HESI Comprehensive Exit Exam 1 (And Rationale) with correct solutions already
n n n n n n n n n n
passed. n
1. The nurse is monitoring neurological vital signs for a male client who lost
n n n n n n n n n n n n
consciousness after falling and hitting his head. Which assessment finding is the
n n n n n n n n n n n n
earliest and most sensitive indication of altered cerebral function?
n n n n n n n n n
a. Unequal pupils. n
b. Loss of central reflexes. n n n
c. Inability to open the eyes. n n n n
d. Change in level of consciousness.:ANS D n n n n n
(Neurological vital signs include serial assessments of TPR, blood pressure, and components of the Glasgow coma scale (GCS),
n n n n n n n n n n n n n n n n n
which includes verbal, musculoskeletal, and pupillary responses. A change in the client's level of consciousness, as indicated by
n n n n n n n n n n n n n n n n n n
responses to commands during the GCS, is the first and the most sensitive sign of change in cerebral function. The other
n n n n n n n n n n n n n n n n n n n n n
assessmentdatachoicesarelatesignsofalteredcerebralfunction.)
n n n n n n n n n n
2. A nurse is planning to teach self-care measures to a female client about
n n n n n n n n n n n n
prevention of yeast infections. Which instructions should the nurse provide?
n n n n n n n n n n
a. Use a douche preparation no more than once a month.
n n n n n n n n n
b. Increase daily intake of fiber and leafy green vegetables. n n n n n n n n
c. Select nylon underwear that is loose-fitting, white, and comfortable.
n n n n n n n n
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts.:ANS D
n n n n n n n n n n n
(A common genital tract infection in females is candidiasis, which is an overgrowth of the normal vaginal flora of Candida albicans
n n n n n n n n n n n n n n n n n n n n
that thrives in an environment that is warm and moist and is perpetuated by tight-fitting clothing, underwear, or pantyhose made of
n n n n n n n n n n n n n n n n n n n n n
nonabsorbent materials. The client should wear clothing that is loose fitting and absorbent, such as cotton underwear, and avoid
n n n n n n n n n n n n n n n n n n n
using bubble-bath or bath salts which further irritate sensitive genital tissue. Douching is not recommended because it can irritate
n n n n n n n n n n n n n n n n n n n
vaginal tissue, alter pH, and contribute to fungal growth. While increasing dietary fiber intake encourages healthy, nutritional
n n n n n n n n n n n n n n n n n
guidelines, it is not the focus of the teaching. Cotton, not nylon undergarments, provide absorbancy and reduce moisture in
n n n n n n n n n n n n n n n n n n n
n n
,the perineal area.)
n n n
3. A client who has active tuberculosis (TB) is admitted to the medical unit. What action
n n n n n n n n n n n n n n
nis most important for the nurse to implement?
n n n n n n n
a. Place an isolation cart in the hallway.
n n n n n n
b. Fittheclientwitharespiratormask.
n n n n n n
c. Don a clean gown for client care.
n n n n n n
n n
,d. Assign the client to a negative air-flow room.:ANS D n n n n n n n n
(Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative
n n n n n n n n n n n n n n n
pressure air-flow room. Although isolation gowns and isolation carts should be implemented for clients in isolation with contact
n n n n n n n n n n n n n n n n n n
precautions, it is most important that air flow from the room is minimized when the client has TB. The respirator mask should be
n n n n n n n n n n n n n n n n n n n n n n n
implemented when the client leaves the isolation environment.)
n n n n n n n n
4. The nurse is planning to conduct nutritional assessments and diet teaching to
n n n n n n n n n n n
clients at a family health clinic. Which individual has the greatest nutritional and
n n n n n n n n n n n n n
energy demands?
n n
a. A pregnant woman. n n
b. A teenager beginning puberty.
n n n
c. A 3-month-old infant.n n
d. A school-aged child.:ANS A
n n n
A pregnant woman's metabolic demands are 20 to 24% more than the basic metabolic rate. The other clients require only 15 to
n n n n n n n n n n n n n n n n n n n n n
20% more than the basic metabolic rate.
