HESI Comprehensive B Practice
1 An 8-year-old child is receiving D.Male-female twins are not
. digoxin (Lanoxin) for congestive heart identical; therefore, their growth
failure (CHF). In assessing the child, cannot be
the nurse finds that her apical heart
rate is 80 beats/min, she complains of
being slightly nauseated, and her
serum digoxin level is 1.2 ng/mL.
What action should the nurse take?
A. Because the child's heart rate and
digoxin level are within normal
range, assess for the cause of the
nausea.
B. Hold the next dose of digoxin
until the health care provider can be
notified because the serum digoxin
level is elevated.
C. Administer the next dose of
digoxin and notify the health care
provider that the child is showing
signs of toxicity.
D. Notify the health care provider
that the child's pulse rate is below
normal for her age group.
2 A 12-year-old boy complains to the
. nurse that he is "short" (4'5" [53
inches]). His twin sister is 5 inches
taller than he is (4'10" [58 inches]).
Based on these findings, what
conclusion should the nurse reach?
A.The boy is not growing as
normally expected.
B. The girl is experiencing a period
of unexpected growth.
C.A normal growth spurt occurs in
girls 1 to 2 years earlier than boys.
,A
Rationale:
Nausea and vomiting are early signs of
digoxin toxicity. However, the normal
resting heart rate for a child 8 to 10 years
of age is 70 to 110 beats/min and the
therapeutic range of serum digoxin levels
is 0.5 to 2 ng/mL. Based on the objective
data,
(A) is the best of the choices provided
because the serum digoxin level is within
normal levels. (B) is not warranted by the
data presented. The digoxin level is
within the therapeutic range and the child
is not showing signs of toxicity (C). The
child's pulse rate is within normal range
for her age group (D).
C
Rationale:
Girls experience a growth spurt at
9.5 to 14.5 years of age and boys at
10.5 to 16 years of age (C). There are
insufficient data to support (A); growth
trends must be assessed to reach such a
conclusion. (B) is not unexpected. The
fact that the children are twins has less
to do with their growth than the fact that
they are male and female (D).
, compared.
3 A 45-year-old female client is admitted C
. to the psychiatric unit for evaluation. Rationale:
Her husband states that she has been Agoraphobia (C) is the fear of
reluctant to leave home for the last 6 crowds or of being in an open
months. The client has not gone to place. (A) is the fear of being in
work for a month, has been terminated closed places. (B) is the fear of high
from her job, and has not left the places. (D) is an abnormal fear of
house since that time. This client is death or bodies after death. A
displaying symptoms of which phobia is an unrealistic fear
disorder? associated with severe anxiety.
A.Claustrophobia
B.Acrophobia
C.Agoraphobia
D.Necrophobia
4 An adult client with a medical C
. diagnosis of substance abuse and Rationale:
schizophrenia was recently switched Alcohol enhances the side effects of
from oral fluphenazine HCl (Prolixin) Prolixin. The half-life of Prolixin
to IM fluphenazine decanoate (Prolixin PO is 8 hours, whereas the half-life
Decanoate) because of medication of the Prolixin Decanoate IM is 2 to
noncompliance. What should the nurse 4 weeks. Therefore, the side effects
teach the client and family about this of drinking alcohol are far more
change in medication regimen? severe when the client drinks
A.Long-acting medication is more alcohol after taking the long-acting
effective than daily medication. Prolixin Decanoate IM (C). (A, B,
B.A client with substance abuse must and D) provide incorrect
not take any oral medications. information.
C.There will continue to be a risk of
alcohol and drug interaction.
D.Support groups are only helpful for
substance abuse treatment.
5 An adult female who presents at the D
. mental clinic trembling and crying Rationale:
becomes distressed when the nurse The client is exhibiting signs of
attempts to conduct an assessment. moderate anxiety, which include
She complains about the number of voice tremors, shakiness, somatic
questions that are being asked, which complaints, and selective inattention.
, she is convinced are going to (D) is the best method for addressing
cause her to have a heart attack. this client's level of anxiety by
What action should the nurse creating a shared understanding of
take? the client's concerns. Although
A. Take the client's blood assessment of her blood pressure (A)
pressure and reassure her that might be a worthwhile intervention,
questioning will not cause a heart reassuring her that questioning will
attack. not cause a heart attack (A) is
B. Explain that treatment is based argumentative. (B) suggests that
on information obtained in the treatment cannot be provided without
assessment. the information, which is
C. Encourage the client to relax so manipulative. Asking the client to
that she can provide the relax (C) is likely to increase her
information requested. anxiety.
D. Empower the client to share her
story of why she is here at the A
mental health clinic. Rationale:
6 After assessing a 26-year-old client A blood pressure of 159/98 mm Hg
. with type 1 diabetes mellitus, which is hypertensive and increases the
data may indicate that the client is client's risk for acute coronary
experiencing chronic complications syndrome and/or stroke (A). (B and
of diabetes? C) are within defined parameters, and
A. Blood pressure, 159/98 mm (D) is not a recognized chronic
Hg B.Hemoglobin A1c (HbA1c), complication of diabetes.
6% C.Creatinine level, 1.0 A
mg/dL D.Chronic sciatica Rationale:
7 The charge nurse is making This client has a need for a skill that
. assignments for the upcoming shift. is within the scope of practice for the
Which client is most appropriate to LPN (A). Titration of an IV drip,
assign to the licensed practical nurse establishing care plans, and discharge
(LPN)? teaching are within the scope of
A.A client with nausea who needs a practice of a registered nurse (RN)
nasogastric tube inserted and are not delegated (B, C, and D).
B.A client in hypertensive crisis who
needs titration of IV nitroglycerin
C.
