HESI Comprehensive Exit Exam 1 (And Rationale)
1. The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head.
Which assessment finding isthe earliest and most sensitive indication of altered cerebral function
ANSW
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness.: 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
ANSW
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.: D
(A common genital tract infection in females is candidiasis, which is an overgrowthof the normal vaginal flora of Candida
albicans that thrives in an environment that iswarm and moist and is perpetuated by tight-fitting clothing, underwear, or
pantyhosemade of nonabsorbent materials. The client should wear clothing that is loose fittingand 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. Whileincreasing dietary fiber
intake encourages healthy, nutritional guidelines, it is not thefocus 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
ANSW
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.: D
, HESI Comprehensive Exit Exam 1 (And Rationale)
(Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative
pressure air-flow room. Although isolation gownsand 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 theclient 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
ANSW
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child.: 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 ofa group of clients over a 24-hour period
ANSW
a. Team nursing.
b. Primary nursing.
c. Case management.
d. Functional nursing.: 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 modelthat 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-staffteam. Case management is the delivery of
care that uses a collaborative process ofassessment, 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 aprocedure
ANSW
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
c. Plan a teaching session to last about 20 minutes.
d. Show equipment but prevent child from handling it.: A
, HESI Comprehensive Exit Exam 1 (And Rationale)
(Imitation is one of the most distinguishing characteristics of toddler play, so demon-stration of a procedure on a doll enables a
non-threatening, dramatic experience thatcan help prepare the toddler for the actual procedure. The primary developmental
task in toddlerhood is acquiring a sense of autonomy, so giving choices whenever possible to a toddler is recommended,
not avoiding asking the toddler to make a choice. Since the toddler's attention span is short, teaching sessions should be brief
and can be repeated for reinforcement. Showing the equipment before its use helpsrelieve anxiety, but the child should be
allowed to handle some of the equipment toprevent frustration and alleviate fear.)
7. The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is
reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requestsinformation about
the client's status. Which standard of nursing practice should the nurse use to respond
ANSW
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality.: D
(Confidentiality is the nurse's primary responsibility and is supported by HIPAA, which mandates that personal
information is not disclosed and access to sensitiveclient information is limited. Caring involves the nurse's concern about how
the clientexperiences the world. Veracity is the nurse's duty to tell the truth and not deceive others. Advocacy is support of
the client's best interests.)
8. A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low calorie
diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals.What
intervention should the nurse implement
ANSW
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 consequences of the behavior.: D
(The nurse should provide a reality check by helping the client realize that there are consequences to his behavior. Removing
the client from the room or table does not help the client realize that his behavior is manipulative and harmful to himself as wel
as others. This behavior needs to be documented, but does not need to be reportedimmediately.)
, HESI Comprehensive Exit Exam 1 (And Rationale)
9. The nurse is assessing a client who complains of weight loss, racing heartrate, and difficulty sleeping. The nurse
determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. Thesefindings
are consistent with which disorder
ANSW
a. Grave's disease.
b. Cushing syndrome.
c. Multiple sclerosis.
d. Addison's disease.: A
(This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease, which is an autoimmune condition
affecting the thyroid. Cushing syndrome,multiple sclerosis, or Addison's disease are not associated with these symptoms.)
10. Which information should the nurse give a client with chronic kidneydisease (CKD)
ANSW
a. Restrict calcium-rich foods.
b. Obtain monthly B12 injections.
c. Avoid salt substitutes.
d. Increase daily intake of fiber.: C
(A client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium, so
they should avoid using them. Hypocal- cemia is a complication of CKD and calcium supplements are often needed.
Anemiarelated to CKD is treated with iron, folic acid, and erythropoietin, not B12 injections.Although increasing fiber is a
common dietary recommendation, it not an essentialpart of client teaching for CKD.)
