HESI Exit V5 160 Questions and
Answers.
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
An adolescent client comes to the clinic 3 weeks after the birth of her
first baby. She tells the nurse she is concerned because she has not returned
to her pre-pregnant weight.
Which action should
the nurse perform
first?
A) Review the client's weight pattern over the year
B) Ask the mother to record her diet for the last 24 hours
C) Encourage her to talk about her view of herself
D) Give her several pamphlets on postpartum nutrition
The correct answer is C: Encourage her to talk about her view of herself
, To prevent a valsalva maneuver in a client recovering from an acute
myocardial infarction, the nurse would
A) Assist the client to use the bedside commode
B) Administer stool softeners every day as ordered
C) Administer anti dysrhythmics prn as ordered
D) Maintain the client on strict bed rest
The correct answer is B: Administer stool softeners every day as ordered
A 3 year-old had a hip spica cast applied 2 hours ago. In order to
facilitate drying, the nurse should
A) Expose the cast to air and turn the child frequently
B) Use a heat lamp to reduce the drying time
C) Handle the cast with the abductor bar
D) Turn the child as little as possible
The correct answer is A: Expose the cast to air and turn the child frequently
, The nurse is caring for a 13 year-old following spinal fusion for scoliosis.
Which of the following interventions is appropriate in the immediate
postoperative period?
A) Raise the head of the bed at least 30 degrees
B) Encourage ambulation within 24 hours
C) Maintain in a flat position, logrolling as needed
D) Encourage leg contraction and relaxation after 48 hours
The correct answer is C: Maintain in a flat position, logrolling as needed
A client was admitted to the psychiatric unit after complaining to her friends
and
family that neighbors have bugged her home in order to hear all of her business.
She remains aloof from other clients, paces the floor and believes that the hospital
is a house of torture.
Nursing interventions for the client should appropriately focus on efforts to
A) Convince the client that the hospital staff is trying to help
B) Help the client to enter into group recreational activities
C) Provide interactions to help the client learn to trust staff
D) Arrange the environment to limit the client’s contact with other clients
The correct answer is C: Provide interactions to help the client learn to trust staff
, 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
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
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
Answers.
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
An adolescent client comes to the clinic 3 weeks after the birth of her
first baby. She tells the nurse she is concerned because she has not returned
to her pre-pregnant weight.
Which action should
the nurse perform
first?
A) Review the client's weight pattern over the year
B) Ask the mother to record her diet for the last 24 hours
C) Encourage her to talk about her view of herself
D) Give her several pamphlets on postpartum nutrition
The correct answer is C: Encourage her to talk about her view of herself
, To prevent a valsalva maneuver in a client recovering from an acute
myocardial infarction, the nurse would
A) Assist the client to use the bedside commode
B) Administer stool softeners every day as ordered
C) Administer anti dysrhythmics prn as ordered
D) Maintain the client on strict bed rest
The correct answer is B: Administer stool softeners every day as ordered
A 3 year-old had a hip spica cast applied 2 hours ago. In order to
facilitate drying, the nurse should
A) Expose the cast to air and turn the child frequently
B) Use a heat lamp to reduce the drying time
C) Handle the cast with the abductor bar
D) Turn the child as little as possible
The correct answer is A: Expose the cast to air and turn the child frequently
, The nurse is caring for a 13 year-old following spinal fusion for scoliosis.
Which of the following interventions is appropriate in the immediate
postoperative period?
A) Raise the head of the bed at least 30 degrees
B) Encourage ambulation within 24 hours
C) Maintain in a flat position, logrolling as needed
D) Encourage leg contraction and relaxation after 48 hours
The correct answer is C: Maintain in a flat position, logrolling as needed
A client was admitted to the psychiatric unit after complaining to her friends
and
family that neighbors have bugged her home in order to hear all of her business.
She remains aloof from other clients, paces the floor and believes that the hospital
is a house of torture.
Nursing interventions for the client should appropriately focus on efforts to
A) Convince the client that the hospital staff is trying to help
B) Help the client to enter into group recreational activities
C) Provide interactions to help the client learn to trust staff
D) Arrange the environment to limit the client’s contact with other clients
The correct answer is C: Provide interactions to help the client learn to trust staff
, 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
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
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
