HESI E2 HESI Exit Exam - Set 2 - Part 3

Correct Answer: Lead hazard education and grants

Primary prevention acts before disease occurs by removing the hazard. Educating families about lead sources and linking landlords and homeowners to remediation funding addresses the environmental cause that screening and treatment cannot prevent. Option a is incorrect because routine blood lead screening at 12 and 24 months is secondary prevention. It identifies disease already present in asymptomatic children rather than preventing the initial exposure that primary prevention targets. Option b is incorrect because chelation is tertiary prevention used after toxicity has occurred. It limits damage from existing poisoning but does nothing to keep additional children from being exposed in the same housing stock. Option c is incorrect because cognitive testing is tertiary surveillance for sequelae of established exposure. While important for long-term care, it does not prevent the initial poisoning that the community intervention should aim to eliminate.

Correct Answer: Ask the client what she prefers

Federal law requires offering qualified interpretation, but the client decides who interprets. Asking honors autonomy and confidentiality, while still ensuring she understands that a qualified ASL interpreter is available at no charge if desired. Option a is incorrect because defaulting to the spouse without asking deprives the client of a federally protected choice. Even well-meaning family interpreters may filter, censor, or distort medical information when sensitive topics arise during the encounter. Option b is incorrect because requiring a qualified interpreter over the client's stated preference overrides autonomy. Federal rules guarantee access to qualified interpretation; they do not strip the client's right to refuse it. Option d is incorrect because written notes are inappropriate for clients whose primary language is ASL, since written English may not match their linguistic strengths. Notes also slow communication and risk significant misunderstandings during care.

Correct Answer: Displacement onto a safer target

Displacement redirects emotions from the threatening source onto a less threatening target. The husband cannot direct anger at the cancer itself, so he aims it at his wife's behavior. Recognizing this allows the nurse to support him without becoming defensive. Option a is incorrect because sublimation channels unacceptable impulses into socially constructive activity, such as painting through grief. The husband is venting hostility rather than channeling it into productive or creative work right now. Option b is incorrect because reaction formation requires acting opposite to true feelings, such as being overly affectionate toward someone you dislike. The husband is expressing anger openly, not masking love with hostility or vice versa here. Option c is incorrect because projection attributes one's own unacceptable feelings to someone else, like a cheating spouse accusing the partner of infidelity. The husband is not assigning his own emotions to his wife; he is misdirecting

Correct Answer: Remove and secure risky items

Standard psychiatric admission protocol requires removing belts, shoelaces, drawstrings, and other potential ligature items before the client enters the unit. These items pose immediate environmental risk and are stored for return at discharge. Option a is incorrect because allowing ligature-risk items violates basic environmental safety standards on a psychiatric unit. Personal property rights yield to documented suicide precautions until the client is reassessed and risk has changed substantially. Option b is incorrect because documentation alone does not address the immediate hazard. Charting that the client wore a belt while leaving the belt accessible would represent negligence if the client used it to attempt self-harm. Option d is incorrect because verbal screening does not substitute for environmental risk reduction. The nurse must remove access to lethal means whether or not the client volunteers an intention to use them at the moment of admission.

Correct Answer: "Common reaction; give acetaminophen and compresses."

Soreness, redness, and low-grade fever within 24 to 48 hours after immunizations are expected, self-limited reactions. Comfort measures such as weight-based acetaminophen and cool compresses address the symptoms without halting routine vaccination. Option b is incorrect because low-grade fever and local soreness do not meet criteria for serious adverse events. Halting all future vaccinations leaves the infant unprotected against potentially deadly diseases that the schedule is designed to prevent. Option c is incorrect because ED evaluation is reserved for severe reactions such as anaphylaxis, persistent high fever, or seizures. Routing every routine vaccine reaction to the ED overwhelms resources and frightens parents unnecessarily. Option d is incorrect because delaying a response for two weeks ignores the parent's reasonable concern in the moment. Reassurance and same-day comfort measures both reassure the family and reduce unnecessary follow-up appointments at the clinic.