n n n n n n n
5. What nursing delivery of care provides the nurse to plan and direct care of a group
n n n n n n n n n n n n n n n
of clients over a 24-hour period?
n n n n n n
a. Team nursing. n
b. Primary nursing. n
c. Casemanagement. n
d. Functional nursing.:ANS B n n
(Primary nursing is a model of delivery of care where a nurse is accountable for planning care for clients around the clock.
n n n n n n n n n n n n n n n n n n n n n
Functional nursing is a care delivery model that provides client care by assignment of functions or tasks. Team nursing is a
n n n n n n n n n n n n n n n n n n n n n
care delivery model where assignments to a group of clients are provided by a mixed-statt team. Case managementisthe
n n n n n n n n n n n n n n n n n n n n
delivery of carethatuses a collaborative process of assessment, planning, facilitation, andadvocacy foroptionsand servicesto
n n n n n n n n n n n n n n n n n n n
meet an individual's healthneeds and promote qualitycost-ettective outcomes.)
n n n n n n n n n n
6. Which approach should the nurse use when preparing a toddler for a proce-
n n n n n n n n n n n n
dure?
n
a. Demonstrate the procedure using a doll. n n n n n
n n
, b. Avoid asking the child to make choices. n n n n n n
c. Plan a teaching session to last about 20 minutes.
n n n n n n n n
d. Show equipment but prevent child from handling it.:ANS A n n n n n n n n
(Imitation is one of the most distinguishing characteristics of toddler play, so demonstration of a procedure on a doll enables a
n n n n n n n n n n n n n n n n n n n n
non-threatening,dramaticexperiencethatcanhelppreparethetoddlerfor theactualprocedure. The primary developmental task in
n n n n n n n n n n n n n n n n n n
toddlerhood is acquiring a sense of autonomy, so giving choices whenever possible to a toddler is recommended, not avoiding
n n n n n n n n n n n n n n n n n n n
asking the toddler to make a choice. Since the toddler's attention span is short, teaching sessions should be brief and can be repeated
n n n n n n n n n n n n n n n n n n n n n n n
for reinforcement. Showing the equipment before its use helps relieve anxiety, but the child should be allowed to handle some of
n n n n n n n n n n n n n n n n n n n n n
the equipment to prevent frustration and alleviate fear.)
n n n n n n n n
7. The nurse is caring for a client who is the daughter of a local politician. When the
n n n n n n n n n n n n n n n n
nurse approaches a man who is reading the names on the hall doors, he identifies
n n n n n n n n n n n n n n n
himself as a reporter for the local newspaper and requests informa- tion about the
n n n n n n n n n n n n n n
client's status. Which standard of nursing practice should the nurse use to
n n n n n n n n n n n n
respond?
n
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality.:ANS D n
(Confidentiality isthe nurse'sprimary responsibility and is supportedby HIPAA, which mandates that personalinfor- mation
n n n n n n n n n n n n n n n n
is not disclosed and access to sensitive client information is limited. Caring involves the nurse's concern about how the client
n n n n n n n n n n n n n n n n n n n n
experiences the world. Veracity is the nurse's duty to tell the truth and not deceive others. Advocacy is support of the client's
n n n n n n n n n n n n n n n n n n n n n n
best interests.)
n n
8. A male client diagnosed with antisocial personality disorder is morbidly obese
n n n n n n n n n n
andis placed on alow fat,low calorie diet. Atdinner the nurse notes that he is trying
n n n n n n n n n n n n n n n n n n n
to get other clients on the unit to give him part of their meals. What intervention
n n n n n n n n n n n n n n n n
should the nurse implement?
