chealth ccare cprovider.
D.Determine ccoping cmechanisms cused cin cthe cpast. c- cCORRECT
cANSWER B
cRationale:
Although cincreased cheart crate, cpalpitations, cand cchest cpain cmay cbe ccaused cby canxiety, cit cis
cimportant cthat cthe cnurse cassess cthe cpatient cand crule cout cphysiologic ccauses c(B).
cNonpharmacologic cmeasures cshould cbe ctaken cfirst c(A). c(C cand cD) cmay cbe cconsidered cbut
care cnot cas chigh cpriority cas cthe cinitial cphysiologic cassessment.
A cclient cis cadmitted cto ca cmental chealth cunit cbecause cof cmild cdepression. cWhen casked, che
cdenies csuicidal cideation, cbut cthe cnurse creads cin cthe cpsychosocial cassessment cthat cthere
cwere cattempts cto coverdose con caspirin c5 cyears cearlier. cWhich cintervention cis cmost
cimportant cfor cthe cnurse cto cimplement?
A.Orient cthe cclient cto cactivities con cthe cunit.
B.Document csuicide cprecautions con cthe cshift creport.
C.Assign cthe cclient cto ca csemiprivate croom.
D.Obtain ca cverbal cno-suicide ccontract cwith cthe cclient. c- cCORRECT cANSWER c C
cRationale:
It cis cmost cimportant cto cprevent cthe crisk cof cself-harm cfrom csocial cisolation, cso cthe cclient
cshould cbe cassigned cto ca csemiprivate croom c(C). c(A) cdoes cnot chave cthe cpriority cof c(C). c(B
cand cD) ccan cbe cimplemented cif cthe cclient cadmits csuicidal cideation. cHowever, cbased con cthe
cfact cthat cthis cclient cis cmildly cdepressed cand cthat che cattempted csuicide c5 cyears cago cusing ca
cmethod cthat cis cusually cnonlethal c(aspirin coverdose), cit cis cmost cimportant cto cprevent csocial
cisolation.
A cclient cis cadmitted cto cthe chospital cwith cthe cdiagnosis cof chypokalemia. cWhich cclinical
cmanifestation cis cmost csignificant?
A.Heart cpalpitations
QUESTIONS AND CORRECT ANSWERS
, A c12-year-old cboy ccomplains cto cthe cnurse cthat che cis c"short" c(4'5" c[53 cinches]). cHis ctwin
csister cis c5 cinches ctaller cthan che cis c(4'10" c[58 cinches]). cBased con cthese cfindings, cwhat
cconclusion cshould cthe cnurse creach?
A.The cboy cis cnot cgrowing cas cnormally cexpected.
B.The cgirl cis cexperiencing ca cperiod cof cunexpected cgrowth.
C.A cnormal cgrowth cspurt coccurs cin cgirls c1 cto c2 cyears cearlier cthan cboys.
ins care cnot cidentical; ctherefore, ctheir cgrowth ccannot cbe ccompared. c- cCORRECT cANSWER C
Rationale:
a cgrowth cspurt cat c9.5 cto c14.5 cyears cof cage cand cboys cat c10.5 cto c16 cyears cof cage c(C). cThere care cinsufficient
cdata cto csupport c(A); cgrowth ctrends cmust cbe cassessed cto creach csuch ca cconclusion. c(B) cis
cnot cunexpected. cThe cfact cthat cthe cchildren care ctwins chas cless cto cdo cwith ctheir cgrowth
cthan cthe cfact cthat cthey care cmale cand cfemale c(D).
A c45-year-old cfemale cclient cis cadmitted cto cthe cpsychiatric cunit cfor cevaluation. cHer chusband
cstates cthat cshe chas cbeen creluctant cto cleave chome cfor cthe clast c6 cmonths. cThe cclient chas cnot
cgone cto cwork cfor ca cmonth, chas cbeen cterminated cfrom cher cjob, cand chas cnot cleft cthe chouse
csince cthat ctime. cThis cclient cis cdisplaying csymptoms cof cwhich cdisorder?
