HESI/Saunders Online Review for the NCLEX-RN Examination (1 Year)
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A nurse provides instructions to a pregnant woman about foods that contain calcium. Which of
the following foods does the nurse recommend? Select all that apply.
A) Cheese
B) Yogurt
C) Spinach
D) Sardines
E) Shellfish Answer: A, B, D
Rationale: Calcium is essential for fetal skeleton and tooth formation. The body also uses
calcium to maintain maternal bone and tooth mineralization during pregnancy. Therefore
adequate intake of calcium is of utmost importance for the bone health of both mother and
fetus. Cheese, sardines (and other fish eaten with bones left in), and yogurt are good sources of
calcium. Shellfish are a good source of zinc and green leafy vegetables (except spinach and
Swiss chard) are good sources of calcium. Spinach is a good source of iron and many vitamins.
An HIV-positive child is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The
laboratory results show the CD4+ as 1000 cells/mm3. Which of the following nursing actions is
appropriate?
A) Contacting the physician
B) Administering the vaccine
C) Asking the laboratory to repeat the CD4+ test
D) Informing the child's mother that the vaccine must not be administered at this time
Answer: B
Rationale: The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is
1000 cells/mm3, the nurse would administer the vaccine. Contacting the physician, asking the
laboratory to repeat the CD4+ test, and telling the mother that the vaccine should not be
administered at this time are all incorrect in light of the results of the CD4+ count.
,A client in a manic state emerges from her room and quickly enters the dayroom. She
announces to the group that she is the star of a burlesque show and will begin her performance
shortly. The priority nursing action is to:
A) Ask the client to go to her room and to change her clothes
B) Tell the client firmly that burlesque shows are not allowed in the nursing unit
C) Tell the client that her bathroom privileges are being suspended because of her behavior
D) Quietly and firmly assist the client to her room and help her dress in appropriate clothes
Answer: D
Rationale: A person who is experiencing mania lacks insight and judgment, has poor impulse
control, and is highly excitable. The nurse must take control without creating increased stress or
anxiety in the client. Taking a quiet, firm approach while distracting the client (i.e., walking her
to her room and helping her dress appropriately) achieves the goal of preserving her
psychosocial integrity. Suspending the client's bathroom privileges because of behavior, having
the client change her clothes and telling the client that burlesque shows are not allowed in the
nursing unit will all increase the client's anxiety.
A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail
in my coffin." Which response by the nurse is therapeutic?
A) "Do you think that having asthma will kill you?"
B) "You seem very distressed at learning that you have asthma."
C) "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your
coffin.'"
D) "Asthma is a very treatable condition, but it's important to learn how to properly administer
your medications. Let's practice with your inhalant." Answer: B
Rationale: A clients who has learned that he or she has a chronic illness may exhibit denial,
anger, or sarcasm because of the fear associated with such illnesses. It is important for the
nurse to convey an accepting attitude as a means of enhancing mutual respect and trust.
Stating, "You seem very distressed at learning that you have asthma" paraphrases the client's
words and focuses on the client's feelings. "Do you think that having asthma will kill you?"
reflects and paraphrases the client's words but is somewhat sarcastic. "Asthma is a very
,treatable condition, but it's important to learn how to properly administer your medications.
Let's practice with your inhalant" lectures the client and does not deal directly with expressed
concerns. "I'm not going to work with you if you can't view this as a challenge rather than as a
'nail in your coffin'" is punitive, threatens the client, and sarcastically quotes the client's words.
During a preoperative assessment, a nurse notices the client is crying. In light of this
observation, which statement by the nurse is appropriate?
A) "You seem upset. Would you rather be alone?"
B) "You're crying. Tell me more about how you are feeling."
C) "Your surgeon is the best and has done many of these operations."
D) "Crying before a serious operation is common, but everything will be okay." Answer: B
Rationale: Taking time to discuss the client's concerns is as important a nursing action in many
instances as any intervention for physical care. Therapeutic communication in this situation
involves focusing on the client's nonverbal cues and encouraging the client to express feelings
or concerns about surgery. Changing the subject and avoiding the client are techniques that also
block communication with the client. False reassurance also blocks communication with the
client.
