HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_j9fhe6
1. The nurse is monitoring neurologi- D
cal vital signs for a male client who
lost consciousness after falling and (Neurological vital signs include serial assessments
hitting his head. Which assessment of TPR, blood pressure, and components of the Glas-
finding is the earliest and most sen- gow coma scale (GCS), which includes verbal, mus-
sitive indication of altered cerebral culoskeletal, and pupillary responses. A change in
function? the client's level of consciousness, as indicated by
a. Unequal pupils. responses to commands during the GCS, is the first
b. Loss of central reflexes. and the most sensitive sign of change in cerebral
c. Inability to open the eyes. function. The other assessment data choices are late
d. Change in level of consciousness. signs of altered cerebral function.)
2. A nurse is planning to teach D
self-care measures to a female client
about prevention of yeast infections. (A common genital tract infection in females is can-
Which instructions should the nurse didiasis, which is an overgrowth of the normal vaginal
provide? flora of Candida albicans that thrives in an environ-
a. Use a douche preparation no ment that is warm and moist and is perpetuated by
more than once a month. tight-fitting clothing, underwear, or pantyhose made
b. Increase daily intake of fiber and of nonabsorbent materials. The client should wear
leafy green vegetables. clothing that is loose fitting and absorbent, such as
c. Select nylon underwear that is cotton underwear, and avoid using bubble-bath or
loose-fitting, white, and comfort- bath salts which further irritate sensitive genital tis-
able. sue. Douching is not recommended because it can
d. Avoid tight-fitting clothing and do irritate vaginal tissue, alter pH, and contribute to
not use bubble-bath or bath salts. fungal growth. While increasing dietary fiber intake
encourages healthy, nutritional guidelines, it is not
the focus of the teaching. Cotton, not nylon under-
garments, provide absorbancy and reduce moisture
in the perineal area.)
3.
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_j9fhe6
A client who has active tuberculosis D
(TB) is admitted to the medical unit.
What action is most important for (Active tuberculosis requires implementation of air-
the nurse to implement? borne precautions, so the client should be assigned
to a negative pressure air-flow room. Although isola-
a. Place an isolation cart in the hall- tion gowns and isolation carts should be implement-
way. ed for clients in isolation with contact precautions,
b. Fit the client with a respirator it is most important that air flow from the room is
mask. minimized when the client has TB. The respirator
c. Don a clean gown for client care. mask should be implemented when the client leaves
d. Assign the client to a negative the isolation environment.)
air-flow room.
4. The nurse is planning to con- A
duct nutritional assessments and
diet teaching to clients at a family A pregnant woman's metabolic demands are 20 to
health clinic. Which individual has 24% more than the basic metabolic rate. The other
the greatest nutritional and energy clients require only 15 to 20% more than the basic
demands? metabolic rate.
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child.
5. What nursing delivery of care pro- B
vides the nurse to plan and direct
care of a group of clients over a (Primary nursing is a model of delivery of care where
24-hour period? a nurse is accountable for planning care for clients
a. Team nursing. around the clock. Functional nursing is a care delivery
b. Primary nursing. model that provides client care by assignment of
c. Case management. functions or tasks. Team nursing is a care delivery
d. Functional nursing. model where assignments to a group of clients are
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_j9fhe6
provided by a mixed-staff team. Case management is
the delivery of care that uses a collaborative process
of assessment, planning, facilitation, and advoca-
cy for options and services to meet an individual's
health needs and promote quality cost-effective out-
comes.)
6. Which approach should the nurse A
use when preparing a toddler for a
procedure? (Imitation is one of the most distinguishing charac-
teristics of toddler play, so demonstration of a proce-
a. Demonstrate the procedure using dure on a doll enables a non-threatening, dramatic
a doll. experience that can help prepare the toddler for the
b. Avoid asking the child to make actual procedure. The primary developmental task
choices. in toddlerhood is acquiring a sense of autonomy,
c. Plan a teaching session to last so giving choices whenever possible to a toddler is
about 20 minutes. recommended, not avoiding asking the toddler to
d. Show equipment but prevent make a choice. Since the toddler's attention span is
child from handling it. short, teaching sessions should be brief and can be
repeated for reinforcement. Showing the equipment
before its use helps relieve anxiety, but the child
should be allowed to handle some of the equipment
to prevent frustration and alleviate fear.)
