HESI Comprehensive Exam (B)
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her
husband states that she has been reluctant to leave home for the last 6 months. The
client has not gone to work for a month, has been terminated from her job, and has
not left the house since that time. This client is displaying symptoms of which
disorder? - ANS-Agoraphobia--fear of crowds
\A client at 32 weeks of gestation is hospitalized with preeclampsia, and magnesium
sulfate is prescribed to control the symptoms. Before the next dose of MgSO4 is
given, which assessment finding indicates that the client is at risk for toxicity? -
ANS-100 mL of urine output in 4 hours
\A client in the psychiatric setting with an anxiety disorder reports chest pain. Which
action should the nurse take first? - ANS-access client's vital signs
\A client is admitted to a mental health unit because of mild depression. When
asked, he denies suicidal ideation, but the nurse reads in the psychosocial
assessment that there were attempts to overdose on aspirin 5 years earlier. Which
intervention is most important for the nurse to implement? - ANS-Assign the client to
a semiprivate room.--It is most important to prevent the risk of self-harm from social
isolation, so the client should be assigned to a semiprivate room
\A client is admitted with a diagnosis of leukemia. This condition is manifested by
which of the following? - ANS-Hyperplastic gums, weakness, and elevated white
blood count are classic signs of leukemia
\A client is receiving substitution therapy during withdrawal from benzodiazepines.
Which expected outcome statement has the highest priority when planning nursing
care? - ANS-Excessive CNS stimulation will be reduced--Substitution therapy with
another CNS depressant is intended to decrease the excessive CNS stimulation that
can occur during benzodiazepine withdrawal
\A client with non-Hodgkin lymphoma has been prescribed cyclophosphamide IV for
therapy. Which assessment finding would need to be reported immediately to the
oncologist? - ANS-Chills, fever, and sore throat--Cyclophosphamide is an
immunosuppressive drug used to treat lymphoma and puts the client at risk for
infection. Signs and symptoms of an infection should be reported to the oncologist
immediately
\A couple expresses concern and fear prior to having an amniocentesis to determine
fetal lung maturity. To assist them in coping with this situation, which intervention is
best for the nurse to implement? - ANS-answer all questions regarding the
procedure--This action assists the couple in coping with the situation
\A primipara presents to the perinatal unit describing rupture of the membranes
(ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin infusion
is begun, and 8 hours later the client's contractions are irregular and mild. What vital
sign should the nurse monitor with greater frequency than the typical unit protocol? -
ANS-Maternal temperature-- this should be monitored frequently as a primary
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her
husband states that she has been reluctant to leave home for the last 6 months. The
client has not gone to work for a month, has been terminated from her job, and has
not left the house since that time. This client is displaying symptoms of which
disorder? - ANS-Agoraphobia--fear of crowds
\A client at 32 weeks of gestation is hospitalized with preeclampsia, and magnesium
sulfate is prescribed to control the symptoms. Before the next dose of MgSO4 is
given, which assessment finding indicates that the client is at risk for toxicity? -
ANS-100 mL of urine output in 4 hours
\A client in the psychiatric setting with an anxiety disorder reports chest pain. Which
action should the nurse take first? - ANS-access client's vital signs
\A client is admitted to a mental health unit because of mild depression. When
asked, he denies suicidal ideation, but the nurse reads in the psychosocial
assessment that there were attempts to overdose on aspirin 5 years earlier. Which
intervention is most important for the nurse to implement? - ANS-Assign the client to
a semiprivate room.--It is most important to prevent the risk of self-harm from social
isolation, so the client should be assigned to a semiprivate room
\A client is admitted with a diagnosis of leukemia. This condition is manifested by
which of the following? - ANS-Hyperplastic gums, weakness, and elevated white
blood count are classic signs of leukemia
\A client is receiving substitution therapy during withdrawal from benzodiazepines.
Which expected outcome statement has the highest priority when planning nursing
care? - ANS-Excessive CNS stimulation will be reduced--Substitution therapy with
another CNS depressant is intended to decrease the excessive CNS stimulation that
can occur during benzodiazepine withdrawal
\A client with non-Hodgkin lymphoma has been prescribed cyclophosphamide IV for
therapy. Which assessment finding would need to be reported immediately to the
oncologist? - ANS-Chills, fever, and sore throat--Cyclophosphamide is an
immunosuppressive drug used to treat lymphoma and puts the client at risk for
infection. Signs and symptoms of an infection should be reported to the oncologist
immediately
\A couple expresses concern and fear prior to having an amniocentesis to determine
fetal lung maturity. To assist them in coping with this situation, which intervention is
best for the nurse to implement? - ANS-answer all questions regarding the
procedure--This action assists the couple in coping with the situation
\A primipara presents to the perinatal unit describing rupture of the membranes
(ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin infusion
is begun, and 8 hours later the client's contractions are irregular and mild. What vital
sign should the nurse monitor with greater frequency than the typical unit protocol? -
ANS-Maternal temperature-- this should be monitored frequently as a primary