11. A young adult female arrives at the emergency department with a black right eye and is bleeding from the left side of
her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history andphysical
examination. How should the nurse document these findings
ANSW
a. Client alleges that her boyfriend beat her up. Client is bleeding from the leftside of the face.
b. Client reports her boyfriend hit her in the eye and on the head. Bruises andlacerations present on face.
c. Client presents with a right black eye and a cut on the left side of her headthat is bleeding. Reports abusive boyfriend
responsible for injuries. Needs referral to a safe place to stay.
d. Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1
cm deep with tissue bridging.States her boyfriend is abusive.: D
1. The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head.
Which assessment finding isthe earliest and most sensitive indication of altered cerebral function
ANSW
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness.: 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
ANSW
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.: D
(A common genital tract infection in females is candidiasis, which is an overgrowthof the normal vaginal flora of Candida
albicans that thrives in an environment that iswarm and moist and is perpetuated by tight-fitting clothing, underwear, or
pantyhosemade of nonabsorbent materials. The client should wear clothing that is loose fittingand 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. Whileincreasing dietary fiber
intake encourages healthy, nutritional guidelines, it is not thefocus 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
ANSW
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.: D
, HESI Comprehensive Exit Exam 1 (And Rationale)
(Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative
pressure air-flow room. Although isolation gownsand 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 theclient 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
ANSW
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child.: 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 ofa group of clients over a 24-hour period
ANSW
a. Team nursing.
b. Primary nursing.
c. Case management.
d. Functional nursing.: 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 modelthat 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-staffteam. Case management is the delivery of
care that uses a collaborative process ofassessment, 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 aprocedure
ANSW
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
c. Plan a teaching session to last about 20 minutes.
d. Show equipment but prevent child from handling it.: A
, HESI Comprehensive Exit Exam 1 (And Rationale)
(Imitation is one of the most distinguishing characteristics of toddler play, so demon-stration of a procedure on a doll enables a
non-threatening, dramatic experience thatcan help prepare the toddler for the actual procedure. The primary developmental
task in toddlerhood is acquiring a sense of autonomy, so giving choices whenever possible to a toddler is recommended,
not avoiding asking the toddler to make a choice. Since the toddler's attention span is short, teaching sessions should be brief
and can be repeated for reinforcement. Showing the equipment before its use helpsrelieve anxiety, but the child should be
allowed to handle some of the equipment toprevent frustration and alleviate fear.)
7. The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is
reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requestsinformation about
the client's status. Which standard of nursing practice should the nurse use to respond
ANSW
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality.: D
(Confidentiality is the nurse's primary responsibility and is supported by HIPAA, which mandates that personal
information is not disclosed and access to sensitiveclient information is limited. Caring involves the nurse's concern about how
the clientexperiences the world. Veracity is the nurse's duty to tell the truth and not deceive others. Advocacy is support of
the client's best interests.)
8. A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low calorie
diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals.What
intervention should the nurse implement
ANSW
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 consequences of the behavior.: D
(The nurse should provide a reality check by helping the client realize that there are consequences to his behavior. Removing
the client from the room or table does not help the client realize that his behavior is manipulative and harmful to himself as wel
as others. This behavior needs to be documented, but does not need to be reportedimmediately.)
, HESI Comprehensive Exit Exam 1 (And Rationale)
9. The nurse is assessing a client who complains of weight loss, racing heartrate, and difficulty sleeping. The nurse
determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. Thesefindings
are consistent with which disorder
ANSW
a. Grave's disease.
b. Cushing syndrome.
c. Multiple sclerosis.
d. Addison's disease.: A
(This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease, which is an autoimmune condition
affecting the thyroid. Cushing syndrome,multiple sclerosis, or Addison's disease are not associated with these symptoms.)
10. Which information should the nurse give a client with chronic kidneydisease (CKD)
ANSW
a. Restrict calcium-rich foods.
b. Obtain monthly B12 injections.
c. Avoid salt substitutes.
d. Increase daily intake of fiber.: C
(A client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium, so
they should avoid using them. Hypocal- cemia is a complication of CKD and calcium supplements are often needed.
Anemiarelated to CKD is treated with iron, folic acid, and erythropoietin, not B12 injections.Although increasing fiber is a
common dietary recommendation, it not an essentialpart of client teaching for CKD.)
11. A young adult female arrives at the emergency department with a black right eye and is bleeding from the left side of
her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history andphysical
examination. How should the nurse document these findings
ANSW
a. Client alleges that her boyfriend beat her up. Client is bleeding from the leftside of the face.
b. Client reports her boyfriend hit her in the eye and on the head. Bruises andlacerations present on face.
c. Client presents with a right black eye and a cut on the left side of her headthat is bleeding. Reports abusive boyfriend
responsible for injuries. Needs referral to a safe place to stay.
d. Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1
cm deep with tissue bridging.States her boyfriend is abusive.: D
