Hesi Exit Cat Exam 3, Answered-An adult client being admitted to the psychiatric unit with a diagnosis of bipolar disorder arrives in an elated state. What is the best room assignment the nurse can make for this client?
- A quiet room away from the nurse's station.
The community mental health ...
Hesi Exit Cat Exam 3, Answered
An adult client being admitted to the psychiatric unit with a diagnosis of bipolar disorder
arrives in an elated state. What is the best room assignment the nurse can make for this
client?
- A quiet room away from the nurse's station.
The community mental health nurse is planning to visit four clients with schizophrenia.
Which client should the nurse see first?
- A mother who took her children from school because aliens were after them.
A female client, the mother of two small children, appears depressed after learning from
her healthcare provider that she has multiple sclerosis. Which nursing intervention should
the nurse implement first?
- Sit quietly with the client and answer questions she may ask.
Which statement by a client with emphysema indicates the best understanding of the
purpose of pulmonary function testing?
- "It will measure how well my lungs are working."
An adolescent male client is admitted to the hospital. Based on Erikson's theory of
psychosocial development, which nursing intervention best assists this adolescent's
adjustment to his hospital stay?
- Invite him to participate in the evening group activity.
Which individual may legally sign an informed consent?
- A 16-year-old mother for her newborn.
The nurse working on a psychiatric unit is concerned about providing ethical and legally
defensible care for clients on the unit. Which occurrence is an indication that a client's
civil rights are being violated?
- refused to take an oral psychiatric medication is administered the same medication as an
IM injection.
Which statement by the mother of a toddler girl indicates to the nurse that scheduled
vaccine should not be administered?
- "Her throat closed up so bad she couldn't breathe the last time she got this shot."
Thirty-six hours after delivery, the nurse assesses a client's fundus just above the
umbilicus and displaced to the right of the midline. What actions should the nurse take
first?
,- Palpate the bladder for distention.
10. A hospitalized 81-year-old female client has numerous complaints and uses her call
button often to summon staff to help her with activities that she is capable of performing
for herself. Which plan might be most beneficial in dealing with this client?
- Check on the client at designated time intervals and let the client know when the nurse
will return.
11. When giving a cooling bath to reduce the fever of a 3-year-old child, which action
should the nurse include?
- Pour tepid water over the child's back and chest.
The nurse determines that a client has a potential (high risk) problem. What is important
for the nurse to do when planning care?
- Direct nursing actions toward reducing risk factors.
The nurse notes that the influenza immunization rates are much lower for certain
demographic groups than for others. Which intervention is likely to be most useful in
increasing the rates of immunization in these lower immunization groups?
- Designated clinics conveniently located in target neighborhoods.
The first time a male client stands at the bedside following a total hip replacement, he
reports severe pain in his left calf. What intervention should the nurse take first?
- Return the client to bed and assess the lower extremities.
A client is receiving an IV of 5% dextrose in Lactated Ringer's solution at a rate of 100
ml/hour. The client tells the nurse, "I don't need to eat because I'm getting all the nutrition
I need through this IV needle." What initial response would be best for the nurse to
provide this client?
- "Only a very small amount of the calories you need are provided by your IV."
The nurse documents that a male client with paranoid schizophrenia is delusional. Which
statement by the client confirms this assessment?
- "The nurse at night is trying to poison me with pills."
A male client returns to the acute care unit following surgery with sequential
compression devices in place. The nurse observes that the client dorsiflexes his feet
frequently. What action should the nurse implement?
- Encourage the client to perform foot exercises regularly while his mobility is limited.
18. Which statement by a 16-year-old male client with acute osteomyelitis in his leg
indicates the best understanding of the appropriate activity level for his disorder?
, - "During this illness, I need to keep my leg as immobile as possible."
The nurse has conducted a cancer prevention community education program. In
evaluating the participant's understanding of the carcinogens, what statement indicates an
accurate understanding?
- Substances that change a cell so that it becomes cancerous are potential cause of cancer
20. A 25-year-old female client is diagnosed with endometriosis by her healthcare
provider. Which nursing diagnosis has the highest priority?
- Pain related to extrauterine tissue inflammation.
The charge nurse is supervising a newly licensed practical nurse (PN) who is
administering medications. The PN notes that a client with exophthalmus is scheduled to
receive artificial tear drops. What action should the charge nurse implement?
- Remind the PN to evaluate the effectiveness of the medication after administration.
The charge nurse is assessing the morning lab work on four clients. Which client's
laboratory findings should prompts the charge nurse to contact the healthcare provider
immediately?
- c. A 29-year-old diagnosed with ulcerative colitis having a serum potassium level of 3.1
mEq/L.
When assessing a client with Raynaud's disease, which symptoms should the nurse
expect the client to exhibit?
- Coldness, pain and pallor of fingertips, toes, and tip of nose.
A client is currently receiving an infusion of 25,000 units of Heparin in 500ml of normal
saline at 10 ml/hour. A prescription is received to change the rate of the infusion to 700
units of Heparin per hour. The nurse should set the infusion pump to deliver how many
ml/hour? (Enter numeric value only.)
- Answer: 14
An elderly client is suspected of having a cardiac dysrhythmia. The nurse knows that it is
most important to obtain which information when assessing this client?
- Changes in mentation, personality, and behavior.
A client has developed drug toxicity after receiving a high dose of a medication with a
prolonged half-life. After consulting with the health care provider, the nurse expects to
administer which treatment plan?
- Several dose of antagonistic medication with a short half life administered at frequent
time intervals.
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