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1. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a

priority nursing diagnosis?

A) Nutrition

B) Elimination

C) Activity

D) Safety

The correct answer is D: Safety

2. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive

development at this age?

A) They are able to make simple association of ideas

B) They are able to think logically in organizing facts

C) Interpretation of events originate from their own perspective D) Conclusions are based on previous

experiences

The correct answer is B: Think logically in organizing facts

3. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the

nurse do first?

A) Clear the area of any hazards

B) Place the child on the side

C) Restrain the child

D) Give the prescribed anticonvulsant

The correct answer is B: Place the child on the side

4. The nurse isreviewing a depressed client's history from an earlier admission.

Documentation of anhedonia is noted. The nurse understands that thisfinding refersto

A) Reports of difficulty falling and staying asleep

B) Expression of persistent suicidal thoughts

2020 HESI RN EXIT V3 FULL 160 ANSWERS

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C) Lack of enjoyment in usual pleasures

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D) Reduced senses of taste and smell

The correct answer is C: Lack of enjoyment in usual pleasures

5. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing

the client, the first nursing action would be to

A) Administer pain medication

B) Suction excessive tracheobronchial secretions

C) Assist client to turn, deep breathe and cough

D) Monitor oxygen saturation

The correct answer is B: Suction excessive tracheobronchial secretions

6. While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough

health history and physical exam. Which finding is most significant for this client?

A) Compulsive behavior

B) Sense of impending doom

C) Fear of flying

D) Predictable episodes

The correct answer is B: Sense of impending doom

7. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the

hospital room for the first time, the toddler runsto the mother, clings to her and beginsto cry. What would be

the initial action by the nurse?

A) Arrange to change client care assignments

B) Explain that this behavior is expected

C) Discuss the appropriate use of "time-out"

D) Explain that the child needs extra attention

The correct answer is B: Explain that this behavior is expected

8. A 15 year-old client with a lengthy confining illness is at risk for altered growth and development of which

task?

A) Loss of control

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B) Insecurity

C) Dependence

D) Lack of trust

The correct answer is C: Dependence

9. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized

children? A) Sports and games with rules

B) Finger paints and water play

C) "Dress-up" clothes and props

D) Chess and television programs

The correct answer is A: Sports and games with rules

10. The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate

statement for the nurse is A) "Eat a balanced diet for your age."

B) "Increase your intake of protein and Vitamin A."

C) "Decrease fatty foods from your diet."

D) "Do not use caffeine in any form, including chocolate."

The correct answer is A: "Eat a balanced diet for your age."

11. The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it

is determined that a person has AIDS other than a positive HIV test. The nurse responds

A) "The complaints of at least 3 common findings."

B) "The absence of any opportunistic infection."

C) "CD4 lymphocyte count isless than 200."

D) "Developmental delaysin children."

The correct answer is C: "CD4 lymphocyte count is less than 200."

12. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and

adenoidectomy. Which action by the nurse is appropriate?

A) Offer ice cream every 2 hours

B) Place the child in a supine position

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