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HESI EXIT
| Question | Answer |
|---|---|
| 1. Which information is a priority for the RN to reinforce to an older client after intravenous pyelography? | D)Measure the urine output for the next day and immediately notify the health care provider if it should decrease. |
| 2. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is | D) weekly weight |
| 3. A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client? | B)It is critical to report promptly to your health care provider any findings of peptic ulcers |
| 4. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first? | B) Have the client turn to the left side |
| 5. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? | C: A cold, pale lower leg |
| 6. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? | B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) |
| 7. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? | A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception |
| 8. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? | * C) The flow of life is believed to flow through major pathways or nerve clusters in your body. |
| 9. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? | C)Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent |
| 10. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? | A) Side-lying on the left with the head elevated 10 degrees |
| 11. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? | C) minimal drainage into the urinary collection bag |
| 12. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse? | C) Participate with the compressions or breathing |
| 13. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? | B) Jugular vein distention |
| 14. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication | A: Can predispose to dysrhythmias |
| 15. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? | B) Pupils fixed and dilated |
| 16. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? | D)”I went to the health care provider last week for a cold and I have gotten worse." |
| 17. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? | B) Pale mucosa of the eyelids and lips |
| 18. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is | D) Pupil responses |
| 19. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? | D) A preschooler with intermittent episodes of alertness |
| 20.20. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive(NOFTT). Upon entering the room, the nurse would expect the baby to be | D) Pale, thin arms and legs, uninterested in surroundings |
| 21. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? | D) Hair loss |
| 22. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to | B) Administer acetaminophen as ordered as this is normal at this time |
| 23. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be | B) Assess for dyspnea or stridor |
| 24. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? | D) I went to the bathroom and my urine looked very red and it didn’t hurt when I went. |
| 25. A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? | D) Fibroids that cause no problems still need to be taken out. |
| 26. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? | A) Stay with client and observe for airway obstruction |
| 27. A nurse to a primigravida whose membranes spontaneously ruptured(ROM) 4 hours ago. At the time of the ROM the vital signs wereT-99.8 Which assessment findings taken an early indication that the client is developing a complication of labor? | A) FHT 168 beats/min |
| 28. A client with pneumococcal pneumonia had antibiotics 16 hours ago. During the nurse’s initial evening rounds notices a foul smell in the room. The client makes all of these statements Which statement would alert the nurse to a complication? | B) "I have been coughing up foul-tasting, brown, thick sputum." |
| 29. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal | A) S3 ventricular gallop |
| 30. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? | B) The client’s entire body turns a bright red color |
| 31. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? | B: "The tube will remove excess air from your chest." |
| 32. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? | D) Serum potassium 6 mEq/L |
| 33. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention? | C) Dyspnea |
| 34. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? | C) Pulse oximetry of 88 |
| 35. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? | D) restlessness |
| 36. The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to | B) Assist client to turn, deep breathe, and cough |
| 37. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote | B) Deep breathing and coughing |
| 38. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? | D) Assist with oral hygiene |
| 39. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? | B) Assess for post operative arrhythmias |
| 40. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flush his respirations are 8 per minute. What should the nurse do first? | C) Lower the oxygen rate |
| 41. A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment ofa fracture of the right femur. The nurse finds that the child is now crying and the rightfoot is pale with the absence of a pulse. What should the nurse do first? | * A) Notify the health care provider |
| 42. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to | C) Reinforce the dressing and elevate the leg |
| 43. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? | B) Leukopenia |
| 44. A client has a chest tube in place following a left lower lobectomy after a stabwound to the chest. repositioning the client, the nurse notices 200 cc of dark, redfluid flows icollection chamber of the chest drain. What isappropriatenursing action? | D) Continue to monitor the rate of drainage |
| 45. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? | C) Loss of pulse in the extremity |
| 46. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He isawake and alert, but has not been able to void since he returned from surgery 6 hours ago.He received 1000 mL of IV fluid. Which action would b to help him void? | C) Assist him to stand by the side of the bed to void |
| 47. The nurse is caring for a client who requires a mechanical ventilator for breathing.The high pressure alarm goes off on the ventilator. What is the first action the nurseshould perform? | B) Perform a quick assessment of the client's condition |
| 48. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? | B) "I am allergic to shrimp." |
| 49. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? | A) Hold the tube feeding and notify the provider |
| 50. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must | A) Apply suction for no more than 10 seconds |
| 51. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to | A) administer the medication in 2 separate injections |
