HESI Comprehensive Exit Exam 1 (And Rationale)

HESI Comprehensive Exit Exam 1 (And Rati vg vg vg vg vg vg


onale)
1. The nurse is monitoring neurological vital signs for a male clie
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nt who lost consciousness after falling and hitting his head. Whic
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h assessment finding is the earliest and most sensitive indication
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of altered cerebral function?
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a. Unequal pupils. vg


b. Loss of central reflexes. vg vg vg


c. Inability to open the eyes. vg vg vg vg


d. Change in level of consciousness.: D vg vg vg vg vg




(Neurological vital signs include serial assessments of TPR, blood pressure, and components of the G
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lasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change
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in the client's level of consciousness, as indicated by responses to commands during the GCS, is th
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e first and the most sensitive sign of change in cerebral function. The other assessment data choic
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es are late signs of altered cerebral function.)
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2. A nurse is planning to teach self-
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care measures to a female client about prevention of yeast infe
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ctions. Which instructions should the nurse provide?
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a. Use a douche preparation no more than once a month.
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b. Increase daily intake of fiber and leafy green vegetables.
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c. Select nylon underwear that is loose-
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fitting, white, and comfortable. v g v g v g


d. Avoid tight-fitting clothing and do not use bubble-
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bath or bath salts.: D vg vg vg vg




(A common genital tract infection in females is candidiasis, which is an overgrowth of the normal vaginal
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flora of Candida albicans that thrives in an environment that is warm and moist and is perpetuated
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by tight-
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fitting clothing, underwear, or pantyhose made of nonabsorbent materials. The client should wear clot
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hing that is loose fitting and absorbent, such as cotton underwear, and avoid using bubble-
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bath or bath salts which further irritate sensitive genital tissue. Douching is not recommended becau
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se it can irritate vaginal tissue, alter pH, and contribute to fungal growth. While increasing dietary fi
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ber intake encourages healthy, nutritional guidelines, it is not the focus of the teaching. Cotton, not
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vgnylon undergarments, provide absorbancy and reduce moisture in the perineal area.)
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1vg/
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, HESI Comprehensive Exit Exam 1 (And Rati
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onale)
3. A client who has active tuberculosis (TB) is admitted to the med
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ical unit. What action is most important for the nurse to imple
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ment?

a. Place an isolation cart in the hallway.
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b. Fit the client with a respirator mask.
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c. Don a clean gown for client care.
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2vg/
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, HESI Comprehensive Exit Exam 1 (And Rati vg vg vg vg vg vg


onale)
d. Assign the client to a negative air-flow room.: Dvg vg vg vg vg vg vg vg




(Active tuberculosis requires implementation of airborne precautions, so the client should be assigned t
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o a negative pressure air-
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flow room. Although isolation gowns and isolation carts should be implemented for clients in isolation
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with contact precautions, it is most important that air flow from the room is minimized when the client h
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as TB. The respirator mask should be implemented when the client leaves the isolation environment
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.)
4. The nurse is planning to conduct nutritional assessments and di
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et teaching to clients at a family health clinic. Which individual ha
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s the greatest nutritional and energy demands?
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a. A pregnant woman. v g v g


b. A teenager beginning puberty.
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c. A 3-month-old infant.
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d. A school-aged child.: A
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A pregnant woman's metabolic demands are 20 to 24% more than the basic metabolic rate. The other
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clients require only 15 to 20% more than the basic metabolic rate.
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5. What nursing delivery of care provides the nurse to plan and di
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rect care of a group of clients over a 24-hour period?
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a. Team nursing. vg


b. Primary nursing. v g


c. Case management. vg


d. Functional nursing.: B v g v g




(Primary nursing is a model of delivery of care where a nurse is accountable for planning care for clie
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nts around the clock. Functional nursing is a care delivery model that provides client care by assign
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ment of functions or tasks. Team nursing is a care delivery model where assignments to a group of
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clients are provided by a mixed-
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statt team. Case management is the delivery of care that uses a collaborative process of assessment
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, planning, facilitation, and advocacy for options and services to meet an individual's health needs an
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d promote quality cost-ettective outcomes.)
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3vg/
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, HESI Comprehensive Exit Exam 1 (And Rati
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onale)
6. Which approach should the nurse use when preparing a toddler
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for a proce- dure?
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a. Demonstrate the procedure using a doll.
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