Cat exam 1-Hesi Exit
10. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse
provides home care instructions to the mother. Which statement by the child's mother
indicates that she understands home care treatment to promote pulmonary function? -
ANS-"Chest physiotherapy should be performed at least twice a day"
101. A mother brings her 15-month-old son and 6-year-old daughter to the clinic for
immunizations. Both children clearly have upper respiratory infections in addition to being
anxious. The mother tells the nurse that the younger child ran a fever of 100.2 F following his
last immunization. What plan is best for the nurse to implement? - ANS-Administer the
boosters and instruct the mother to cal the clinic if either child's temperature exceeds 101 F
134. In completing the treatment plan for an 11-year-old who was bipolar disorder, the
nurse plans outcomes for the nursing diagnosis, "Risk for violence towards peers related to
impulsivity." Which outcome is most important? - ANS-Reach out to employees when they
think about harming other people. 135. Fluids are restricted for a 4-year-old boy with acute
poststreptococcal glomerulonephritis (APSGN). Which nursing intervention makes fluid
restriction less
obvious to this child? - ANS-Play a game of tea party and serve the allowed amount of
liquids in small medicine
cups
137. The nurse is caring for a client who has a transcutaneous electrical nerve
stimulator(TENS) unit that was inserted at the incisional site following a lumbar laminectomy.
What information should the nurse teach the client about the action of this pain
modality? - ANS-A mild electrical stimulus at the skin surface blocks transmission of pain
stimulus
139. During a family baseball game, an adult male is hit on the head with a bat, and he is
suspected of sustaining an epidural bleed. What is the most important information for the
emergency center nurse to obtain from the client's spouse, who witnessed his
injury? - ANS-"Was your husband knocked out by the blow?"
140. An 86-year-old female client complains to the nurse that she does not like to eat as
much as she used to because things taste differently to her now that she is older. The
nurse's response should be based on which fact? - ANS-C. A loss of appetite often occurs
in older adults as a result of a decreased sense of
141. A client with a compound fracture of the left ankle is being discharged with a
below-the-knee cast. Before being discharged, the nurse should provide the client with what
instruction? - ANS-A. Do not attempt to scratch the skin under the cast
142. The charge nurse is implementing a quality assurance policy and accompanies a
nurse while administering medications. The nurse identifies a male client by asking him to
state his name prior to administering the medication. Which action should the charge nurse
implement? - ANS-Tell the nurse in a private area that the client identification was
incomplete
145. A 50-year-old male client has just been informed that he will require open heart
surgery. He tells the nurse, "This will change my whole life. Nothing will ever be the same
, again." What action should the nurse implement first? - ANS-Encourage the client to discuss
his perceptions of the changes his life will undergo
15. A 14-year-old male client arrives at the emergency room in status epilepticus. He was
diagnosed with a seizure disorder in childhood. What is the most likely cause of his present
condition? - ANS-Acute withdrawal from anticonvulsant medication
151. The nurse is assessing a 2-week-old breastfeeding infant. To obtain information about
adequate nutrition, which question should the nurse ask the breastfeeding mother? -
ANS-"How many diapers does the infant wet daily?"
159. An infant has a medical diagnosis of tracheoesophageal fistula (TFE). Which nursing
Is intervention necessary for this infant prior to surgical repair? - ANS-Always have suction
equipment on hand. 160. The nurse has identified four nursing problems for a 13-year-old
admitted for depression and anxiety. What is the priority problem? - ANS-Risk for
self-directed violence related to history of self-mutilation
17. A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In planning
care for this child, which nursing diagnosis has the highest priority? - ANS-High risk for fluid
volume deficit related to temperature elevation
28. A 72-year-old male client reports that he has felt depressed since his wife died six
months ago. What question is most important for the nurse to ask this client? - ANS-"Have
you ever felt like hurting yourself?"