| 52. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to | D) prevent the drug from tissue irritation |
| 53. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? | C) improved respiratory status and increased urinary output |
| 54. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response? | C) ”The medication must be continued so the fluid problem is controlled." |
| 55. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? | B) Sore throat, fever |
| 56. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? | D) No bowel movement for 3 days |
| 57. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? | C) Activated PTT |
| 58. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? | D) Flush adequately with water before and after using the tube |
| 59. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? | B) ”Our child should brush and floss carefully after every meal." |
| 60. Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? | D) Occult bleeding |
| 61. The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? | A: Avoid chocolate and cheese |
| 62. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? | D) Application of pediculicides |
| 63. The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication? | A) Non-steroidal anti-inflammatory drugs |
| 64. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? | B) Potassium |
| 65. The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? | A) Stop the infusion |
| 66. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? | B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares |
| 67. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? | B) Hemoglobin and hematocrit |
| 68. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? | A) Protamine |
| 69. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? | D) "I always make sure to shake the NPH bottle hard to mix it well." |
| 70. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? | A) Orthostatic hypotension is a common side effect |
| 71. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs | D) Baked potato |
| 72. An 86 year-old nursing home resident who has decreased mental status is hospitalizedwith pneumonic infiltrates in the right lower lobe. the nurse assists the client with aclear liquid diet, the client begins to cough. What should the nurse do next? | B) Check the client’s gag reflex |
| 73. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? | C) Reposition every two hours |
| 74. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? | A) A 79 year-old malnourished client on bed rest |
| 75. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? | B) Obtain a health and dietary history |
| 76. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is | A) Abdominal x-ray |
| 77. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? | C) Perform frequent oral care with a tooth sponge |
| 78. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to | A) Exercise doing weight bearing activities |
| 79. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? | B) Sliced turkey sandwich and canned pineapple |
| 80. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? | D) Bed in lowest position, wheels locked, place bed against wall |
| 81. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula | B) Continuously |
| 82. The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID | C) Laxatives |
| 83. A client with diarrhea should avoid which of the following? | A) Orange juice |
| 84. Which statement best describes the effects of immobility in children? | B) Immobility in children has similar physical effects to those found in adults |
| 85. A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client’s comfort? | C) Keep conversations short |
| 86. After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate | D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange |
| 87. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? | B) Decreased sodium and potassium |
| 88. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? | B) Oozing liquid stool |
| 89. A client in a long term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to | C) accept the client’s report of pain |
| 90. An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be | A) Assess the severity and location of the pain |
| 91. A 20 year-old client has an infected leg wound from a mot home from the hospital. The client is to keep the affected leg elevatedand is on contactprecautions. The client wants if visitors can come. appropriate response home health nurse is that: | C) Visitors should wash their hands before and after touching the client |
| 92. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? | C) Place in respiratory/secretion precautions |
| 93. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? | D) Altered patterns of urinary elimination related to nocturia |
| 94. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? | A) An infant who has been identified to have botulism |
| 95. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse shouldreinforce to the staff members that the most significant routine infection control strategy,in addition to hand washing, to be implemented is which of these? | D) Have gloves on while handling bedpans with feces |
| 96. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? | B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear |
| 97. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? | D) Contact |
| 98. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? | C) Children are not to share hats, scarves and combs. |
| 99. During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? | A) Wash hands thoroughly before and after client contact |
| 100. A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? | B) roast beef, mashed potatoes, and green beans |
| 101. After an explosion at a workers approaches the nurse and says “Iam an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign to this worker who wants to help during the care of the woundedworkers? | C) Palpate pulses |
| 102. Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? | D) A young adult in the second day of treatment for an overdose of acetometaphen |
| 103. The mother of a toddler who is being treated for pesticide poisoning asks: “Why is activated charcoal used? What does it do?” What is the nurse's best response? | B) ”The charcoal absorbs the poison and forms a compound that doesn't hurt your child." |
| 104. The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say | B) ”What is your name? What allergies do you have?" then check the client's name band and allergy band As the room is entered say |
| 105. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? | B) A positive purified protein derivative with an abnormal chest x-ray |
| 106. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? | A) In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice. |
