Hesi Level 2 Practice Questions with complete solutions 2023

Hesi Level 2 Practice Questions with complete solutions 2023 What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? A. Vesicular breath sounds decrease B. Bronchodilators stimulate coughing C. Cough remains unproductive D. Wheezing becomes louder Answer : Wheezing becomes louder. In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing becomes louder (A) as air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough becomes more productive, not (B). Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard over lung fields (C) and is not an indicator of improvement during asthma treatment. Bronchodilators do not stimulate coughing (D). A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? A. Evaluate the effectiveness of narcotic analgesics. B. Limit the client's intake of oral fluids and food. C. Teach the client about prevention of crises. D. Encourage the client to ambulate as tolerated. Answer: Evaluate the effectiveness of narcotic analgesics. Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated (B) frequently to determine if the client's pain is adequately controlled. (A, C, and D) are not indicated at this time. The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further? A. Thinning hair and dry scalp. B. Increase in muscle tone but decreased muscle strength. C. Increase in abdominal fat deposits. D. Increase in appetite and taste-bud acuity. Answer: Increase in abdominal fat deposits. An increase in the abdominal girth (D) may be indicative of the onset of metabolic syndrome, which places the client at risk for cardiac disease and requires further assessment. During middle adulthood, common findings include thinning hair, dry skin and scalp (A), changes in taste bud acuity (B), and muscle size and strength (C), which are consistent with normal system functioning during aging. The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? A. Assessment of the client's vital signs. B. Determine the time the client last voided. C. Document the finding as the only action. D. Insert a rectal tube for the passage of flatus. Answer: Determine the time the client last voided. Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided (C) should be determined next. Documentation (B) should be made, but the client's distended bladder requires additional intervention. (A and D) are not priority actions based on the client's abdominal findings. The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? A. Avoid consuming alcohol and caffeinated beverages. B. Wear a condom when having sexual intercourse. C. Have intercourse or masturbate at least twice a week. D. Empty the bladder completely with each voiding. Answer: Have intercourse or masturbate at least twice a week. The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation (D) decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated fluids. (A, B, and C) do not reduce the risk of spreading the infection internally. A 3-year-old boy is brought to the emergency room because of a possible diazepam (Valium) overdose. He is lethargic and confused, and his vital signs are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30. Which nursing intervention has the highest priority? A. Insert an orogastric tube for gastric lavage. B. Prepare a set-up for an endotracheal intubation. C.Draw blood for stat chemistries and blood gases. D. Insert a Foley catheter to monitor renal functioning. Answer: Prepare a set-up for an endotracheal intubation. Diazepam causes respiratory depression, so preparation for intubation (B) to protect the airway is the priority intervention at this time. (A) may be necessary, but the child is lethargic and confused, with a lowered respiratory rate, so (B) takes priority. (C and D) are interventions that should be implemented, but they are both secondary to ensuring an open airway. The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis, and the infant has had three loose stools since surgery yesterday. Which nursing diagnosis has the highest priority? A. Pain related to postoperative condition. B. Potential for fluid volume deficit. C. Alteration in bowel elimination. D. Anxiety of parents related to newborn's condition. Answer: Potential for fluid volume deficit. All stated nursing diagnoses are appropriate for a postoperative colostomy client. However, fluid balance is the priority concern (A) for any newborn infant. Though three loose stools in 24-hours is not significant, depending on the amount of fluid lost with each stool, potential for fluid volume deficit is always a concern for a postoperative infant. Newborns are extremely vulnerable to fluid imbalances due to immature body systems and a larger percentage of their body weight consisting of fluid. (B, C, and D) do not have the priority of (A). The community health nurse teaches the parents of school-aged children about the need for fluoride as part of a dental health program. Which statement by the parents indicates that they understand the teaching? A. "Having our children brush with fluoride toothpaste is not effective." B. "Excessive amounts of fluoride will make teeth turn brittle and yellow." C. "Use of fluoride in water is mostly effective during initial tooth formation." D. "Dental caries can be prevented through fluoridation of public water." Answer: "Dental caries can be