7. The nurse is caring for a client who D
is the daughter of a local politician.
When the nurse approaches a man (Confidentiality is the nurse's primary responsibility
who is reading the names on the and is supported by HIPAA, which mandates that
hall doors, he identifies himself as personal information is not disclosed and access to
a reporter for the local newspaper sensitive client information is limited. Caring involves
and requests information about the the nurse's concern about how the client experiences
client's status. Which standard of the world. Veracity is the nurse's duty to tell the truth
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_j9fhe6
nursing practice should the nurse and not deceive others. Advocacy is support of the
use to respond? client's best interests.)
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality.
8. A male client diagnosed with anti- D
social personality disorder is mor-
bidly obese and is placed on a low (The nurse should provide a reality check by helping
fat, low calorie diet. At dinner the the client realize that there are consequences to his
nurse notes that he is trying to get behavior. Removing the client from the room or table
other clients on the unit to give him does not help the client realize that his behavior is
part of their meals. What interven- manipulative and harmful to himself as well as oth-
tion should the nurse implement? ers. This behavior needs to be documented, but does
not need to be reported immediately.)
a. Remove the client from the table
and have him sit alone.
b. Send the client back to his room
and do not allow him to eat.
c. Report the behavior to the on-call
psychologist immediately.
d. Confront the client about the con-
sequences of the behavior.
9. The nurse is assessing a client who A
complains of weight loss, racing
heart rate, and difficulty sleeping. (This client is exhibiting symptoms associated with
The nurse determines the client has hyperthyroidism or Grave's disease, which is an au-
moist skin with fine hair, prominent toimmune condition affecting the thyroid. Cushing
eyes, lid retraction, and a staring ex- syndrome, multiple sclerosis, or Addison's disease
pression. These findings are consis- are not associated with these symptoms.)
Study online at https://quizlet.com/_j9fhe6
1. The nurse is monitoring neurologi- D
cal vital signs for a male client who
lost consciousness after falling and (Neurological vital signs include serial assessments
hitting his head. Which assessment of TPR, blood pressure, and components of the Glas-
finding is the earliest and most sen- gow coma scale (GCS), which includes verbal, mus-
sitive indication of altered cerebral culoskeletal, and pupillary responses. A change in
function? the client's level of consciousness, as indicated by
a. Unequal pupils. responses to commands during the GCS, is the first
b. Loss of central reflexes. and the most sensitive sign of change in cerebral
c. Inability to open the eyes. function. The other assessment data choices are late
d. Change in level of consciousness. signs of altered cerebral function.)
2. A nurse is planning to teach D
self-care measures to a female client
about prevention of yeast infections. (A common genital tract infection in females is can-
Which instructions should the nurse didiasis, which is an overgrowth of the normal vaginal
provide? flora of Candida albicans that thrives in an environ-
a. Use a douche preparation no ment that is warm and moist and is perpetuated by
more than once a month. tight-fitting clothing, underwear, or pantyhose made
b. Increase daily intake of fiber and of nonabsorbent materials. The client should wear
leafy green vegetables. clothing that is loose fitting and absorbent, such as
c. Select nylon underwear that is cotton underwear, and avoid using bubble-bath or
loose-fitting, white, and comfort- bath salts which further irritate sensitive genital tis-
able. sue. Douching is not recommended because it can
d. Avoid tight-fitting clothing and do irritate vaginal tissue, alter pH, and contribute to
not use bubble-bath or bath salts. fungal growth. While increasing dietary fiber intake
encourages healthy, nutritional guidelines, it is not
the focus of the teaching. Cotton, not nylon under-
garments, provide absorbancy and reduce moisture
in the perineal area.)
3.
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_j9fhe6
A client who has active tuberculosis D
(TB) is admitted to the medical unit.