35. With osteomyelitis, a 13-year-old client presents with non-union of a comminuted tibia
fracture. The healthcare provider collects bone aspirate specimens for culture and sensitivity
and applies a cast to the adolescent's lower leg. What action
should the nurse implement next? - ANS-Initiate parenteral antibiotic therapy
44. A 22-year-old is involved in a motor vehicle collision and the spinal cord is severed at
the second cervical spine (C-2). What is the most likely outcome of this injury? - ANS-Death
at the scene of the accident due to respiratory arrest
61. The nurse is performing a routine well-child exam on a 5-year-old. While palpating the
lymph nodes, the nurse feels several 0.5 cm nodes in the cervical area that are round,
mobile, non-tender, and non-warm to the touch. What do these findings most likely
represent? - ANS-An expected finding for a well child of this age
69. The nurse should instruct the parents of a 2-year-old toddler with Tetralogy of Fallot to
immediately contact their healthcare provider if their child exhibits which symptom? -
ANS-Becomes pale and lethargic
82. A 60-year-old female client takes NPH insulin each morning. What would necessitate
holding this client's usual morning NPH insulin dose? - ANS-The client is NPO for surgical
debridement of a leg ulcer at 11:00 a.m
9. A nurse who is new to the pediatric unit is positioning a 6-month-old for an injection of
penicillin V (Pen V) in the dorsogluteal muscle. Which action should the nurse-manager who
is supervising this nurse take first? - ANS-C. Instruct the nurse to select another injection
site
93. A 19-year-old male client is brought to the emergency room by a group of fraternity
brothers after a hazing event at the university. The client arrives with a blood alcohol level
(BAL) of 3.8 and a Glasgow Coma Scale of 3. Which action should the nurse implement
first? - ANS-Initiate IV access using Lactated Ringer's solution 1000 ml with thiamine 100 mg
Due to Crohn's disease, a dancer client in her 25s recently underwent an ileostomy. In
evaluating the client's response to this life change, which behavior would indicate to the
nurse that he is coping effectively? The client - ANS-Discusses modified costume designs
10. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse
provides home care instructions to the mother. Which statement by the child's mother
indicates that she understands home care treatment to promote pulmonary function? -
ANS-"Chest physiotherapy should be performed at least twice a day"
101. A mother brings her 15-month-old son and 6-year-old daughter to the clinic for
immunizations. Both children clearly have upper respiratory infections in addition to being
anxious. The mother tells the nurse that the younger child ran a fever of 100.2 F following his
last immunization. What plan is best for the nurse to implement? - ANS-Administer the
boosters and instruct the mother to cal the clinic if either child's temperature exceeds 101 F
134. In completing the treatment plan for an 11-year-old who was bipolar disorder, the
nurse plans outcomes for the nursing diagnosis, "Risk for violence towards peers related to
impulsivity." Which outcome is most important? - ANS-Reach out to employees when they
think about harming other people. 135. Fluids are restricted for a 4-year-old boy with acute
poststreptococcal glomerulonephritis (APSGN). Which nursing intervention makes fluid
restriction less
obvious to this child? - ANS-Play a game of tea party and serve the allowed amount of
liquids in small medicine
cups
137. The nurse is caring for a client who has a transcutaneous electrical nerve
stimulator(TENS) unit that was inserted at the incisional site following a lumbar laminectomy.
What information should the nurse teach the client about the action of this pain
modality? - ANS-A mild electrical stimulus at the skin surface blocks transmission of pain
stimulus
139. During a family baseball game, an adult male is hit on the head with a bat, and he is
suspected of sustaining an epidural bleed. What is the most important information for the
emergency center nurse to obtain from the client's spouse, who witnessed his
injury? - ANS-"Was your husband knocked out by the blow?"
