HESI Comprehensive Exit Exam 1 (And
Rationale) Questions and Answers
1.The nurse is monitoring neurological vital signs for a male
client who lost consciousness after falling and hitting his head.
Which assessment finding is the earliest and most sensitive
indication of altered cerebral function?
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness.
ANS D
(Neurological vital signs include serial assessments of TPR, blood
pressure, and components of the Glasgow coma scale (GCS), which
includes verbal, muscu- loskeletal, and pupillary responses. A change in
the client's level of consciousness, as indicated by responses to
commands during the GCS, is the first and the most sensitive sign of
change in cerebral function. The other assessment data choices are late
signs of altered cerebral function.)
2.A nurse is planning to teach self-care measures to a female
client about
prevention of yeast infections. Which instructions should the
,nurse provide?
a. Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and
comfortable.
d. Avoid tight-fitting clothing and do not use bubble-bath or bath
salts.
ANS D
(A common genital tract infection in females is candidiasis, which is an
overgrowth of the normal vaginal flora of Candida albicans that thrives
in an environment that is warm and moist and is perpetuated by tight-
fitting clothing, underwear, or pantyhose made of nonabsorbent
materials. The client should wear clothing that is loose fitting and
absorbent, such as cotton underwear, and avoid using bubble-bath or
bath salts which further irritate sensitive genital tissue. Douching is not
recommended because it can irritate vaginal tissue, alter pH, and
contribute to fungal growth. While increasing dietary fiber intake
encourages healthy, nutritional guidelines, it is not the focus of the
teaching. Cotton, not nylon undergarments, provide absorbancy and
reduce moisture in the perineal area.)
3.A client who has active tuberculosis (TB) is admitted to the
medical unit.
What action is most important for the nurse to implement?
,a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room.
ANS D
(Active tuberculosis requires implementation of airborne precautions, so
the client should be assigned to a negative pressure air-flow room.
Although isolation gowns and isolation carts should be implemented for
clients in isolation with contact precautions, it is most important that air
flow from the room is minimized when the client has TB. The respirator
mask should be implemented when the client leaves the isolation
environment.)
4.The nurse is planning to conduct nutritional assessments and
diet teaching
to clients at a family health clinic. Which individual has the
greatest nutritional and energy demands?
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child.
ANS A
A pregnant woman's metabolic demands are 20 to 24% more than the
basic meta- bolic rate. The other clients require only 15 to 20% more
, than the basic metabolic rate.
5.What nursing delivery of care provides the nurse to plan and
direct care of a group of clients over a 24-hour period?
a. Team nursing.
b. Primary nursing.
c. Case management.
d. Functional nursing.
ANS B
(Primary nursing is a model of delivery of care where a nurse is
accountable for planning care for clients around the clock. Functional
nursing is a care delivery model that provides client care by assignment
of functions or tasks. Team nursing is a care delivery model where
assignments to a group of clients are provided by a mixed-staff team.
Case management is the delivery of care that uses a collaborative
process of assessment, planning, facilitation, and advocacy for options
and services to meet an individual's health needs and promote quality
cost-effective outcomes.)
6.Which approach should the nurse use when preparing a
toddler for a procedure?
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
Rationale) Questions and Answers
1.The nurse is monitoring neurological vital signs for a male
client who lost consciousness after falling and hitting his head.
Which assessment finding is the earliest and most sensitive
indication of altered cerebral function?
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness.
ANS D
(Neurological vital signs include serial assessments of TPR, blood
pressure, and components of the Glasgow coma scale (GCS), which
includes verbal, muscu- loskeletal, and pupillary responses. A change in
the client's level of consciousness, as indicated by responses to
commands during the GCS, is the first and the most sensitive sign of
change in cerebral function. The other assessment data choices are late
signs of altered cerebral function.)
2.A nurse is planning to teach self-care measures to a female
client about
prevention of yeast infections. Which instructions should the
,nurse provide?
a. Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and
comfortable.
d. Avoid tight-fitting clothing and do not use bubble-bath or bath
salts.
ANS D
(A common genital tract infection in females is candidiasis, which is an
overgrowth of the normal vaginal flora of Candida albicans that thrives
in an environment that is warm and moist and is perpetuated by tight-
fitting clothing, underwear, or pantyhose made of nonabsorbent
materials. The client should wear clothing that is loose fitting and
absorbent, such as cotton underwear, and avoid using bubble-bath or
bath salts which further irritate sensitive genital tissue. Douching is not
recommended because it can irritate vaginal tissue, alter pH, and
contribute to fungal growth. While increasing dietary fiber intake
encourages healthy, nutritional guidelines, it is not the focus of the
teaching. Cotton, not nylon undergarments, provide absorbancy and
reduce moisture in the perineal area.)
3.A client who has active tuberculosis (TB) is admitted to the
medical unit.
What action is most important for the nurse to implement?
,a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room.
ANS D
(Active tuberculosis requires implementation of airborne precautions, so
the client should be assigned to a negative pressure air-flow room.
Although isolation gowns and isolation carts should be implemented for
clients in isolation with contact precautions, it is most important that air
flow from the room is minimized when the client has TB. The respirator
mask should be implemented when the client leaves the isolation
environment.)
4.The nurse is planning to conduct nutritional assessments and
diet teaching
to clients at a family health clinic. Which individual has the
greatest nutritional and energy demands?
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child.
ANS A
A pregnant woman's metabolic demands are 20 to 24% more than the
basic meta- bolic rate. The other clients require only 15 to 20% more
, than the basic metabolic rate.
5.What nursing delivery of care provides the nurse to plan and
direct care of a group of clients over a 24-hour period?
a. Team nursing.
b. Primary nursing.
c. Case management.
d. Functional nursing.
ANS B
(Primary nursing is a model of delivery of care where a nurse is
accountable for planning care for clients around the clock. Functional
nursing is a care delivery model that provides client care by assignment
of functions or tasks. Team nursing is a care delivery model where
assignments to a group of clients are provided by a mixed-staff team.
Case management is the delivery of care that uses a collaborative
process of assessment, planning, facilitation, and advocacy for options
and services to meet an individual's health needs and promote quality
cost-effective outcomes.)
6.Which approach should the nurse use when preparing a
toddler for a procedure?
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