A newly admitted client who needs to
have a plan of care established
D.A client who is ready for
discharge who needs discharge
teaching
1 An 8-year-old child is receiving D.Male-female twins are not
. digoxin (Lanoxin) for congestive heart identical; therefore, their growth
failure (CHF). In assessing the child, cannot be
the nurse finds that her apical heart
rate is 80 beats/min, she complains of
being slightly nauseated, and her
serum digoxin level is 1.2 ng/mL.
What action should the nurse take?
A. Because the child's heart rate and
digoxin level are within normal
range, assess for the cause of the
nausea.
B. Hold the next dose of digoxin
until the health care provider can be
notified because the serum digoxin
level is elevated.
C. Administer the next dose of
digoxin and notify the health care
provider that the child is showing
signs of toxicity.
D. Notify the health care provider
that the child's pulse rate is below
normal for her age group.
2 A 12-year-old boy complains to the
. nurse that he is "short" (4'5" [53
inches]). His twin sister is 5 inches
taller than he is (4'10" [58 inches]).
Based on these findings, what
conclusion should the nurse reach?
A.The boy is not growing as
normally expected.
B. The girl is experiencing a period
of unexpected growth.
C.A normal growth spurt occurs in
girls 1 to 2 years earlier than boys.
,A
Rationale:
Nausea and vomiting are early signs of
digoxin toxicity. However, the normal
resting heart rate for a child 8 to 10 years
of age is 70 to 110 beats/min and the
therapeutic range of serum digoxin levels
is 0.5 to 2 ng/mL. Based on the objective
data,
(A) is the best of the choices provided
because the serum digoxin level is within
normal levels. (B) is not warranted by the
data presented. The digoxin level is
within the therapeutic range and the child
is not showing signs of toxicity (C). The
child's pulse rate is within normal range
for her age group (D).
C
Rationale:
Girls experience a growth spurt at
9.5 to 14.5 years of age and boys at
10.5 to 16 years of age (C). There are
insufficient data to support (A); growth
trends must be assessed to reach such a
conclusion. (B) is not unexpected. The
fact that the children are twins has less
to do with their growth than the fact that
they are male and female (D).
, compared.
3 A 45-year-old female client is admitted C
. to the psychiatric unit for evaluation. Rationale:
Her husband states that she has been Agoraphobia (C) is the fear of
reluctant to leave home for the last 6 crowds or of being in an open
months. The client has not gone to place. (A) is the fear of being in
work for a month, has been terminated closed places. (B) is the fear of high
from her job, and has not left the places. (D) is an abnormal fear of
house since that time. This client is death or bodies after death. A
displaying symptoms of which phobia is an unrealistic fear
disorder? associated with severe anxiety.
A.Claustrophobia
B.Acrophobia
C.Agoraphobia
D.Necrophobia
4 An adult client with a medical C
. diagnosis of substance abuse and Rationale:
schizophrenia was recently switched Alcohol enhances the side effects of
from oral fluphenazine HCl (Prolixin) Prolixin. The half-life of Prolixin
to IM fluphenazine decanoate (Prolixin PO is 8 hours, whereas the half-life
Decanoate) because of medication of the Prolixin Decanoate IM is 2 to
noncompliance. What should the nurse 4 weeks. Therefore, the side effects
teach the client and family about this of drinking alcohol are far more
change in medication regimen? severe when the client drinks
A.Long-acting medication is more alcohol after taking the long-acting
effective than daily medication. Prolixin Decanoate IM (C). (A, B,
B.A client with substance abuse must and D) provide incorrect
not take any oral medications. information.
C.There will continue to be a risk of
alcohol and drug interaction.
D.Support groups are only helpful for
substance abuse treatment.
5 An adult female who presents at the D
. mental clinic trembling and crying Rationale:
becomes distressed when the nurse The client is exhibiting signs of
attempts to conduct an assessment. moderate anxiety, which include
She complains about the number of voice tremors, shakiness, somatic
questions that are being asked, which complaints, and selective inattention.
, she is convinced are going to (D) is the best method for addressing
cause her to have a heart attack. this client's level of anxiety by
What action should the nurse creating a shared understanding of
take? the client's concerns. Although
A. Take the client's blood assessment of her blood pressure (A)
pressure and reassure her that might be a worthwhile intervention,
questioning will not cause a heart reassuring her that questioning will
attack. not cause a heart attack (A) is
B. Explain that treatment is based argumentative. (B) suggests that
on information obtained in the treatment cannot be provided without
assessment. the information, which is
C. Encourage the client to relax so manipulative. Asking the client to
that she can provide the relax (C) is likely to increase her
information requested. anxiety.
D. Empower the client to share her
story of why she is here at the A
mental health clinic. Rationale:
6 After assessing a 26-year-old client A blood pressure of 159/98 mm Hg
. with type 1 diabetes mellitus, which is hypertensive and increases the
data may indicate that the client is client's risk for acute coronary
experiencing chronic complications syndrome and/or stroke (A). (B and
of diabetes? C) are within defined parameters, and
A. Blood pressure, 159/98 mm (D) is not a recognized chronic
Hg B.Hemoglobin A1c (HbA1c), complication of diabetes.
6% C.Creatinine level, 1.0 A
mg/dL D.Chronic sciatica Rationale:
7 The charge nurse is making This client has a need for a skill that
. assignments for the upcoming shift. is within the scope of practice for the
Which client is most appropriate to LPN (A). Titration of an IV drip,
assign to the licensed practical nurse establishing care plans, and discharge
(LPN)? teaching are within the scope of
A.A client with nausea who needs a practice of a registered nurse (RN)
nasogastric tube inserted and are not delegated (B, C, and D).
B.A client in hypertensive crisis who
needs titration of IV nitroglycerin
C.
A newly admitted client who needs to
have a plan of care established
D.A client who is ready for
discharge who needs discharge
teaching