140. An 86-year-old female client complains to the nurse that she does not like to eat as
much as she used to because things taste differently to her now that she is older. The
nurse's response should be based on which fact? - ANS-C. A loss of appetite often occurs
in older adults as a result of a decreased sense of
141. A client with a compound fracture of the left ankle is being discharged with a
below-the-knee cast. Before being discharged, the nurse should provide the client with what
instruction? - ANS-A. Do not attempt to scratch the skin under the cast
142. The charge nurse is implementing a quality assurance policy and accompanies a
nurse while administering medications. The nurse identifies a male client by asking him to
state his name prior to administering the medication. Which action should the charge nurse
implement? - ANS-Tell the nurse in a private area that the client identification was
incomplete
145. A 50-year-old male client has just been informed that he will require open heart
surgery. He tells the nurse, "This will change my whole life. Nothing will ever be the same
, again." What action should the nurse implement first? - ANS-Encourage the client to discuss
his perceptions of the changes his life will undergo
15. A 14-year-old male client arrives at the emergency room in status epilepticus. He was
diagnosed with a seizure disorder in childhood. What is the most likely cause of his present
condition? - ANS-Acute withdrawal from anticonvulsant medication
151. The nurse is assessing a 2-week-old breastfeeding infant. To obtain information about
adequate nutrition, which question should the nurse ask the breastfeeding mother? -
ANS-"How many diapers does the infant wet daily?"
159. An infant has a medical diagnosis of tracheoesophageal fistula (TFE). Which nursing
Is intervention necessary for this infant prior to surgical repair? - ANS-Always have suction
equipment on hand. 160. The nurse has identified four nursing problems for a 13-year-old
admitted for depression and anxiety. What is the priority problem? - ANS-Risk for
self-directed violence related to history of self-mutilation
17. A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In planning
care for this child, which nursing diagnosis has the highest priority? - ANS-High risk for fluid
volume deficit related to temperature elevation
28. A 72-year-old male client reports that he has felt depressed since his wife died six
months ago. What question is most important for the nurse to ask this client? - ANS-"Have
you ever felt like hurting yourself?"
35. With osteomyelitis, a 13-year-old client presents with non-union of a comminuted tibia
fracture. The healthcare provider collects bone aspirate specimens for culture and sensitivity
and applies a cast to the adolescent's lower leg. What action
should the nurse implement next? - ANS-Initiate parenteral antibiotic therapy
44. A 22-year-old is involved in a motor vehicle collision and the spinal cord is severed at
the second cervical spine (C-2). What is the most likely outcome of this injury? - ANS-Death
at the scene of the accident due to respiratory arrest
61. The nurse is performing a routine well-child exam on a 5-year-old. While palpating the
lymph nodes, the nurse feels several 0.5 cm nodes in the cervical area that are round,
mobile, non-tender, and non-warm to the touch. What do these findings most likely
represent? - ANS-An expected finding for a well child of this age
69. The nurse should instruct the parents of a 2-year-old toddler with Tetralogy of Fallot to
immediately contact their healthcare provider if their child exhibits which symptom? -
ANS-Becomes pale and lethargic
82. A 60-year-old female client takes NPH insulin each morning. What would necessitate
holding this client's usual morning NPH insulin dose? - ANS-The client is NPO for surgical
debridement of a leg ulcer at 11:00 a.m
9. A nurse who is new to the pediatric unit is positioning a 6-month-old for an injection of
penicillin V (Pen V) in the dorsogluteal muscle. Which action should the nurse-manager who
is supervising this nurse take first? - ANS-C. Instruct the nurse to select another injection
site
93. A 19-year-old male client is brought to the emergency room by a group of fraternity
brothers after a hazing event at the university. The client arrives with a blood alcohol level
(BAL) of 3.8 and a Glasgow Coma Scale of 3. Which action should the nurse implement
first? - ANS-Initiate IV access using Lactated Ringer's solution 1000 ml with thiamine 100 mg
Due to Crohn's disease, a dancer client in her 25s recently underwent an ileostomy. In
evaluating the client's response to this life change, which behavior would indicate to the
nurse that he is coping effectively? The client - ANS-Discusses modified costume designs