B.Acrophobia cC.Agoraphobia
CORRECT cANSWER C
cRationale:
is cthe cfear cof ccrowds cor cof cbeing cin can copen cplace. c(A) cis cthe cfear cof cbeing cin cclosed cplaces. c(B) cis cthe
cfear cof chigh cplaces. c(D) cis can cabnormal cfear cof cdeath cor cbodies cafter cdeath. cA cphobia cis can
cunrealistic cfear cassociated cwith csevere canxiety.
A cclient cat c32 cweeks cof cgestation cis chospitalized cwith cpreeclampsia, cand cmagnesium csulfate cis
cprescribed cto ccontrol cthe csymptoms. cBefore cthe cnext cdose cof cMgSO4 cis cgiven, cwhich
cassessment cfinding cindicates cthat cthe cpatient cis cat crisk cfor ctoxicity?
A.Deep ctendon creflexes—decrease cto c2+
e coutput cin c4 chours cC.Respiratory crate cdecreases cto c16
cbreaths/min
um clevel, c7.5 cmg/dL c- cCORRECT cANSWER B
cRationale:
Magnesium csulfate, ca ccentral cnervous csystem c(CNS) cdepressant, chelps cprevent cseizures, cso c(A)
cis ca cpositive csign cthat cthe cmedication cis chaving ca cdesired ceffect. cThe cminimum curine coutput
cexpected cfor ca
,repeat cdose cof cmagnesium csulfate cis c30 cmL/hr, cso c100 cmL cof curine cin c4 chours ccan clead cto
cpoor cexcretion cof cmagnesium, cwith ca cpossible ccumulative ceffect c(B). cA cdecreased
crespiratory crate c(C) cindicates cthat cthe cdrug cis ceffective. cA crespiratory crate cbelow c12
cbreaths/min cindicates ctoxic ceffects. cThe ctherapeutic clevel cof cmagnesium csulfate cfor ca cPIH
cclient cis c4 cto c8 cmg/dL c(D).
A cclient ccomes cto cthe cobstetric cclinic cfor cher cfirst cprenatal cvisit cand ccomplains cof cfeeling
cnauseated cevery cmorning. cThe cclient ctells cthe cnurse, c"I'm chaving csecond cthoughts cabout
cwanting cto chave cthis cbaby." cWhich cresponse cis cbest cfor cthe cnurse cto cmake?
A."It's cnormal cto cfeel cambivalent cabout ca cpregnancy cwhen cyou care cnot cfeeling cwell."
B."I cthink cyou cshould cdiscuss cthese cfeelings cwith cyour chealth ccare cprovider."
C."How cdoes cthe cfather cof cyour cchild cfeel cabout cyour chaving cthis cbaby?"
D."Tell cme cabout cthese csecond cthoughts cyou care chaving cabout cthis cpregnancy." c- cCORRECT
cANSWER cD
Rationale:
Although cambivalence cis cnormal cduring cthe cfirst ctrimester, c(D) cis cthe cbest cnursing cresponse
cat cthis ctime. cIt cis creflective cand ckeeps cthe clines cof ccommunication copen. c(A) cis cnot cthe cbest
cresponse cbecause cit coffers cfalse creassurance. c(B) cdismisses cthe cclient's cfeelings. cThe cnurse
cshould cuse ccommunication cskills cthat cencourage cthis ctype cof cdiscussion, cnot cshift
cresponsibility cto cthe ccare cprovider. c(C) cmay ceventually cbe cdiscussed, cbut cit cis cnot cthe cmost
cimportant cinformation cto cobtain cat cthis ctime.
A cclient cexhibits csymptoms cof calcohol cintoxication. cThe cblood calcohol clevel cis c200 cmg c(0.2%).
cWhich cmeasurement ctool cis cbest cfor cthe cnurse cto cuse cduring cthe cinitial cassessment cof cthis
cclient?
A.CAGE cquestionnaire cfor
calcoholism cB.Addiction cSeverity
cIndex cC.Glasgow cComa cScale
D.DSM cmultiaxial cevaluation c- cCORRECT cANSWER c C
cRationale:
Evaluation cof clevel cof cconsciousness, cwhich cis cthe cpurpose cof cthe cGlasgow cComa cScale c(C),
chas cthe chighest cpriority. c(A) cis cuseful cin chelping cclients crecognize ctheir calcoholism. c(B cand cD)
care ccomprehensive cassessments cthat cshould cbe ccompleted cafter cthe cacute cphase cis cresolved.
