HESI EXIT V4 160 Questions and Answers Part 3

45. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? A) May drink as much milk as desired B) Can have milk mixed with other foods C) Will benefit from fat-free cow's milk D) Should be limited to 3-4 cups of milk daily The correct answer is D: Should be limited to three to four cups of milk daily 46. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client’s behavior most likely indicates A) Neologisms B) Dissociation * C) Flight of ideas D) Word salad The correct answer is C: Flight of ideas 47. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? A) Jumping rope B) Tying shoelaces C) Riding a tricycle D) Playing hopscotch The correct answer is C: Riding a tricycle 48. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is A) A transparent film dressing B) Wet dressing with debridement granules C) Wet to dry with hydrogen peroxide D) Moist saline dressing The correct answer is D: Moist saline dressing 49. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action? A) Leave the room and return five minutes later and give the medicine B) Explain to the child that the medicine must be taken now C) Give the medication to the father and ask him to give it D) Mix the medication with ice cream or applesauce The correct answer is A: Leave the room and return five minutes later and give themedicine 50. A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? A) "I understand that a glass of wine with dinner is healthy." B) "Beer is not really hard alcohol, so I guess I can drink some." C) "If I drink, my baby may be harmed before I know I am pregnant." D) "Drinking with meals reduces the effects of alcohol." The correct answer is C: "If I drink, my baby may be harmed before I know I ampregnant." 51. The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should A) Review the medications the client is receiving B) Increase the formula infusion rate C) Increase the amount of water used to flush the tube D) Attach a rectal bag to protect the skin The correct answer is A: Review the medications the client is receiving 52. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated bythe nurse as associated with the diagnosis and communicated? A) "My partner's breathing rate is usually below 12." B) "I find the mood swings and the change from a calm person to being angry all the time hard to deal with." C) "It seems our sex life is non existant over the past 6 months." D) "In the morning and evening I hear complaints that reading is next to impossible from blurred print." The correct answer is B: "I find the mood swings and the change from a calm person to being angry all the time hard to deal with." 53. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver? A) It measures a child’s intelligence. B) It assesses a child's development. C) It evaluates psychological responses. D) It helps to determine problems. The correct answer is B: It assesses a child''s development. 54. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would be best to prepare the child? A) Introduce the child to all staff the day before surgery B) Explain the surgery 1 week prior to the procedure C) Arrange a tour of the operating and recovery rooms D) Encourage the child to bring a favorite toy to the hospital The correct answer is B: Explain the surgery 1 week prior to the procedure 55. The nurse, assisting in applying a cast to a client with a broken arm, knows that A) The cast material should be dipped several times into the warm water B) The cast should be covered until it dries C) The wet cast should be handled with the palms of hands D) The casted extremity should be placed on a cloth-covered surface The correct answer is C: The wet cast should be handled with the palms of hands 56. Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass? A) Touring the coronary intensive unit B) Mailing a video tape to the home C) Assessing the client's learning style D) Administering a written pre-test The correct answer is C: Assessing the client''s learning style 57. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child? A) All lesions crusted B) Elevated temperature C) Rhinorrhea and coryza D) Presence of vesicles The correct answer is A: All lesions crusted 58. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction? A) "I should position my baby completely facing me with my baby's mouth in front ofmy nipple." B) "The baby should latch onto the nipple and areola areas." C) "There may be times that I will need to manually express milk." D) I can switch to a bottle if I need to take a break from breast feeding. The correct answer is D: I can switch to a bottle if I need to take a break from breastfeeding. 59. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unitfor schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment? A) Stressors in the home B) Medication compliance C) Exposure to hot temperatures D) Alcohol use The correct answer is B: Medication compliance 60. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care? A) Increase fluid intake to prevent dehydration B) Place client on a pressure reducing support surface C) Use skin care products designed for use with incontinence D) Increase caloric intake to aid healing The correct answer is B: Place client on a pressure reducing support surface 61. A nurse is conducting a community wide seminar on childhood safety issues. Whichof these children is at the highest risk for poisoning? A) 9 month-old who stays with a sitter 5 days a week B) 20 month-old who has just learned to climb stairs C) 10 year-old who occasionally stays at home unattended D) 15 year-old who likes to repair bicycles The correct answer is B: Twenty month-old who has just learned to climb stairs 62. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother? A) My child has lost 3 pounds in the last month. B) Urinary output seemed to be less over the past 2 days. C) All the pants have become tight around the waist. D) The child prefers some salty foods more than others. The correct answer is C: Clothing has become tight around the waist 63. What is the most important aspect to include when developing a home care plan for a client with severe arthritis? A) Maintaining and preserving function B) Anticipating side effects of therapy C) Supporting coping with limitations D) Ensuring compliance with medications The correct answer is A: Maintaining and preserving function 64. A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent? A) Age of the child B) Sibling position in family C) Stressful family events D) Parental discipline strategies The correct answer is A: Age of the child 65. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants? A) Contains less lactose B) Is higher in calories/ounce C) Provides antibodies D) Has less fatty acid The correct answer is C: Provides antibodies 66. Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects? A) Red reflex test B) Visual acuity C) Pupil response to light D) Cover test The correct answer is A: Red reflex test