prevented through fluoridation of public water." Dental caries can be prevented through fluoridation of public water (D). Large amounts of fluoride (A) produces yellow and discolored teeth, not brittle teeth. (B) is effective for young teeth. Fluoride is effective throughout the life span, not just during initial tooth formation (C). A Spanish-speaking 5-year-old child starts kindergarten in an English-speaking school. The child cries most of the time, appears helpless and unable to function in the new situation. After assessing the child, how should the school nurse document the situation? A. Experiencing culture shock. B. Refuses to participate in school activities. C. Lacks the maturity needed in school. D. Going through minority group discrimination. Answer: Experiencing culture shock. An inability to function may apply to persons of all ages undergoing transitions, such as moving to a new country and adjusting to a subculture within a larger culture that is unfamiliar. Culture shock (A) describes feelings of discomfort and disorientation when adapting to new cultural settings. Language barriers inhibit effective communication, so a child who is unable to communicate in the spoken language in the school environment may lack the skills necessary to participate, and is not refusing to participate (C). The child may be adequately mature (B), accepted by peers (D) within the environment, but continues to not join in because of the impact of culture shock. The nurse is assessing a child's skin turgor and grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended and tented for a few seconds, then slowly falls back on the abdomen. How should the nurse document this finding? A. Assessment inconclusive. B. Poor skin turgor. C. Adequate hydration. D. Normal skin elasticity Answer: Poor skin turgor Tissue turgor refers to the amount of elasticity in the skin and is one of the best estimates of adequate hydration and nutrition. Elastic tissue immediately resumes its normal position without residual marks or creases. In a child with poor turgor (B), the skin remains tented or suspended for a few seconds before returning to a normal position. (A, C and D) are inaccurate. A 4-month-old breastfeeding infant is at the 10th percentile for weight and the 75th percentile for height. How should the nurse interpret this finding? A. Inadequate milk supply in mother. B. Milk allergy. C. Normal growth curve of a breast-fed infant. D. Failure to thrive. Answer: Normal growth curve of a breast-fed infant. When plotting weights and heights on a standard growth chart used for both breast-fed and formula-fed infants, the breast-fed infant grows more rapidly during the first 2 months of life, and then growth slows from 3 to 12 months. A breast-fed infant is leaner and has less body fat than a formula-fed infant. Normal patterns of infants who are breast fed (D) differ from those who are formula fed. (A) is an incorrect interpretation of the data. This finding is not consistent with failure to thrive (B) or an inadequate milk supply (C) The nurse is instructing an adolescent with bulimia and a low potassium level about the risk for complications. Which medical problem should be the focus of the nurse's instruction to this client? A. Heightened neurologic reflexes. B. Gastrointestinal reflux. C. Anemia. D. Cardiac arrhythmias. Answer: Cardiac arrhythmias. An adolescent with bulimia who purges by frequent self-induced vomiting, diuretic or laxative abuse can experience potassium depletion, which increases the risk for cardiac arrhythmias (B). (A) is more likely related to inadequate iron intake and absorption, not hypokalemia. (C) is related to frequent binging and gastric over-distention. Potassium depletion causes diminished reflexes, not (D) The parents of a toddler brought to the clinic for a well-child visit tell the nurse that their child becomes upset if even the smallest things change in the environment. What information should the nurse provide the parents? A. A child is insecure because trust is not fostered and developed during infancy. B. A toddler should be exposed to different routines to promote adapting to new experiences. C. Children of this age are comfortable with ritualism and display global thinking. D. Should be frequently moved in the environment to teach the child to acclimate to change. Answer: Children of this age are comfortable with ritualism and display global thinking. A 2-year-old is ritualistic and wants consistency and routine, so changes in the toddler's environment or schedule is upsetting. Another mark of the toddler's sensitivity to change is global thinking (change in one small part, such as a minor shift in room arrangement or changes in the whole environment), and the 2-year-old's equanimity disintegrates (C). There is not enough information to make the assumption the child did not develop trust (A). Frequent changes (B and D) in the schedule or the environment can lead to insecurity on the part of the toddler. An infant weighs 7 lb at birth. How much should the nurse expect the infant to weigh at age 6-months? A. 12 lb. B. 17 lb. C. 14 lb. D. 21 lb Answer: 14 lb. Infancy growth spurts double the birthweight by 4 to 6 months and triple it by one year. Twelve pounds (A) represents a lower-than-expected weight. A weight of 17 (C) or 21 (D) pounds is greater than expected. The