n n n n
a. Remove the client from the table and have him sit alone. n n n n n n n n n n
b. Send the client back to his room and do not allow him to eat. n n n n n n n n n n n n n
c. Report the behavior to the on-call psychologist immediately. n n n n n n n
n n
n n n n n n n n n n
passed. n
1. The nurse is monitoring neurological vital signs for a male client who lost
n n n n n n n n n n n n
consciousness after falling and hitting his head. Which assessment finding is the
n n n n n n n n n n n n
earliest and most sensitive indication of altered cerebral function?
n n n n n n n n n
a. Unequal pupils. n
b. Loss of central reflexes. n n n
c. Inability to open the eyes. n n n n
d. Change in level of consciousness.:ANS D n n n n n
(Neurological vital signs include serial assessments of TPR, blood pressure, and components of the Glasgow coma scale (GCS),
n n n n n n n n n n n n n n n n n
which includes verbal, musculoskeletal, and pupillary responses. A change in the client's level of consciousness, as indicated by
n n n n n n n n n n n n n n n n n n
responses to commands during the GCS, is the first and the most sensitive sign of change in cerebral function. The other
n n n n n n n n n n n n n n n n n n n n n
assessmentdatachoicesarelatesignsofalteredcerebralfunction.)
n n n n n n n n n n
2. A nurse is planning to teach self-care measures to a female client about
n n n n n n n n n n n n
prevention of yeast infections. Which instructions should the nurse provide?
n n n n n n n n n n
a. Use a douche preparation no more than once a month.
n n n n n n n n n
b. Increase daily intake of fiber and leafy green vegetables. n n n n n n n n
c. Select nylon underwear that is loose-fitting, white, and comfortable.
n n n n n n n n
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts.:ANS D
n n n n n n n n n n n
(A common genital tract infection in females is candidiasis, which is an overgrowth of the normal vaginal flora of Candida albicans
n n n n n n n n n n n n n n n n n n n n
that thrives in an environment that is warm and moist and is perpetuated by tight-fitting clothing, underwear, or pantyhose made of
n n n n n n n n n n n n n n n n n n n n n
nonabsorbent materials. The client should wear clothing that is loose fitting and absorbent, such as cotton underwear, and avoid
n n n n n n n n n n n n n n n n n n n
using bubble-bath or bath salts which further irritate sensitive genital tissue. Douching is not recommended because it can irritate
n n n n n n n n n n n n n n n n n n n
vaginal tissue, alter pH, and contribute to fungal growth. While increasing dietary fiber intake encourages healthy, nutritional
n n n n n n n n n n n n n n n n n
guidelines, it is not the focus of the teaching. Cotton, not nylon undergarments, provide absorbancy and reduce moisture in
n n n n n n n n n n n n n n n n n n n
n n
,the perineal area.)
n n n
3. A client who has active tuberculosis (TB) is admitted to the medical unit. What action
n n n n n n n n n n n n n n
nis most important for the nurse to implement?
n n n n n n n
a. Place an isolation cart in the hallway.
n n n n n n
b. Fittheclientwitharespiratormask.
n n n n n n
c. Don a clean gown for client care.
n n n n n n
n n
,d. Assign the client to a negative air-flow room.:ANS D n n n n n n n n
(Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative
n n n n n n n n n n n n n n n
pressure air-flow room. Although isolation gowns and isolation carts should be implemented for clients in isolation with contact
n n n n n n n n n n n n n n n n n n
precautions, it is most important that air flow from the room is minimized when the client has TB. The respirator mask should be
n n n n n n n n n n n n n n n n n n n n n n n
implemented when the client leaves the isolation environment.)
n n n n n n n n
4. The nurse is planning to conduct nutritional assessments and diet teaching to
n n n n n n n n n n n
clients at a family health clinic. Which individual has the greatest nutritional and
n n n n n n n n n n n n n
energy demands?
n n
a. A pregnant woman. n n
b. A teenager beginning puberty.
n n n
c. A 3-month-old infant.n n
d. A school-aged child.:ANS A
n n n
A pregnant woman's metabolic demands are 20 to 24% more than the basic metabolic rate. The other clients require only 15 to
n n n n n n n n n n n n n n n n n n n n n
20% more than the basic metabolic rate.
