HESI COMPREHENSIVE EXAM 3 QUESTION AND ANSWERS 2024/2025 UPDATED
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HESI
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HESI
HESI COMPREHENSIVE EXAM 3 QUESTION AND ANSWERS 2024/2025 UPDATED
A primiparous client has been in labor for 15 hours. Two hours ago, vaginal examination revealed the cervix dilated to 5 cm, 100% effaced, and the presenting part at station 0. Five minutes ago, the vaginal examination reveals no ...
HESI COMPREHENSIVE EXAM 3 QUESTION
AND ANSWERS 2024/2025 UPDATED
A primiparous client has been in labor for 15 hours. Two hours ago, vaginal
examination revealed the cervix dilated to 5 cm, 100% effaced, and the presenting
part at station 0. Five minutes ago, the vaginal examination reveals no change in
the cervix or decent of the fetus. Which labor pattern should the nurse document
to describe the client' s progress?
a. Protracted descent.
b. Arrest of active phase.
c. Prolonged latent phase.
d. Protracted active phase
b. Arrest of active phase.
Arrest of active phase is indicated if there is no change in the dilation of the cervix for 2
hours or more in a primigravida. Prolonged latent phase is labor lasting longer than 20
hours in a primigravida. Protracted active phase occurs when dilatation of the cervix is
less than 1.2 cm/hour. Protracted descent occurs when the fetus decends less than 1
cm/hour into the pelvis.
What assessment finding should the nurse identify in a client with fluid volume
excess?
a. Flushed skin.
b. Elevated blood pressure.
c. Weak, thready pulse.
d. Dry mucous membranes.
b. Elevated blood pressure.
Blood pressure is the product of heart rate, stroke volume, and peripheral resistance, so
an elevated blood pressure occurs as fluid volume increases.
In reviewing the medical record, the nurse notes that a client' s last eye
examination revealed an intraocular pressure (IOP) of 28 mmHg. What
information should the nurse ask the client?
a. Length of time the client has been wearing prescription lenses.
b. Recent experience of seeing light flashes or floaters.
c. Complaints of any blind spots in the client's field of vision.
d. Use of prescribed eye drops since last exam by ophthalmologist.
d. Use of prescribed eye drops since last exam by ophthalmologist.
Normal intraocular pressures range between 10 and 21 mmHg, so the client's use of
any prescribed eye drops should be determined to evaluate the client's intraocular
pressure.
A 50-year-old male client with amyotropic lateral sclerosis (ALS) is becoming
increasingly debilitated and tells the nurse, "Since I haven't been able to go to
church, I feel out of touch with God. I pray, but I wonder whether my prayers are
,heard." Which nursing diagnosis should the nurse include in the client' s plan of
care?
a. Death anxiety.
b. Powerlessness.
c. Spiritual distress.
d. Disturbed thought processes.
c. Spiritual distress.
Based on the client's verbalized concern about his relationship with God and the
inability to participate in religious services are defining characteristics for the nursing
diagnosis of spiritual distress. Although the client may be experiencing death anxiety
and powerlessness about his clinical diagnosis and prognosis, the client's spiritual
coping strategies are compromised.
To avoid a false positive result for fecal occult blood in a stool specimen, the
nurse should instruct the client to avoid ingestion of which substances prior to
collecting a sample? (Select all that apply.)
a. Fish.
b. Beef.
c. Vitamin C tablets.
d. Turkey.
e. Ibuprofen (Advil).
f. Coffee.
a. Fish.
b. Beef.
c. Vitamin C tablets.
e. Ibuprofen (Advil).
The fecal occult blood test, or guaiac test, measures microscopic amounts of blood in
the feces. False positive results can occur from food products such as fish, beef and
other red meats, green vegetables, vitamin C supplements, aspirin, and nonsteroidal
antiinflammatory medications, including ibuprofen.
Which family-centered care concept(s) should the nurse encourage family
members to use to promote child growth, development, and independence?
a. Tough love.
b. Therapeutic care.
c. Enabling and empowerment.
d. Teaching and care provision.
c. Enabling and empowerment.
Family-centered care includes enabling and empowering the child with opportunities
that build on identified strengths, enhance self-efficacy, and promote growth within the
collaborative family unit.
An older client who is admitted with terminal cancer of the liver begins to talk
with the nurse about spiritual life after death. Which response by the nurse best
assesses the client's spiritual needs?
a. "What do you believe happens to your spirit when you die?"
,b. "Has your terminal condition made you lose your faith or beliefs?"
c. "Members of your church are allowed to visit you whenever you desire."
d. "I notice you have a Bible. Is that a source of spiritual strength for you?"
d. "I notice you have a Bible. Is that a source of spiritual strength for you?"
