HESI Comprehensive Review for the NCLEX-RN® Examination | Mock Test & Study Guide
HESI Comprehensive Review for the
NCLEX-RN® Examination | Mock
Test & Study Guide
,HESI Comprehensive Review for the NCLEX-RN® Examination | Mock Test & Study Guide
SECTION A
1. The nurse is performing a neurological assessment on a client and notes a
positive Romberg's test. The nurse makes this determination based on which
observation?
1. An involuntary rhythmic, rapid, twitching of the eyeballs
2. A dorsiflexion of the great toe with fanning of the other toes
3. A significant sway when the client stands erect with feet together, arms at the side, and the
eyes closed
4. A lack of normal sense of position when the client is unable to return extended fingers to a
point of reference: Correct: 3
Rationale: In Romberg's test, the client is asked to stand with the feet together and the arms
at the sides, and to close the eyes and hold the position; normally the client can maintain
posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found
when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar
ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position
coupled with an inability to return extended fingers to a point of reference is a finding that
indicates a problem with coordination. A positive gaze nystagmus evaluation results in an
involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in
dorsiflexion of the great toe with fanning of the other toes; if this occurs in anyone older than
2 years it indicates the presence of central nervous system disease.
2. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations.
On assessment of the client, the nurse should expect to note which finding?
1. Rhythmic respirations with periods of apnea
2. Regular rapid and deep, sustained respirations
,HESI Comprehensive Review for the NCLEX-RN® Examination | Mock Test & Study Guide
3. Totally irregular respiration in rhythm and depth
4. Irregular respirations with pauses at the end of inspiration and expiration-
: Correct: 1
Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and
can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic
hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a
dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in
rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are
irregular respirations with pauses at the end of inspiration and expiration and can indicate a
dysfunction in the middle or caudal pons.
3. A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the
hearing problem. The nurse plans to explain to the client that this condition is caused by
which problem?
1.A defect in the cochlea
2.A defect in cranial nerve VIII
3.A physical obstruction to the transmission of sound waves
4. A defect in the sensory fibers that lead to the cerebral cortex: Correct: 3
Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the
transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological
process in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that
lead to the cerebral cortex.
4. While performing a cardiac assessment on a client with an incompetent heart valve, the
nurse auscultates a murmur. The nurse documents the finding and describes the sound as
which?
1. Lub-dub sounds
2. Scratchy, leathery heart noise
,HESI Comprehensive Review for the NCLEX-RN® Examination | Mock Test & Study Guide
3. A blowing or swooshing noise
4. Abrupt, high-pitched snapping noise: Correct: 3
Rationale: A heart murmur is an abnormal heart sound and is described as a faint or loud
blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are normal and
represent the S1 (first) heart sound and S2 (second) heart sound, respectively. A pericardial
friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt,
high-pitched snapping sound
5. The nurse is testing the extraocular movements in a client to assess for muscle weakness
in the eyes. The nurse should implement which assessment technique to assess for muscle
weakness in the eye?
1. Test the corneal reflexes.
2. Test the 6 cardinal positions of gaze.
3. Test visual acuity, using a Snellen eye chart.
4. Test sensory function by asking the client to close the eyes and then lightly touching the
forehead, cheeks, and chin.: Correct: 2
Rationale: Testing the 6 cardinal positions of gaze (diagnostic positions test) is done to assess
for muscle weakness in the eyes. The client is asked to hold the head steady, and then to
follow movement of an object through the positions of gaze. The client should follow the object
in a parallel manner with the 2 eyes. A Snellen eye chart assesses visual acuity and cranial
nerve II (optic). Testing sensory function by having the client close his or her eyes and then
lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V
(trigeminal).
6. The nurse is instructing a client how to perform a testicular self-examination
(TSE). The nurse should explain that which is the best time to perform this exam?
1. After a shower or bath
2. While standing to void
3. After having a bowel movement
HESI Comprehensive Review for the
NCLEX-RN® Examination | Mock
Test & Study Guide
,HESI Comprehensive Review for the NCLEX-RN® Examination | Mock Test & Study Guide
SECTION A
1. The nurse is performing a neurological assessment on a client and notes a
positive Romberg's test. The nurse makes this determination based on which
observation?
1. An involuntary rhythmic, rapid, twitching of the eyeballs
2. A dorsiflexion of the great toe with fanning of the other toes
3. A significant sway when the client stands erect with feet together, arms at the side, and the
eyes closed
4. A lack of normal sense of position when the client is unable to return extended fingers to a
point of reference: Correct: 3
Rationale: In Romberg's test, the client is asked to stand with the feet together and the arms
at the sides, and to close the eyes and hold the position; normally the client can maintain
posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found
when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar
ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position
coupled with an inability to return extended fingers to a point of reference is a finding that
indicates a problem with coordination. A positive gaze nystagmus evaluation results in an
involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in
dorsiflexion of the great toe with fanning of the other toes; if this occurs in anyone older than
2 years it indicates the presence of central nervous system disease.
2. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations.
On assessment of the client, the nurse should expect to note which finding?
1. Rhythmic respirations with periods of apnea
2. Regular rapid and deep, sustained respirations
,HESI Comprehensive Review for the NCLEX-RN® Examination | Mock Test & Study Guide
3. Totally irregular respiration in rhythm and depth
4. Irregular respirations with pauses at the end of inspiration and expiration-
: Correct: 1
Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and
can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic
hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a
dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in
rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are
irregular respirations with pauses at the end of inspiration and expiration and can indicate a
dysfunction in the middle or caudal pons.
3. A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the
hearing problem. The nurse plans to explain to the client that this condition is caused by
which problem?
1.A defect in the cochlea
2.A defect in cranial nerve VIII
3.A physical obstruction to the transmission of sound waves
4. A defect in the sensory fibers that lead to the cerebral cortex: Correct: 3
Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the
transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological
process in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that
lead to the cerebral cortex.
4. While performing a cardiac assessment on a client with an incompetent heart valve, the
nurse auscultates a murmur. The nurse documents the finding and describes the sound as
which?
1. Lub-dub sounds
2. Scratchy, leathery heart noise
,HESI Comprehensive Review for the NCLEX-RN® Examination | Mock Test & Study Guide
3. A blowing or swooshing noise
4. Abrupt, high-pitched snapping noise: Correct: 3
Rationale: A heart murmur is an abnormal heart sound and is described as a faint or loud
blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are normal and
represent the S1 (first) heart sound and S2 (second) heart sound, respectively. A pericardial
friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt,
high-pitched snapping sound
5. The nurse is testing the extraocular movements in a client to assess for muscle weakness
in the eyes. The nurse should implement which assessment technique to assess for muscle
weakness in the eye?
1. Test the corneal reflexes.
2. Test the 6 cardinal positions of gaze.
3. Test visual acuity, using a Snellen eye chart.
4. Test sensory function by asking the client to close the eyes and then lightly touching the
forehead, cheeks, and chin.: Correct: 2
Rationale: Testing the 6 cardinal positions of gaze (diagnostic positions test) is done to assess
for muscle weakness in the eyes. The client is asked to hold the head steady, and then to
follow movement of an object through the positions of gaze. The client should follow the object
in a parallel manner with the 2 eyes. A Snellen eye chart assesses visual acuity and cranial
nerve II (optic). Testing sensory function by having the client close his or her eyes and then
lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V
(trigeminal).
6. The nurse is instructing a client how to perform a testicular self-examination
(TSE). The nurse should explain that which is the best time to perform this exam?
1. After a shower or bath
2. While standing to void
3. After having a bowel movement
