HESI EXIT Exam V2 Latest
2022
The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which
nursing intervention is appropriate for this child?
Make certain the child is maintained in correct body alignment.
Be sure the traction weights touch the end of the bed.
Adjust the head and foot of the bed for the child's comfort
Release the traction for 15-20 minutes every 6 hours PRN.
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?
Height and weight percentiles vary widely
Growth pattern appears to have slowed
Recumbent and standing height are different
Short term weight changes are uneven
The parents of a 2 year-old child report that he has been holding his breath wheneverhe
has temper tantrums. What is the best action by the nurse?
Teach the parents how to perform cardiopulmonary resuscitation
Recommend that the parents give in when he holds his breath to prevent anoxia Advise
the parents to ignore breath holding because breathing will begin as a reflexInstruct
the parents on how to reason with the child about possible harmful effects
The nurse is assessing a client in the emergency room. Which statement suggests that
the problem is acute angina?
"My pain is deep in my chest behind my sternum."
"When I sit up the pain gets worse."
"As I take a deep breath the pain gets worse."
"The pain is right here in my stomach area."
.
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
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memory?
"Name the year." "What season is this?" (pause for answer after each question)
"Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now
continue to subtract 7 from the new number."
"I am going to say the names of three things and I want you to repeat them after me:
blue, ball, pen."
"What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of
it?"
In planning care for a 6 month-old infant, what must the nurse provide to assist in the
development of trust?
Food
Warmth C)
Security
D) Comfort
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?"
"I am having difficulty reading your handwriting. It would save me time if you would be
more careful."
"Please print in the future so I do not have to spend extra time attempting to read your
writing."
What is the most important consideration when teaching parents how to reduce risks in
the home?
Age and knowledge level of the parents
Proximity to emergency services
Number of children in the home D)
Age of children in the home
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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
Administer a placebo
Encourage increased fluid intake C)
Administer the prescribed analgesia
D) Recommend relaxation exercises for pain control
While caring for a toddler with croup, which initial sign of croup requires the
nurse's immediate attention?
Respiratory rate of 42
Lethargy for the past hour
Apical pulse of 54
Coughing up copious secretions
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
Heat intolerance
Diarrhea
Skin eruptions
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."
"Since this was the first convulsion, it may not happen again."
"Long term treatment will prevent future seizures."
Alcohol and drug abuse impairs judgment and increases risk taking behavior. What
nursing diagnosis best applies?
Risk for injury
Risk for knowledge deficit
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Altered thought process
Disturbance in self-esteem
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?
Mouth
Nasal
passagesBack
of throat
Bronchials
The nurse is providing instructions for a client with pneumonia. What is the most
important information to convey to the client?
"Take at least 2 weeks off from work."
"You will need another chest x-ray in 6 weeks."
"Take your temperature every day."
"Complete all of the antibiotic even if your findings decrease."
When counseling a 6 year old who is experiencing enuresis, what must the nurse
understand about the pathophysiological basis of this disorder?
Has no clear etiology
May be associated with sleep phobia
Has a definite genetic link
Is a sign of willful misbehavior
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?
Reprimand the child and give a 15 minute "time out"
Maintain a permissive attitude for this behavior
Use patience and a sense of humor to deal with this behavior
Assert authority over the child through limit setting
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?
Chewable aspirin is the preferred analgesic
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Topical cortisone ointment relieves itching
Papules, vesicles, and crusts will be present at one timeThe
illness is only contagious prior to lesion eruption
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?
Take the client's vital signs
Place the client in a sitting position with legs dangling
Contact the health care provider
Administer the PRN anti-anxiety agent
The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct
the parents to
Dress the child warmly to avoid chilling
Keep the child away from other children for the duration of the rashClean
the affected areas with tepid water and detergent
Wrap the child's hand in mittens or socks to prevent scratching
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 recovering person has to be very careful not to lose control, therefore, confine yourdrinking
just at family gatherings."
"At your next AA meeting discuss the possibility of limited drinking with your
sponsor."
"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."
In taking the history of a pregnant woman, which of the following would the
nurse recognize as the primary contraindication for breast feeding?
Age 40 years
Lactose intolerance
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Family history of breast cancer
D) Uses cocaine on weekends
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?
Potassium
Arterial blood gasses
Blood urea nitrogen D)
Thiocyanate
A victim of domestic violence tells the batterer she needs a little time away.
How would the nurse expect that the batterer might respond?
With acceptance and views the victim’s comment as an indication that their marriage isin
trouble
With fear of rejection causing increased rage toward the victim
With a new commitment to seek counseling to assist with their marital problems
With relief, and welcomes the separation as a means to have some personal time
A postpartum mother is unwilling to allow the father to participate in the newborn'scare,
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?
Discuss with the mother sharing parenting responsibilities
Set time aside to get the mother to express her feelings and concernsArrange
for the parents to attend infant care classes
Talk with the father and help him accept the wife's decision
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
Perform exercise after respiratory therapy enhances appetite
Cleanse the mouth of dried secretions reduces risk of infection
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Which of these parents’ comment for a newborn would most likely reveal an initial
finding of a suspected pyloric stenosis?