father of an 8-year-old tells the nurse he is interested in seeing his child succeed in soccer. The nurse talks with the boy, who expresses a sincere interest in playing chess and feels like a failure at soccer. How should the nurse respond to this father? A. The father should decrease his expectations to give the son a chance to succeed. B. The child has an introverted personality and should be encouraged to play isolated games. C. The child should be given opportunities to achieve a sense of competency in an area he chooses. D. The father should encouraged the son to participate in team sports instead of less physical activities. Answer:The child should be given opportunities to achieve a sense of competency in an area he chooses. According to Erickson, the developmental stage "Industry versus inferiority" builds feelings of confidence, competence, and industry if there is achievement in an area of interest. If a child believes that he or she cannot measure up to society's expectations, the child loses confidence and may not find pleasure in the activity. Children should be encouraged to do the things they enjoy and succeed in (D). The father does not need to decrease his expectations (A), but should be encouraged to shift the expectation to an activity the child takes pleasure in. (B) does not encourage autonomy. (C) can cause a feeling of inadequacy. During the well-child assessment of an 18-month-old male toddler, the nurse determines the child does not walk while holding on to furniture but prefers to crawl, rarely speaks, has a flat affect, and is small for his age. Which nursing diagnosis should the nurse formulate? A. Delayed growth and development. B. Alteration in health maintenance. C. Alteration in parenting. D. Alteration in nutrition. Answer: Delayed growth and development. This child does not demonstrate gross motor or psychosocial skills typical of an 18-month-old toddler, which best supports delayed growth and development (C). Additional information about the child's growth parameters is needed to support (A, B, or D). The nurse plans to mix a medication with food to make it more palatable for a pediatric client. Which food should the nurse choose? A. Formula or milk. B. Syrup. C. Applesauce. D. Orange juice. Answer: Applesauce In order to prevent the child from developing a negative association with an essential food, a nonessential food such as applesauce is best for mixing with medications (B). Syrup is not used to mix with medications because of its high sugar content (A). Medications may alter the flavor of the food and cause the child to avoid those foods in the future, so orange juice (C), which provides essential nutritional elements, and formula or milk (D), which are essential foods in a child's diet, should not be mixed with medications. A 4-year-old is brought to the emergency room for a laceration on the right foot. What action should the nurse implement to help the child in coping with the emergency room experience? A. Avoid using jargon, such as a "shot" when giving care B. Give the child some time after explaining procedures. C. Remind the preschooler how big children should act. D. Avoid the use of bandages to keep wounds open to air. Answer: Avoid using jargon, such as a "shot" when giving care. Using positive terms and avoiding words that have frightening connotations (D) assist the preschool-age child in coping with an emergency room experience. Bandages (A) are important to preschool-aged children because this age group often believe bandages stop their insides from leaking out. Children need to feel comfortable expressing their fears and feelings and should not be shamed into cooperation by referencing expected "big" children behaviors (B). Preschool-age children should be told about procedures immediately before they are performed (C), which minimizes the time a child fantasies about the treatment, which causes increased anxiety. A 14-year-old is brought to the emergency room after a biking accident. How should the nurse interact with the adolescent? A. Provide clear explanations while encouraging questions. B. Limit the number of choices to be made by the adolescent. C. Have the parents remain with the adolescent at all times. D. Furnish rewards for cooperation during procedures. Answer: Provide clear explanations while encouraging questions. Adolescents are capable of abstract thinking and understand explanations, so the opportunity to ask questions (C) should be provided. Giving rewards (A), such as stickers for cooperation with treatments or procedures are best used with a younger child. An adolescent's modesty should be respected, so the presence of the parents (B) at the bedside should be a choice made by the adolescent. An adolescent's ability to think abstractly engages problem solving, so the 14-year-old should be allowed to make decisions about care, not (D). The nurse is triaging a child with a fever brought to the emergency department by the parents. Which finding requires the nurse's immediate intervention? A. Frequent nonproductive cough. B. Prolonged exhalations. C. Oxygen saturation is 95% by pulse oximeter. D. Thick yellow rhinorrhea. Answer: Prolonged exhalations. Prolonged exhalation (A) indicates breathing difficulty, and intervention for this should be taken immediately. Nasal discharge (B) and a productive cough (C) are