Exit HESI

A client with Crohn's disease is recovering from a bowel resection. The nurse realizes which of the following may occur?

2. The patient will possibly have a recurrence in another portion of the bowel.

A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next?

Touch the pin on the same area of the left hand.

A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best?

a. "Because eye pressure was too high, the tissue died."

The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction?

b. "Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle."

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

b. Darting eyes, tilted head, mumbling to self

The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority?

b. Notify the health care provider immediately

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take?

b. Turn the client's head to the side.

A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which of the following clinical manifestations associated with this disorder would the nurse expect to be documented in the client's record?

c) painless progressive loss of vision

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?

c. A 45-year-old American Indian woman with diabetes mellitus

What is a nurse's legal responsibility if child abuse or neglect is suspected?

c. Report the suspicion according to state regulations.

Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective?

a. "Converses with few interruptions; clothing matches; participates in activities."

A client is taking warfarin (Coumadin) and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best?

a. "No, it may interfere with the warfarin."

The nurse planning to assess the structure of a family. Which question should the nurse ask?

a. "Who lives with you in this home?"

A client has a foreign body in the eye. What action by the nurse takes priority?

a. Administering ordered antibiotics

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)

a. Have suction equipment at the bedside. d. Keep bed rails up at all times. f. Ensure that the client has IV access.

A patient diagnosed with borderline personality disorder is hospitalized several times after self-inflicted lacerations. The patient remains impulsive. Which nursing diagnosis is the focus of this therapy?

a. Risk for self-directed violence

The nurse is caring for a client preparing to have a laparascopic cholecystectomy in the morning. Which statement by the client indicates a need for further teaching?

3. "I am glad I won't need to have an open cholecystectomy."

A nurse is assessing a client with suspected cholecystitis. Where would the nurse expect the client's pain to be located?

4. Right upper quadrant, radiating to the right scapula and shoulder

A priority nursing intervention for a patient diagnosed with major depressive disorder is:

B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock.

The nurse is providing discharge teaching for a client who has peptic ulcer disease caused by Helicobacter pylori infection. Which statement by the client indicates that additional teaching is needed?

D. I will take my medication every day until my heartburn is gone

After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?

d. "If I am nauseated, I will not take my epilepsy medication."

A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond?

d. "You should have a colonoscopy more frequently to identify abnormal polyps early."

A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, "I feel like a failure. This baby is the root of my problems." The priority nursing diagnosis is:

d. Risk for other-directed violence

Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will:

d. gain 1 to 2 pounds.