Exam (elaborations) - hesi rn exit v3 full 160
answers 2020 - 2021
2020/2021 HESI RN EXIT V3
FULL 160
1. 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
The correct answer is D: Safety
2. 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
The correct answer is B: Think logically in organizing facts
3. 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
The correct answer is B: Place the child on the side
4. 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
The correct answer is C: Lack of enjoyment in usual pleasures
5. 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
The correct answer is B: Suction excessive tracheobronchial secretions
6. 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 significant for this client?
A) Compulsive behavior
B) Sense of impending doom
C) Fear of flying
D) Predictable episodes
The correct answer is B: Sense of impending doom
7. 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
The correct answer is B: Explain that this behavior is expected
8. 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
answers 2020 - 2021
2020/2021 HESI RN EXIT V3
FULL 160
1. 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
The correct answer is D: Safety
2. 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
The correct answer is B: Think logically in organizing facts
3. 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
The correct answer is B: Place the child on the side
4. 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
The correct answer is C: Lack of enjoyment in usual pleasures
5. 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
The correct answer is B: Suction excessive tracheobronchial secretions
6. 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 significant for this client?
A) Compulsive behavior
B) Sense of impending doom
C) Fear of flying
D) Predictable episodes
The correct answer is B: Sense of impending doom
7. 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
The correct answer is B: Explain that this behavior is expected
8. 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