not findings that indicate the child is in immediate distress. An oxygen saturation of 95% is a normal finding (D). A mother expresses concern to the nurse about the behavior of her 15-year-old adolescent who is frequently finding fault and criticizing her. What information should the nurse provide? A. Teens create psychological distance from parents in order to separate from them. B. The family value system may need to be changed to meet the teen's changing needs. C. Parents should relinquish their relationship with their teen to the teen's peers. D. Conflicts in the parent-teen relationship are to be expected during adolescence. Answer: Teens create psychological distance from parents in order to separate from them. Although a mutually respectful parent-adolescent relationship is important, an adolescent may use critical and fault-finding behavior as a mechanism to separate from the parent (B). Changing the family's value system to meet the teen's needs (A) does not provide consistency for an adolescent who is examining oneself. (C) does not provide guidance or boundary setting that is needed to foster judgment during adolescence. Although (D) may occur as an adolescent struggles for independence, healthy family dynamics foster the parent-teen relationship even though it may not seem as important to the teen as it was in earlier years. A seven-month old infant is admitted with nonorganic failure to thrive (NFTT). To aid the child's growth and development, which intervention is most important for the nurse to implement? A. Provide instructions about formula preparation and feeding schedules. B. Demonstrate feeding strategies and infant cues that indicate hunger and satiation. C. Encourage the parents to participate in a planned program of play with the infant. D. Refer the parents for psychological counseling to identify parental detachment. Answer: Demonstrate feeding strategies and infant cues that indicate hunger and satiation. NFTT most often occurs due to inadequate parent knowledge or a disturbance in maternal-child attachment, but the first goal for infants with NFTT is to provide nutrition to promote "catch-up" growth. The nurse should demonstrate positive feeding strategies that reduce parent and infant frustration, such as recognizing the infant's cues indicated by vigorous sucking and satiation (C). (A) encourages normal growth and development, but is not likely to teach the parents how to respond to the infant's nutritional needs. Although family dysfunction may contribute to NFTT and (B) may eventually be indicated, additional assessment is needed before such a referral is made. (D) provides a structured schedule, but positive infant feeding strategies should be implemented first. Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client? A. Context. B. Counter transference. C. Therapeutic self-disclosure. D. Self-analysis. Answer: Self-analysis Self-analysis is a tool for the nurse to examine oneself, view one's responses in various mental and emotional moments, and provide a sense of how sensitive care should be provided relative to one's own needs, so (B) is a primary tool used by the nurse to establish therapeutic empathy and achieve authentic, open, and personal communication with a client. Although (A, C, and D) may occur in a nurse-client relationship, they may not contribute to establishing a therapeutic relationship. Which client should the nurse identify as the highest risk for the onset of stress-related problems? A. A man whose new business is growing slowly, who plans to adopt a child with his wife, and says, "I think I'm in control of my destiny." B. A woman who is graduating from college, getting married in one month, and states, "I'm anticipating the changes these events will make in my life." C. A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless." D. A client who is passed over for promotion, quits a job to start a new business, and states, "This is just one of a series of challenges I've faced in my life." Answer: A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless." A client who is dealing with two stressful life events and expresses a cognitive appraisal of loss and helplessness (D) is at the highest risk for a stress-related health problem. (A, B, and C) describe persons who are coping with change using healthy strategies, such as perceiving change as challenging, expressing commitment to change, and believing they have control over their life paths. When assessing a client's emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness? A. Logical mathematics and linguistic abilities. B. Bodily kinesthetic and spatial abilities. C. Linguistic and musical abilities. D. Interpersonal and intrapersonal skills. Answer: Interpersonal and intrapersonal skills. Interpersonal and intrapersonal intelligence form one's personal intelligence or "emotional quotient," so the nurse should focus inquiries on social skills (B). (A and D) assesses cognitive and mental status. (C) determines neurophysical interpretation of one's body within the environment, but does not assess emotional intelligence. A female client with severe depression is given information about the risks, benefits, alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for treatment. After the client's family leaves, the client tells the nurse, "I signed the papers because my husband