A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in
my head say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority
concern for this client?
A) Ineffective coping skills
B) Perceptual disturbances
C) Chronic low self-esteem
D) Risk for self-directed violence Answer: D
Rationale: The altered perceptions and cognitive distortions experienced by the client with
schizophrenia put the client at risk for self-harm. A fundamental responsibility of the nurse is to
provide a safe environment for this client and others. Although ineffective coping skills,
disturbed perceptual ability, and low self-esteem may be appropriate concerns, the risk for self-
directed violence is the priority.
, A client who was recently sexually assaulted is self-contained and calm. The client says to the
nurse, "It doesn't seem real." Which defense mechanism is the client using?
A) Denial
B) Projection
C) Rationalization
D) Intellectualization Answer: A
Rationale: Denial is a common reaction by a victim of sexual assault. This defense mechanism is
an adaptive and protective reaction. Projection is blaming or scapegoating. Rationalization is
justifying unacceptable attributes. Intellectualization is the excessive use of abstract thinking or
generalizations to decrease painful thinking.
A nurse completes an initial assessment of a client admitted to the mental health unit. Which
assessment finding is the matter of greatest concern?
A) Bruises on the client's neck
B) The client's report of not sleeping well
C) The client's report of suicidal thoughts
D) The spouse's statement "I don't approve of this treatment." Answer: C
Rationale: The client's verbalized thoughts are extremely important. The verbalization of
suicidal thoughts must be incorporated by the nurse into the plan of care. The nurse has the
legal responsibility to protect the client from harm. The presence of bruises on the client's neck,
the client's report of not sleeping well, and the spouse's statement are concerns to be
addressed but are not priority concerns.
A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How
should the nurse respond to the client?
A) "No one is going to kill you."
B) "Your medication is making you feel like this."
C) "Are you worried that people are trying to hurt you?"
D) "What makes you think that terrorists were sent to hurt you?" Answer: C
Exam Questions and Answers| Latest Update 100% Solved |
Guaranteed Success
A nurse provides instructions to a pregnant woman about foods that contain calcium. Which of
the following foods does the nurse recommend? Select all that apply.
A) Cheese
B) Yogurt
C) Spinach
D) Sardines
E) Shellfish Answer: A, B, D
Rationale: Calcium is essential for fetal skeleton and tooth formation. The body also uses
calcium to maintain maternal bone and tooth mineralization during pregnancy. Therefore
adequate intake of calcium is of utmost importance for the bone health of both mother and
fetus. Cheese, sardines (and other fish eaten with bones left in), and yogurt are good sources of
calcium. Shellfish are a good source of zinc and green leafy vegetables (except spinach and
Swiss chard) are good sources of calcium. Spinach is a good source of iron and many vitamins.
An HIV-positive child is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The
laboratory results show the CD4+ as 1000 cells/mm3. Which of the following nursing actions is
appropriate?
A) Contacting the physician
B) Administering the vaccine
C) Asking the laboratory to repeat the CD4+ test
D) Informing the child's mother that the vaccine must not be administered at this time
Answer: B
Rationale: The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is
1000 cells/mm3, the nurse would administer the vaccine. Contacting the physician, asking the
laboratory to repeat the CD4+ test, and telling the mother that the vaccine should not be
administered at this time are all incorrect in light of the results of the CD4+ count.
,A client in a manic state emerges from her room and quickly enters the dayroom. She
announces to the group that she is the star of a burlesque show and will begin her performance
shortly. The priority nursing action is to:
A) Ask the client to go to her room and to change her clothes
B) Tell the client firmly that burlesque shows are not allowed in the nursing unit
C) Tell the client that her bathroom privileges are being suspended because of her behavior
D) Quietly and firmly assist the client to her room and help her dress in appropriate clothes
Answer: D
Rationale: A person who is experiencing mania lacks insight and judgment, has poor impulse
control, and is highly excitable. The nurse must take control without creating increased stress or
anxiety in the client. Taking a quiet, firm approach while distracting the client (i.e., walking her
to her room and helping her dress appropriately) achieves the goal of preserving her
psychosocial integrity. Suspending the client's bathroom privileges because of behavior, having
the client change her clothes and telling the client that burlesque shows are not allowed in the
nursing unit will all increase the client's anxiety.
