HESI PN EXIT EXAM V4

1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained in correct body alignment. B) Be sure t ...

1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained in correct body alignment. B) Be sure the traction weights touch the end of the bed. C) Adjust the head and foot of the bed for the child's comfort D) Release the traction for 15-20 minutes every 6 hours PRN. The correct answer is A: Make certain the child is maintained in correct body alignment. 2. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider? A) Height and weight percentiles vary widely B) Growth pattern appears to have slowed C) Recumbent and standing height are different D) Short term weight changes are uneven The correct answer is A: Height and weight percentiles vary widely 3. The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? A) Teach the parents how to perform cardiopulmonary resuscitation B) Recommend that the parents give in when he holds his breath to prevent anoxia C) Advise the parents to ignore breath holding because breathing will begin as a reflex D) Instruct the parents on how to reason with the child about possible harmful effects The correct answer is C: Advise the parents to ignore breath holding because breathing will begin as a reflex 4. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? A) "My pain is deep in my chest behind my sternum." B) "When I sit up the pain gets worse." C) "As I take a deep breath the pain gets worse." D) "The pain is right here in my stomach area." The correct answer is A: "My pain is deep in my chest behind my sternum." . 5. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory? A) "Name the year." "What season is this?" (pause for answer after each question) B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number." C) "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?" The correct answer is C: "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." 6. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? A) Food B) Warmth C) Security D) Comfort The correct answer is C: Security 7. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A) "I cannot give this medication as it is written. I have no idea of what you mean." B) "Would you please clarify what you have written so I am sure I am reading it correctly?" C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful." D) "Please print in the future so I do not have to spend extra time attempting to read your writing." The correct answer is B) "Would you please clarify what you have written so I am sure I am reading it correctly?" 8. What is the most important consideration when teaching parents how to reduce risks in the home? A) Age and knowledge level of the parents B) Proximity to emergency services C) Number of children in the home D) Age of children in the home The correct answer is D: Age of children in the home 9. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should A) Administer a placebo B) Encourage increased fluid intake C) Administer the prescribed analgesia D) Recommend relaxation exercises for pain control The correct answer is C: Administer the prescribed analgesia 10. While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? A) Respiratory rate of 42 B) Lethargy for the past hour C) Apical pulse of 54 D) Coughing up copious secretions The correct answer is A: Respiratory rate of 30 11. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? A) Lethargy B) Heat intolerance C) Diarrhea D) Skin eruptions The correct answer is A: Lethargy 12. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? A) "Do not worry. Epilepsy can be treated with medications." B) "The seizure may or may not mean your child has epilepsy." C) "Since this was the first convulsion, it may not happen again." D) "Long term treatment will prevent future seizures." The correct answer is B: "The seizure may or may not mean your child has epilepsy." 13. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? A) Risk for injury B) Risk for knowledge deficit C) Altered thought process D) Disturbance in self-esteem The correct answer is A: Risk for injury 14. The nurse is caring for a 10 month-old infant who is has oxygen via mask. It is important for the nurse to maintain patency of which of these areas? A) Mouth B) Nasal passages C) Back of throat D) Bronchials The correct answer is B: Nasal passages 15. The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client? A) "Take at least 2 weeks off from work." B) "You will need another chest x-ray in 6 weeks." C) "Take your temperature every day." D) "Complete all of the antibiotic even if your findings decrease." The correct answer is D: "Complete all of the antibiotic even if your findings decrease." 16. When counseling a 6 year old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder? A) Has no clear etiology B) May be associated with sleep phobia C) Has a definite genetic link D) Is a sign of willful misbehavior The correct answer is A: Has no clear etiology 17. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? A) Reprimand the child and give a 15 minute "time out" B) Maintain a permissive attitude for this behavior C) Use patience and a sense of humor to deal with this behavior D) Assert authority over the child through limit setting The correct answer is C: Use patience and a sense of humor to deal with this behavior 18. The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse? A) Chewable aspirin is the preferred analgesic B) Topical cortisone ointment relieves itching C) Papules, vesicles, and crusts will be present at one time D) The illness is only contagious prior to lesion eruption The correct answer is C: Papules, vesicles, and crusts will be present at one time 19. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first? A) Take the client's vital signs B) Place the client in a sitting position with legs dangling C) Contact the health care provider D) Administer the PRN anti anxiety agent The correct answer is B: Place the client in a sitting position with legs dangling 20. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to A) Dress the child warmly to avoid chilling B) Keep the child away from other children for the duration of the rash C) Clean the affected areas with tepid water and detergent D) Wrap the child's hand in mittens or socks to prevent scratching The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching 21. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best? A) "A recovering person has to be very careful not to lose control, therefore, confine your drinking just at family gatherings." B) "At your next AA meeting discuss the possibility of limited drinking with your sponsor." C) "A recovering person needs to get in touch with their feelings. Do you want a drink?" D) "A recovering person cannot return to drinking without starting the addiction process over." The correct answer is D: "The recovering person cannot return to drinking without starting the addiction process over." 22. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding? A) Age 40 years B) Lactose intolerance C) Family history of breast cancer D) Uses cocaine on weekends The correct answer is D: Uses cocaine on weekends 23. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication? A) Potassium B) Arterial blood gasses C) Blood urea nitrogen D) Thiocyanate The correct answer is D: Thiocyanate 24. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond? A) With acceptance and views the victim’s comment as an indication that their marriage is in trouble B) With fear of rejection causing increased rage toward the victim C) With a new commitment to seek counseling to assist with their marital problems D) With relief, and welcomes the separation as a means to have some personal time The correct answer is B: With fear of rejection causing increased rage toward the victim 25. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus? A) Discuss with the mother sharing parenting responsibilities B) Set time aside to get the mother to express her feelings and concerns C) Arrange for the parents to attend infant care classes D) Talk with the father and help him accept the wife's decision The correct answer is B: Set time aside to get the mother to express her feelings and concerns 26. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client A) Eat foods high in sodium increases sputum liquefaction B) Use oxygen during meals improves gas exchange C) Perform exercise after respiratory therapy enhances appetite D) Cleanse the mouth of dried secretions reduces risk of infection