A cclient cin can cacute cpsychiatric csetting casks cthe cnurse cif ctheir cconversations cwill cremain
cconfidential. cHow cshould cthe cnurse crespond?
A."The cHealth cInsurance cPortability cand cAccountability cAct c(HIPAA) cprevents cme cfrom
crepeating cwhat cyou csay."
B."You ccan cbe cassured cthat cI cwill ckeep call cof cour cconversations cconfidential cbecause cit cis
cimportant cthat cyou ccan ctrust cme."
C."For cyour csafety cand cwell-being, cit cmay cbe cnecessary cto cshare csome cof cour cconversations
cwith cthe chealth ccare cteam."
, D."I cam clegally crequired cto cdocument call cof cour cconversations cin cthe celectronic cmedical
crecord." c- cCORRECT cANSWER c C
Rationale:
Some cinformation, csuch cas ca csuicide cplan, cmust cbe cshared cwith cother cteam cmembers cfor cthe
cclient's csafety cand coptimal ctherapy c(C). cHIPAA cdoes cnot cprevent ca cmember cof cthe chealth
ccare cteam cfrom crepeating call cconversations, cparticularly cif csafety cis can cissue c(A). cEnsuring ca
cclient cthat ca cconversation cwill cremain cconfidential cputs cthe cnurse cat crisk, cparticularly cif csafety
cis can cissue c(B). cAlthough cpertinent cinformation cshould cbe cdocumented, cthe cnurse cis cnot
clegally crequired cto cdocument call cconversations cwith ca cclient c(D).
A cclient cin cthe cpsychiatric csetting cwith can canxiety cdisorder creports cchest cpain. cWhich caction
cshould cthe cnurse ctake cfirst?
A.Administer can cantianxiety cmedication cPRN.
B.Assess cthe cclient's cvital csigns.
C.Notify cthe cprimary chealth ccare cprovider.
D.Determine ccoping cmechanisms cused cin cthe cpast. c- cCORRECT
cANSWER B
cRationale:
Although cincreased cheart crate, cpalpitations, cand cchest cpain cmay cbe ccaused cby canxiety, cit cis
cimportant cthat cthe cnurse cassess cthe cpatient cand crule cout cphysiologic ccauses c(B).
cNonpharmacologic cmeasures cshould cbe ctaken cfirst c(A). c(C cand cD) cmay cbe cconsidered cbut
care cnot cas chigh cpriority cas cthe cinitial cphysiologic cassessment.
A cclient cis cadmitted cto ca cmental chealth cunit cbecause cof cmild cdepression. cWhen casked, che
cdenies csuicidal cideation, cbut cthe cnurse creads cin cthe cpsychosocial cassessment cthat cthere
cwere cattempts cto coverdose con caspirin c5 cyears cearlier. cWhich cintervention cis cmost
cimportant cfor cthe cnurse cto cimplement?
A.Orient cthe cclient cto cactivities con cthe cunit.
B.Document csuicide cprecautions con cthe cshift creport.
C.Assign cthe cclient cto ca csemiprivate croom.
D.Obtain ca cverbal cno-suicide ccontract cwith cthe cclient. c- cCORRECT cANSWER c C
cRationale:
It cis cmost cimportant cto cprevent cthe crisk cof cself-harm cfrom csocial cisolation, cso cthe cclient
cshould cbe cassigned cto ca csemiprivate croom c(C). c(A) cdoes cnot chave cthe cpriority cof c(C). c(B
cand cD) ccan cbe cimplemented cif cthe cclient cadmits csuicidal cideation. cHowever, cbased con cthe
cfact cthat cthis cclient cis cmildly cdepressed cand cthat che cattempted csuicide c5 cyears cago cusing ca
cmethod cthat cis cusually cnonlethal c(aspirin coverdose), cit cis cmost cimportant cto cprevent csocial
cisolation.
A cclient cis cadmitted cto cthe chospital cwith cthe cdiagnosis cof chypokalemia. cWhich cclinical
cmanifestation cis cmost csignificant?
A.Heart cpalpitations