I noticed a little lump a little above the belly button.
The baby seems hungry all the time.
Mild vomiting that progressed to vomiting shooting across the room.Irritation
and spitting up immediately after feedings.
The nurse is assessing a child for clinical manifestations of iron deficiency anemia.
Which factor would the nurse recognize as cause for the findings?
A) Decreased cardiac output
B) Tissue hypoxia
Cerebral edema
Reduced oxygen saturation
The nurse would expect the cystic fibrosis client to receive supplemental pancreatic
enzymes along with a diet
High in carbohydrates and proteins
Low in carbohydrates and proteins
High in carbohydrates, low in proteins
Low in carbohydrates, high in proteins
In evaluating the growth of a 12 month-old child, which of these findings would the
nurse expect to be present in the infant?
Increased 10% in height
2 deciduous teeth
Tripled the birth weight
Head > chest circumference
A Hispanic client in the postpartum period refuses the hospital food because it
is "cold." The best initial action by the nurse is to
Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
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Ask the client what foods are acceptable or bad
Encourage her to eat for healing and strength
Schedule the dietitian to meet with the client as soon as possible
The father of an 8 month-old infant asks the nurse if his infant's vocalizations are
normal for his age. Which of the following would the nurse expect at this age?
Cooing
Imitation of sounds
Throaty sounds
Laughter
The nurse should recognize that physical dependence is accompanied by what
findings when alcohol consumption is first reduced or ended?
A) Seizures B)
Withdrawal
Craving
Marked tolerance
Immediately following an acute battering incident in a violent relationship, the
batterer may respond to the partner’s injuries by
Seeking medical help for the victim's injuries
Minimizing the episode and underestimating the victim’s injuries
Contacting a close friend and asking for help
Being very remorseful and assisting the victim with medical care
The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is
the best approach by the nurse?
"Do you want to take this pretty red
medicine?" "You will feel better if you take
your medicine."
"This is your medicine, and you must take it all right now."
"Would you like to take your medicine from a spoon or a cup?"
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In planning care for a child diagnosed with minimal change nephrotic syndrome, the
nurse should understand the relationship between edema formation and
A) Increased retention of albumin in the vascular system B)
Decreased colloidal osmotic pressure in the capillaries Fluid
shift from interstitial spaces into the vascular space
Reduced tubular reabsorption of sodium and water
An eighteen month-old has been brought to the emergency room with irritability,
lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of
these initial findings, the nurse would assess the child for additional findings of
A) Septicemia B)
Dehydration
Hypokalemia
Hypercalcemia
A client who has been drinking for five years states that he drinks when he gets upset
about "things" such as being unemployed or feeling like life is not leading anywhere. The
nurse understands that the client is using alcohol as a way to deal with
Recreational and social needs
Feelings of anger C)
Life’s stressors
D) Issues of guilt and disappointment
The nurse is monitoring the contractions of a woman in labor. A contraction is recordedas
beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15
A.M. What is the frequency of the
contractions? 14 minutes
10 minutes C)
15 minutes
D) Nine minutes
The nurse is performing an assessment on a child with severe airway obstruction.
Which finding would the nurse anticipate finding?
Retractions in the intercostal tissues of the thorax
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Chest pain aggravated by respiratory movement
Cyanosis and mottling of the skin
Rapid, shallow respirations
During the evaluation phase for a client, the nurse should focus on
A) All finding of physical and psychosocial stressors of the client and in the family B)
The client's status, progress toward goal achievement, and ongoing re-evaluation
Setting short and long-term goals to insure continuity of care from hospital to home
Select interventions that are measurable and achievable within selected timeframes
The school nurse suspects that a third grade child might have Attention Deficit
Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse
should
Observe the child's behavior on at least 2 occasions
Consult with the teacher about how to control impulsivity
Compile a history of behavior patterns and developmental accomplishments
Compare the child's behavior with classic signs and symptoms
Which of the actions suggested to the RN by the PN during a planning conference for a 10
month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add
to the plan of care?
Measure head circumference
Place in airborne isolation
Provide passive range of motion
Provide an over-the-crib protective top
A client is admitted with a diagnosis of hepatitis B. In reviewing the initial
laboratory results, the nurse would expect to find elevation in which of the following
values? Blood urea nitrogen
Acid phosphatase C)
Bilirubin
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D) Sedimentation rate
The nurse is discussing nutritional requirements with the parents of an 18 month-
old child. Which of these statements about milk consumption is correct?
May drink as much milk as desired
Can have milk mixed with other foods Will
benefit from fat-free cow's milk Should be
limited to 3-4 cups of milk daily
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
Neologisms
Dissociation
Flight of ideas
Word salad
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?
Jumping rope
Tying shoelaces C)
Riding a tricycle
D) Playing hopscotch
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 transparent film dressing
Wet dressing with debridement granules
Wet to dry with hydrogen peroxide D)
Moist saline dressing
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2022 HESI Child Care Exit Exam Version 2 With Answers (159 Solved Questions)

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