Correct Answer: Monitor for re-sedation and re-dose

Naloxone's duration is 30 to 90 minutes, shorter than most opioids, so re-sedation is expected. Continuous monitoring with repeat naloxone doses as needed prevents recurrent respiratory depression until the opioid metabolizes completely. Option a is incorrect because discharging after a single naloxone dose risks fatal re-sedation outside of clinical observation. Standard practice mandates extended monitoring, often 4 to 6 hours minimum and longer for long-acting opioids. Option b is incorrect because administering more opioids after a reversal is dangerous and clinically contradictory. The client just experienced opioid-induced respiratory depression, and additional opioid would re-trigger the very emergency naloxone reversed. Option d is incorrect because oral antidotes are not part of opioid overdose management. Naloxone is given by IV, IM, or intranasal routes, and an imaginary oral antidote schedule would delay or replace the actual treatment with an ineffective plan.

Correct Answer: Suggestive of depression; refer for evaluation

A GDS-15 score of 5 or greater suggests depression and warrants further evaluation. Combined with recent bereavement and decreased pleasure, the nurse refers for clinical workup including suicide screening, medication review, and treatment planning. Option a is incorrect because a score of 9 exceeds the GDS-15 threshold and cannot be dismissed as normal. Sending the client home without further evaluation misses an opportunity to intervene at a vulnerable transition point in her life. Option c is incorrect because the GDS-15 screens for depression rather than diagnosing it. Inpatient hospitalization requires acute safety concerns such as active suicidal ideation, not simply an elevated screen score in an outpatient setting today. Option d is incorrect because the GDS-15 does not assess cognition. A Mini-Cog or MoCA would screen for cognitive impairment, while imaging is reserved for confirmed cognitive decline with specific clinical features warranting structural evaluation.

Correct Answer: "You will sleep then wake scratchy."

Preschoolers benefit from concrete, honest language without scary words like "cut" or "shot." Comparing the postop sensation to a familiar scratchy feeling helps the child anticipate without overwhelming preoperative anxiety about body mutilation. Option a is incorrect because words like "cut out lumps" trigger preschoolers' intense fear of body mutilation. Using clinical or violent vocabulary undermines the trust the nurse needs and frequently worsens preoperative behavioral distress. Option b is incorrect because abstract terms like "postoperative discomfort" exceed the cognitive level of a 5-year-old. Preschoolers think concretely and need familiar reference points rather than medical terminology to make sense of the experience. Option c is incorrect because saying "special air" without further explanation can frighten a literal thinker who imagines a strange substance. The statement also omits the postop sensation, leaving the

Correct Answer: About 1 minute per year of age

The standard pediatric guideline is approximately one minute per year of age, so 18 months supports a brief one to two minute pause. This length matches toddler attention span and avoids prolonged isolation that fails to teach the desired behavior. Option b is incorrect because 10 minutes far exceeds a toddler's attention span and developmental capacity to connect the consequence with the behavior. Long isolation feels punitive and damages the secure attachment that underlies behavior change. Option c is incorrect because 30 minutes is developmentally inappropriate and may be considered abusive isolation at this age. Time-out aims to interrupt the behavior briefly, not to inflict prolonged emotional distress on the toddler. Option d is incorrect because verbal apology is beyond the typical expressive language of an 18-month-old. Requiring verbal repair sets an impossible standard that prolongs separation and confuses the toddler about how to end the time-out.

Correct Answer: Use grounding by naming objects

Grounding brings the client out of the flashback by anchoring attention in the present sensory environment. Naming five visible objects, feeling textures, and orienting to date and place rapidly reduces dissociation without medication or coercion. Option a is incorrect because restraints inflict secondary trauma on PTSD survivors and may intensify the dissociative experience. The intervention is reserved for imminent harm to self or others, not for acute psychological symptoms responsive to verbal techniques. Option b is incorrect because benzodiazepines are not first-line for PTSD and may worsen dissociation over time. Evidence supports SSRIs, prazosin for nightmares, and trauma-focused psychotherapy rather than acute IM sedation for a flashback. Option c is incorrect because asking the client to describe trauma in detail during a flashback intensifies the very symptoms the nurse is trying to relieve. Detailed trauma processing belongs in structured therapy under specialized clinician