EVOLVE HESI LEADERSHIP
PRIORITIZING CARE PRACTICE EXAM
WITH RATIONALES
DELEGATION CLINICAL JUDGMENT
AND PATIENT SAFETY UPDATED 2026
After sustaining a head trauma, a client reports hearing ringing noises. Which area
should the nurse assess further?
Frontal lobe
Occipital lobe
Sixth cranial nerve (abducens)
Eighth cranial nerve (vestibulocochlear) - Answer--Eighth cranial nerve
(vestibulocochlear)
A client is admitted to the hospital after sustaining a head injury. Which is the most
reliable sign of increased intracranial pressure the nurse can monitor for?
Rise in respiratory rate
Narrowing of pulse pressure
,Decrease in the level of consciousness
Increase in the diastolic blood pressure - Answer--Decrease in the level of
consciousness
In caring for the client with burr holes for a subdural hematoma postoperatively on day
2, the nurse notes the client has an increased temperature to 101.3 F° (38.5° C). What
does the nurse understand about this reaction?
This is a normal assessment for the client with a subdural hematoma.
This is a normal reaction day 2 postoperatively, and the nurse will administer
acetaminophen as prescribed by the healthcare provider.
Because the client has burr holes, this is not an accurate measurement.
The client is exhibiting signs of an infection, and the healthcare provider needs to be
notified. - Answer--The client is exhibiting signs of an infection, and the healthcare
provider needs to be notified.
Difficulty learning something new - Answer--Loss of recent memory
Perceptual disturbances
Difficulty learning something new
After a cerebrovascular accident (also known as brain attack) a client is unable to
differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of
the brain should the nurse conclude is likely affected?
Frontal
Parietal
Occipital
Temporal - Answer--Parietal
, A male client with a brain attack (cerebrovascular accident) has regained control of
bowel movements but still is incontinent of urine. To help reestablish bladder control,
what should the nurse encourage the client to do?
Assume a standing position for voiding.
Void every four hours and attempt to hold urine between set times.
Attempt to void more frequently in the afternoon than in the morning.
Drink a minimum of 4 L of fluid daily and divide it equally among the hours while awake.
- Answer--Assume a standing position for voiding.
A client comes into the emergency department with neurologic deficits after falling off a
ladder. Which client assessment will the nurse perform for the Glasgow Coma Scale?
Breathing patterns
Deep tendon reflexes
Eye accommodation to light
Motor response to verbal commands - Answer--Motor response to verbal commands
The nurse is performing a neurologic assessment on a client and is completing the
Glasgow Coma Scale (GCS). What components make up this assessment tool?
Best verbal response
Best pupillary response
Best motor response
Best eye-opening response - Answer--Best verbal response
Best motor response
Best eye-opening response
PRIORITIZING CARE PRACTICE EXAM
WITH RATIONALES
DELEGATION CLINICAL JUDGMENT
AND PATIENT SAFETY UPDATED 2026
After sustaining a head trauma, a client reports hearing ringing noises. Which area
should the nurse assess further?
Frontal lobe
Occipital lobe
Sixth cranial nerve (abducens)
Eighth cranial nerve (vestibulocochlear) - Answer--Eighth cranial nerve
(vestibulocochlear)
A client is admitted to the hospital after sustaining a head injury. Which is the most
reliable sign of increased intracranial pressure the nurse can monitor for?
Rise in respiratory rate
Narrowing of pulse pressure
,Decrease in the level of consciousness
Increase in the diastolic blood pressure - Answer--Decrease in the level of
consciousness
In caring for the client with burr holes for a subdural hematoma postoperatively on day
2, the nurse notes the client has an increased temperature to 101.3 F° (38.5° C). What
does the nurse understand about this reaction?
This is a normal assessment for the client with a subdural hematoma.
This is a normal reaction day 2 postoperatively, and the nurse will administer
acetaminophen as prescribed by the healthcare provider.
Because the client has burr holes, this is not an accurate measurement.
The client is exhibiting signs of an infection, and the healthcare provider needs to be
notified. - Answer--The client is exhibiting signs of an infection, and the healthcare
provider needs to be notified.
Difficulty learning something new - Answer--Loss of recent memory
Perceptual disturbances
Difficulty learning something new
After a cerebrovascular accident (also known as brain attack) a client is unable to
differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of
the brain should the nurse conclude is likely affected?
Frontal
Parietal
Occipital
Temporal - Answer--Parietal
, A male client with a brain attack (cerebrovascular accident) has regained control of
bowel movements but still is incontinent of urine. To help reestablish bladder control,
what should the nurse encourage the client to do?
Assume a standing position for voiding.
Void every four hours and attempt to hold urine between set times.
Attempt to void more frequently in the afternoon than in the morning.
Drink a minimum of 4 L of fluid daily and divide it equally among the hours while awake.
- Answer--Assume a standing position for voiding.
A client comes into the emergency department with neurologic deficits after falling off a
ladder. Which client assessment will the nurse perform for the Glasgow Coma Scale?
Breathing patterns
Deep tendon reflexes
Eye accommodation to light
Motor response to verbal commands - Answer--Motor response to verbal commands
The nurse is performing a neurologic assessment on a client and is completing the
Glasgow Coma Scale (GCS). What components make up this assessment tool?
Best verbal response
Best pupillary response
Best motor response
Best eye-opening response - Answer--Best verbal response
Best motor response
Best eye-opening response