| 107. Which approach is the best way to prevent infections when providing care to clients in the home setting? | A) Hand washing before and after examination of clients |
| 108. A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure would be to | D) Place the hands or a folded blanket under the head of the child |
| 109. A mother calls hospital hot line connected to triage nurse. mother: “I found my child with odd stuff coming mouth andanunmarkedbottle .”comments the best for the nurse to ask the mother todetermine if the childswallowed a corrosive substance | A) Ask the child if the mouth is burning or throat pain is present |
| 110. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? | D) Place client in a negative pressure private room and have all who enter the room use masks with shields |
| 111. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN? | C) Irrigate and redress a leg wound |
| 112. When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because | A) Normal patterns of behavior may be labeled as deviant, immoral, or insane |
| 113. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? | D) Supervise a nursing assistant for skin care |
| 114. The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process? | C) Care for a client with discharge orders |
| 115. After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can’t do anything that pleases him. I’m not going in there again." The nurse should respond by saying | C) ”He is scared and taking it out on you. Let's talk to figure out what to do." |
| 116. A client with a diagnosis of bipolar disorder referred to a boarding home for placement. The social worker telephoned hospital unit forinformation about the client’s mental status and adjustment.appropriate response nurse these statements? | D) I need to get the client’s written consent before I release any information to you. |
| 117. A client with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make sleepydrowsy. I insist that you explain their use and side effects.” The nurse should understand | B) The client has a right to know about the prescribed medications |
| 118. Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time? | A) ”Have the client sit on the side of the bed for at least 2 minutes before helping him stand." |
| 119. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client | C) Was minimally responsive to voice and touch |
| 120. A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is | B) ”I can’t make such a promise." |
| 121. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? | D) Apply and care for a client's rectal pouch |
| 122. A client asks the nurse to call the police and states: “I need to report that I am being abused by a nurse.” The nurse should first | C) Obtain more details of the client’s claim of abuse |
| 123. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with | B) A myocardial infarction that is free from pain and dysrhythmias |
| 124. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? | D) ”Have you reviewed the list of expected skills you might need on this unit?" |
| 125. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to | D) Discuss the boundaries of the therapeutic relationship with the client |
| 126. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? | D) Perform nostril and mouth care |
| 127. The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)? | A) Test blood sugar every 2 hours by accu check |
| 128. A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP? | B) A middle-aged client with an obsessive compulsive disorder |
| 129. The unlicensed assistive personnel (UAP) reports increase in temperature101 post surgical client. The nurse checks on the client’s condition andobserves a cup of steaming coffee at the bedside. What instructions are appropriate togive to the UAP? | B) Check temperature 15 minutes after hot liquids are taken |
| 130. A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to | B) Assign 1 of the nursing staff to visit the client regularly |
| 131. A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? | B) Observation of affect and behavior |
| 132. A mother with a Roman Catholic birth in an ambulance on the way hospital. The neonate very critical condition with little expectation of surviving the trip hospital. Which of these requests the nurse anticipate and be prepared to do? | D) Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen." |
| 133. An American Indian chief visits his newborn son performs traditional ceremonyt involves feathers and chanting. attending nurse tells a colleague "I wonder any idea howridiculous he looks -- he's a grown man!" The nurse's response is an example | D) Prejudice |
| 134. A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is | D) "I see this is frustrating for you. I have a few minutes so let's talk." |
| 135. An elderly livesretirement community admitted with behaviors as reported by the daughter: absence daily senior group activity, missingweekly card games, a change calling daughter from daily once week, client's tomato garden isovergrown weeds. T | B) A middle aged person who has been on the unit for 72 hours with a dysthymia |
| 136. A client diagnosed with anorexia nervosa states after lunch, "I shouldn’t have eaten all of that sandwich, I don’t know why I ate it, I wasn’t hungry." The client’s comments indicate that the client is likely experiencing | A) Guilt |
| 137. A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly refuses pain medicationclient believes that suffering is part of life. The client states “everyone’s life is in God's hands.” The next action for the nurse to take is to | C) Ask the client if talking with a priest would be desired |
| 138. A teenage female is admitteddiagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills client’s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be | C) "Tell me about your week prior to being admitted." |
| 139. A client who has a belief based in Hinduism is nearing death. The nurse should plan for which action? | A) After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client's wrist |
| 140. An explosion high school for children special needs severe developmental delays. One ostudents accompanied parent seen community health center day later. After initial assessment the nurse concludes thatthe student crisis state. Whichinterventions | B) Ask the parent to identify the major problem |
| 141. Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode? | C) "I have powers to get you whatever you wish, no matter the cost." |
| 142. A client says, "It's raining outside it's raining in my heart. Did you know that St.Patrick snakes out of Ireland? I've never been to Ireland." The nurse woulddocument this behavior as | D) Flight of ideas |
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