A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail
in my coffin." Which response by the nurse is therapeutic?
A) "Do you think that having asthma will kill you?"
B) "You seem very distressed at learning that you have asthma."
C) "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your
coffin.'"
D) "Asthma is a very treatable condition, but it's important to learn how to properly administer
your medications. Let's practice with your inhalant." Answer: B
Rationale: A clients who has learned that he or she has a chronic illness may exhibit denial,
anger, or sarcasm because of the fear associated with such illnesses. It is important for the
nurse to convey an accepting attitude as a means of enhancing mutual respect and trust.
Stating, "You seem very distressed at learning that you have asthma" paraphrases the client's
words and focuses on the client's feelings. "Do you think that having asthma will kill you?"
reflects and paraphrases the client's words but is somewhat sarcastic. "Asthma is a very
,treatable condition, but it's important to learn how to properly administer your medications.
Let's practice with your inhalant" lectures the client and does not deal directly with expressed
concerns. "I'm not going to work with you if you can't view this as a challenge rather than as a
'nail in your coffin'" is punitive, threatens the client, and sarcastically quotes the client's words.
During a preoperative assessment, a nurse notices the client is crying. In light of this
observation, which statement by the nurse is appropriate?
A) "You seem upset. Would you rather be alone?"
B) "You're crying. Tell me more about how you are feeling."
C) "Your surgeon is the best and has done many of these operations."
D) "Crying before a serious operation is common, but everything will be okay." Answer: B
Rationale: Taking time to discuss the client's concerns is as important a nursing action in many
instances as any intervention for physical care. Therapeutic communication in this situation
involves focusing on the client's nonverbal cues and encouraging the client to express feelings
or concerns about surgery. Changing the subject and avoiding the client are techniques that also
block communication with the client. False reassurance also blocks communication with the
client.
A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in
my head say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority
concern for this client?
A) Ineffective coping skills
B) Perceptual disturbances
C) Chronic low self-esteem
D) Risk for self-directed violence Answer: D
Rationale: The altered perceptions and cognitive distortions experienced by the client with
schizophrenia put the client at risk for self-harm. A fundamental responsibility of the nurse is to
provide a safe environment for this client and others. Although ineffective coping skills,
disturbed perceptual ability, and low self-esteem may be appropriate concerns, the risk for self-
directed violence is the priority.
, A client who was recently sexually assaulted is self-contained and calm. The client says to the
nurse, "It doesn't seem real." Which defense mechanism is the client using?
A) Denial
B) Projection
C) Rationalization
D) Intellectualization Answer: A
Rationale: Denial is a common reaction by a victim of sexual assault. This defense mechanism is
an adaptive and protective reaction. Projection is blaming or scapegoating. Rationalization is
justifying unacceptable attributes. Intellectualization is the excessive use of abstract thinking or
generalizations to decrease painful thinking.
A nurse completes an initial assessment of a client admitted to the mental health unit. Which
assessment finding is the matter of greatest concern?
A) Bruises on the client's neck
B) The client's report of not sleeping well
C) The client's report of suicidal thoughts
D) The spouse's statement "I don't approve of this treatment." Answer: C
Rationale: The client's verbalized thoughts are extremely important. The verbalization of
suicidal thoughts must be incorporated by the nurse into the plan of care. The nurse has the
legal responsibility to protect the client from harm. The presence of bruises on the client's neck,
the client's report of not sleeping well, and the spouse's statement are concerns to be
addressed but are not priority concerns.
A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How
should the nurse respond to the client?
A) "No one is going to kill you."
B) "Your medication is making you feel like this."
C) "Are you worried that people are trying to hurt you?"
D) "What makes you think that terrorists were sent to hurt you?" Answer: C