Assessing a client's source of strength and faith can direct interaction and treatment
plans, so making an observation about the client's Bible identifies the client's spiritual
basis and opens communication regarding the client's source of strength. Questioning
the client's beliefs does not provide information that assists in meeting the client's
spiritual needs.
Which entry in the client' s medical record provides the best documentation of
client care?
a. 1230 - Client's vital signs taken.
b. 0700 - Client drank adequate amount of fluids.
c. 0900 - Meperidine (Demerol) given for lower abdominal pain.
d. 0830 - IV fluid rate increased to 100 ml/hour according to protocol.
d. 0830 - IV fluid rate increased to 100 ml/hour according to protocol.
A recorded entry in the medical record should include client-centered interventions that
include thorough, yet succinct, specific information. provides the most specific data and
includes time, action, and rationale for implementation.
A mother brings her 4-year-old boy to the clinic because he spends his day in
constant motion, talks excessively, and is easily distracted from playing with his
toys. His preschool teacher is unable to keep him focused in the classroom and
suggested he undergo a mental health evaluation. Which nursing diagnosis
should the nurse formulate?
a. Risk for Injury.
b. Compromised Family Coping.
c. Impaired Social Interaction.
d. Deficient Knowledge.
c. Impaired Social Interaction.
Attention-deficit hyperactivity disorder (ADHD) is a behavioral disorder of children with
significant problems in attention and concentration, impulse control, and overactivity.
The nursing diagnosis, "Impaired Social Interaction" addresses the child's
hyperverbalism, shortened attention span, and increased need for mobility that created
his classroom difficulties.
A mother asks the nurse to explain how using "time-out" to discipline her 2-year-
old child is an effective method. Which rationale should the nurse provide?
a. Offers positive reinforcement.
b. Provides a consequence to behavior.
c. Extinguishes the behavior by ignoring it.
d. Removes a reinforcer that a child is receiving.
d. Removes a reinforcer that a child is receiving.
Time-out is a disciplinary approach that removes a reinforcer, such as the satisfaction or
, attention the child receives from a behavior or activity. When placed in an unstimulating
and isolated place, the child becomes bored and consequently agrees to behave in
order to reenter the family group.
A male client tells the nurse that he is frequently constipated. Which finding
should the nurse identify as a common dietary cause of constipation?
a. Megacolon or Hirschsprung's disease.
b. Inadequate intake of dietary fiber and fluids.
c. Chronic intake of excessive amounts of caffeine.
d. Inadequate intake of fruit and vegetable juices.
b. Inadequate intake of dietary fiber and fluids.
Functional causes of constipation include failure to respond to the urge to defecate, lack
of fiber and fluids prolonged bed rest or lack of regular exercise, and habitual use of
laxatives or enemas. The colon becomes atonic when these conditions are prolonged or
not treated. Megacolon or Hirschsprung's disease occurs when constipation becomes
severe, as feces accumulate in the colon, causing its diameter to extend, ultimately
leading to loss of defecation reflexes and peristalic mobility. Chronic and heavy use of
caffeine may cause diarrhea. Fruit and vegetable juices have minimal fiber compared to
fresh, raw fruits and uncooked vegetables.
The nurse is teaching a client who is newly diagnosed with Type 1 diabetes
mellitus about diet and insulin. The client should be instructed to perform
glucose self-monitoring when which symptom occurs after exercising?
a. Shakiness.
b. Unusual thirst.
c. Sudden anorexia.
d. Excessive urination.
a. Shakiness.
The primary response to acute exercise is an increase in glucose utilization, so the
client should recognize shakiness as an early sign of hypoglycemia. Excessive urination
(polyuria) and unusual thirst (polydipsia) are manifestations of hyperglycemia related to
excess dietary intake or stressors, such as infection. Anorexia may be experienced with
hyperglycemia, but serum glucose should be evaluated if the client demonstrates signs
of hypoglycemia, which is more likely after exercising.
The nurse is supervising an unlicensed assistive personnel (UAP) who is feeding
an older client with dysphagia. Which action by the UAP requires the nurse ' s
intervention?
a. Thickens the broth and juice on the client's tray.
b. Assists the client from the bed to a chair for the meal.
c. Divides solid food items into one inch cube pieces.
d. Keeps the client upright for 60 minutes after eating.
c. Divides solid food items into one inch cube pieces.
Solid food should be smaller to minimize the risk of food becoming lodged in the
oropharynx or aspirated. Thickened liquids, sitting the client upright for 45 to 60 minutes
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