told me I will be deported if my depression is not cured." What information should the nurse report to the healthcare provider? A. The client is not competent to sign permission for treatment. B. All the elements of informed consent were met. C. The client's consent may have been coerced. D. The woman may not fully understand the risks and benefits. Answer: The client's consent may have been coerced. Informed consent requires that the choice is freely given. Although the staff acted ethically and observed the client's right to give informed consent, the decision may have been coerced (A) based on family pressure. (B, C, and D) are not accurate. A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded sensorium. What is the priority nursing intervention for this client at this time? A. Begin one-on-one supervision immediately. B. Keep the room dimly lit and turn on the radio. C. Push fluids and provide calorie-rich nutritional supplements. D. Check on the client every 15 minutes. Answer: Begin one-on-one supervision immediately. One-on-one supervision (B) ensures the client's physical safety until the client is sedated adequately to reduce feelings of terror and tactile and visual hallucinations. Checking every 15 minutes (A) does not provide sufficient assessment of the client's safety. Additional auditory stimulation and a dimly lit room (C) can create illusions that contribute to the client's altered sensory distress and should be avoided. Fluid replacement and nutritional supplements (D) should be initiated when the client is more stable because the risk for overhydration can occur as blood alcohol levels fall and fluids are retained. A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, "There wasn't anything I could do to stop her drinking this morning." What intervention should the nurse take at this time? A. Arrange for emergency admission to a detoxification unit. B. Tell the client that therapy cannot take place while she is intoxicated. C. Talk to the spouse about strategies to limit the client's drinking. D. Have the client admitted to the inpatient psychiatric unit. Answer: Tell the client that therapy cannot take place while she is intoxicated. Therapy sessions are designed to confront the issues that the client with alcohol dependence may be experiencing. If the client presents inebriated, a therapeutic and confrontational meeting cannot occur (D) because the client's judgment is altered. (A and C) are not necessary at this time. (B) is ineffective. Which action should the nurse implement first for a client experiencing alcohol withdrawal? A. Apply vest or extremity restraints. B. Provide a diet high in protein and calories. C. Give an alpha-adrenergic blocker. D. Prepare the environment to prevent self-injury. Answer: Prepare the environment to prevent self-injury. Self-destructive or violent behavior provides a potentially immediate and life-threatening risk to the client and others, so a safe environment should be provided (D) by removing any potential objects that could inflict self-injury. Secondary prevention strategies (frequent orientation to surroundings, restraints to prevent self-injury (A), and the administration of antianxiety agents or alpha-adrenergic blockers (B) for hallucinations, delusions, confusion, and agitation) should then be implemented. Once the client is stabilized, nutritional issues (C) should be addressed. The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the healthcare provider? A. Low-grade fever, diaphoresis, hypertension, and tachycardia. B. Global confusion and inability to recognize family members. C. Agitation, vomiting, and visual and auditory hallucinations. D. Restlessness, anxiety, and difficulty sleeping. Answer: Global confusion and inability to recognize family members. Delirium tremens (DT) or alcohol withdrawal delirium usually peaks 2 to 3 days (48 to 72 hours) after cessation or reduction of intake (although it can occur later) and lasts 2 to 3 days. The risk of DT carries a 2% to 5% mortality rate, so this critical syndrome of alcohol withdrawal, manifested as global confusion and an inability to recognize family members (B), is life-threatening and requires emergency medical intervention. The early signs of withdrawal (A) develop within a few hours after cessation or reduction of alcohol (ethanol) intake; the signs peak after 24 to 48 hours (C and D) and then rapidly and dramatically disappear, unless the withdrawal progresses to alcohol withdrawal delirium. An older client is admitted to a psychiatric hospital with the diagnosis, "Major depression, single episode." Which laboratory value is most important for the nurse to report to the healthcare provider immediately? A. Elevated serum calcium level. B. Positive rapid plasma reagin (RPR). C. Increased serum creatinine level. D. Increased thyroid stimulating hormone (TSH). Answer: Increased thyroid stimulating hormone (TSH). The healthcare provider should be notified of (D) immediately. An increased TSH suggests a low thyroxine level because the TSH is trying to stimulate thyroxine production, and hypothyroidism symptoms mimic those of depression. (A) often increases with aging. (B) is indicative of syphilis and should be reported, but does not have the priority of (C). (D) has implications for other illnesses, such as non-Hodgkin's lymphoma or hyperparathyroidism.