What action is most important for (Active tuberculosis requires implementation of air-
the nurse to implement? borne precautions, so the client should be assigned
to a negative pressure air-flow room. Although isola-
a. Place an isolation cart in the hall- tion gowns and isolation carts should be implement-
way. ed for clients in isolation with contact precautions,
b. Fit the client with a respirator it is most important that air flow from the room is
mask. minimized when the client has TB. The respirator
c. Don a clean gown for client care. mask should be implemented when the client leaves
d. Assign the client to a negative the isolation environment.)
air-flow room.
4. The nurse is planning to con- A
duct nutritional assessments and
diet teaching to clients at a family A pregnant woman's metabolic demands are 20 to
health clinic. Which individual has 24% more than the basic metabolic rate. The other
the greatest nutritional and energy clients require only 15 to 20% more than the basic
demands? metabolic rate.
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child.
5. What nursing delivery of care pro- B
vides the nurse to plan and direct
care of a group of clients over a (Primary nursing is a model of delivery of care where
24-hour period? a nurse is accountable for planning care for clients
a. Team nursing. around the clock. Functional nursing is a care delivery
b. Primary nursing. model that provides client care by assignment of
c. Case management. functions or tasks. Team nursing is a care delivery
d. Functional nursing. model where assignments to a group of clients are
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_j9fhe6
provided by a mixed-staff team. Case management is
the delivery of care that uses a collaborative process
of assessment, planning, facilitation, and advoca-
cy for options and services to meet an individual's
health needs and promote quality cost-effective out-
comes.)
6. Which approach should the nurse A
use when preparing a toddler for a
procedure? (Imitation is one of the most distinguishing charac-
teristics of toddler play, so demonstration of a proce-
a. Demonstrate the procedure using dure on a doll enables a non-threatening, dramatic
a doll. experience that can help prepare the toddler for the
b. Avoid asking the child to make actual procedure. The primary developmental task
choices. in toddlerhood is acquiring a sense of autonomy,
c. Plan a teaching session to last so giving choices whenever possible to a toddler is
about 20 minutes. recommended, not avoiding asking the toddler to
d. Show equipment but prevent make a choice. Since the toddler's attention span is
child from handling it. short, teaching sessions should be brief and can be
repeated for reinforcement. Showing the equipment
before its use helps relieve anxiety, but the child
should be allowed to handle some of the equipment
to prevent frustration and alleviate fear.)
7. The nurse is caring for a client who D
is the daughter of a local politician.
When the nurse approaches a man (Confidentiality is the nurse's primary responsibility
who is reading the names on the and is supported by HIPAA, which mandates that
hall doors, he identifies himself as personal information is not disclosed and access to
a reporter for the local newspaper sensitive client information is limited. Caring involves
and requests information about the the nurse's concern about how the client experiences
client's status. Which standard of the world. Veracity is the nurse's duty to tell the truth
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_j9fhe6
nursing practice should the nurse and not deceive others. Advocacy is support of the
use to respond? client's best interests.)
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality.
8. A male client diagnosed with anti- D
social personality disorder is mor-
bidly obese and is placed on a low (The nurse should provide a reality check by helping
fat, low calorie diet. At dinner the the client realize that there are consequences to his
nurse notes that he is trying to get behavior. Removing the client from the room or table
other clients on the unit to give him does not help the client realize that his behavior is
part of their meals. What interven- manipulative and harmful to himself as well as oth-
tion should the nurse implement? ers. This behavior needs to be documented, but does
not need to be reported immediately.)
a. Remove the client from the table
and have him sit alone.
b. Send the client back to his room
and do not allow him to eat.
c. Report the behavior to the on-call
psychologist immediately.
d. Confront the client about the con-
sequences of the behavior.
9. The nurse is assessing a client who A
complains of weight loss, racing
heart rate, and difficulty sleeping. (This client is exhibiting symptoms associated with
The nurse determines the client has hyperthyroidism or Grave's disease, which is an au-
moist skin with fine hair, prominent toimmune condition affecting the thyroid. Cushing
eyes, lid retraction, and a staring ex- syndrome, multiple sclerosis, or Addison's disease
pression. These findings are consis- are not associated with these symptoms.)
