HESI EXIT V4 160 Questions and Answers Part 4

67. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for thiswound? A) Transparent dressing B) Dry sterile dressing with antibiotic ointment C) Wet to dry dressing D) Occlusive moist dressing The correct answer is D: Occlusive moist dressing 68. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? A) Cartoon stickers B) Large wooden puzzle C) Blunt scissors and paper D) Beach ball The correct answer is B: Large wooden puzzle 69. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the A) Yang, the positive force that represents light, warmth, and fullness B) Yin, the negative force that represents darkness, cold, and emptiness C) Use of improper hot foods, herbs and plants D) A failure to keep life in balance with nature and others The correct answer is B: Yin, the negative force that represents darkness, cold, andemptiness 70. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asksthe nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? A) "There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns that can be dealt with." C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." D) "You will work with a team of experts and also have access to a support group that the family can attend." The correct answer is C: "Thin, tenacious secretions from the lungs are a constantstruggle in cystic fibrosis." 71. Which type of accidental poisoning would the nurse expect to occur in children underage 6? A) Oral ingestion B) Topical contact C) Inhalation D) Eye splashes The correct answer is A: Oral ingestion 72. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client? A) Reading B) Checkers C) Cards D) Ping-pong The correct answer is D: Ping-pong 73. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia The correct answer is C: Distended neck veins 74. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? A) Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure The correct answer is D: Note patterns of increased blood pressure 75. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? A) Schedule the therapy thirty minutes after meals B) Teach the child not to cough during the treatment C) Confine the percussion to the rib cage area D) Place the child in a prone position for the therapy The correct answer is C: Confine the percussion to the rib cage area 76. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behavior is a warning sign to indicate that the client may be A) headed for relapse B) feeling hopeless C) approaching recovery D) in need of increased socialization The correct answer is A: headed for relapse 77. A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for A) Anxiety, unconscious anger, and hostility B) Guilt, indecisiveness, poor self-concept C) Psychomotor retardation or agitation D) Meticulous attention to grooming and hygiene The correct answer is C: Psychomotor retardation or agitation 78. A client is experiencing hallucinations that are markedly increased at night. The clientis very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response bythe nurse demonstrating emotional support for the client? A) "No, it would be best if you brought the client some reading material that she could read at night." B) "No, your presence may cause the client to become more anxious." C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety." D) "Yes, would you like to spend the night when the client’s behavior indicates that she is frightened?" The correct answer is C: "Yes, staying with the client and orienting her to hersurroundings may decrease her anxiety." 79. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be ableto perform? A) Say 2 words B) Pull up to stand C) Sit without support D) Drink from a cup The correct answer is C: Sit without support 80. The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group? A) Bulimia B) Anorexia * C) Obesity D) Malnutrition The correct answer is C: Obesity 81. At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should A) Invite the client to join the exercise group B) Tell the client you will call someone to come for her C) Give the client simple information about what she will be doing D) Firmly direct the client to her assigned group activity The correct answer is C: Give the client simple information about what she will be doing 82. A victim of domestic violence states to the nurse, "If only I could change and be howmy companion wants me to be, I know things would be different." Which would be the best response by the nurse? A) "The violence is temporarily caused by unusual circumstances, don’t stop hoping for a change." B) "Perhaps, if you understood the need to abuse, you could stop the violence." C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?" D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do." The correct answer is D: "Batterers lose self control because of their own internal reasons, not because of what their partner did or did not do." 83. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation? A) Degeneration of the alveoli B) Chronic broncho constriction of the large airways C) Lung remodeling and permanent changes in lung function D) Frequent pneumonia The correct answer is C: Lung remodeling and permanent changes in lung function 84. A mother wants to switch her 9 month-old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice bythe nurse? A) Change the baby to whole milk B) Add chocolate syrup to the bottle C) Continue with the present formula D) Offer fruit juice frequently The correct answer is C: Continue with the present formula 85. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice? A) When a family member offers information about their loved one B) When the client threatens self-harm and harm to others C) When the health care provider decides the family has a right to know the client's diagnosis D) When a visitor insists that the visitor has been given permission by the client The correct answer is B: When the client threatens self-harm and harm to others 86. The nurse is caring for a client who is in the late stage of multiple myeloma. Which ofthe following should be included in the plan of care? A) Monitor for hyperkalemia B) Place in protective isolation C) Precautions with position changes D) Administer diuretics as ordered The correct answer is C: Precautions with position changes