n n n n n n n
5. What nursing delivery of care provides the nurse to plan and direct care of a group
n n n n n n n n n n n n n n n
of clients over a 24-hour period?
n n n n n n
a. Team nursing. n
b. Primary nursing. n
c. Casemanagement. n
d. Functional nursing.:ANS B n n
(Primary nursing is a model of delivery of care where a nurse is accountable for planning care for clients around the clock.
n n n n n n n n n n n n n n n n n n n n n
Functional nursing is a care delivery model that provides client care by assignment of functions or tasks. Team nursing is a
n n n n n n n n n n n n n n n n n n n n n
care delivery model where assignments to a group of clients are provided by a mixed-statt team. Case managementisthe
n n n n n n n n n n n n n n n n n n n n
delivery of carethatuses a collaborative process of assessment, planning, facilitation, andadvocacy foroptionsand servicesto
n n n n n n n n n n n n n n n n n n n
meet an individual's healthneeds and promote qualitycost-ettective outcomes.)
n n n n n n n n n n
6. Which approach should the nurse use when preparing a toddler for a proce-
n n n n n n n n n n n n
dure?
n
a. Demonstrate the procedure using a doll. n n n n n
n n
, b. Avoid asking the child to make choices. n n n n n n
c. Plan a teaching session to last about 20 minutes.
n n n n n n n n
d. Show equipment but prevent child from handling it.:ANS A n n n n n n n n
(Imitation is one of the most distinguishing characteristics of toddler play, so demonstration of a procedure on a doll enables a
n n n n n n n n n n n n n n n n n n n n
non-threatening,dramaticexperiencethatcanhelppreparethetoddlerfor theactualprocedure. The primary developmental task in
n n n n n n n n n n n n n n n n n n
toddlerhood is acquiring a sense of autonomy, so giving choices whenever possible to a toddler is recommended, not avoiding
n n n n n n n n n n n n n n n n n n n
asking the toddler to make a choice. Since the toddler's attention span is short, teaching sessions should be brief and can be repeated
n n n n n n n n n n n n n n n n n n n n n n n
for reinforcement. Showing the equipment before its use helps relieve anxiety, but the child should be allowed to handle some of
n n n n n n n n n n n n n n n n n n n n n
the equipment to prevent frustration and alleviate fear.)
n n n n n n n n
7. The nurse is caring for a client who is the daughter of a local politician. When the
n n n n n n n n n n n n n n n n
nurse approaches a man who is reading the names on the hall doors, he identifies
n n n n n n n n n n n n n n n
himself as a reporter for the local newspaper and requests informa- tion about the
n n n n n n n n n n n n n n
client's status. Which standard of nursing practice should the nurse use to
n n n n n n n n n n n n
respond?
n
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality.:ANS D n
(Confidentiality isthe nurse'sprimary responsibility and is supportedby HIPAA, which mandates that personalinfor- mation
n n n n n n n n n n n n n n n n
is not disclosed and access to sensitive client information is limited. Caring involves the nurse's concern about how the client
n n n n n n n n n n n n n n n n n n n n
experiences the world. Veracity is the nurse's duty to tell the truth and not deceive others. Advocacy is support of the client's
n n n n n n n n n n n n n n n n n n n n n n
best interests.)
n n
8. A male client diagnosed with antisocial personality disorder is morbidly obese
n n n n n n n n n n
andis placed on alow fat,low calorie diet. Atdinner the nurse notes that he is trying
n n n n n n n n n n n n n n n n n n n
to get other clients on the unit to give him part of their meals. What intervention
n n n n n n n n n n n n n n n n
should the nurse implement?
n n n n
a. Remove the client from the table and have him sit alone. n n n n n n n n n n
b. Send the client back to his room and do not allow him to eat. n n n n n n n n n n n n n
c. Report the behavior to the on-call psychologist immediately. n n n n n n n
n n
