HESI Comprehensive Exam Success: Verified
Questions & Detailed Answer Rationales from
Premier Universities for Guaranteed Achievement
A nurse is caring for a client who has had a stroke and is experiencing hemianopsia. Which
measure does the nurse take in the care of the client?
Approaching the client from the side of nonintact vision
Teaching the client to move the head from side to side (scan) when eating
Placing objects needed for self-care within the client's nonintact visual field
Positioning the client in the room so that his nonintact visual field faces the door -
CORRECT ANS- -Teaching the client to move the head from side to side (scan) when eating
Rationale: Hemianopsia is the loss of vision in a portion of the visual field. Approaching the
client from the side of nonintact vision, placing objects needed for self-care within the
client's nonintact visual field, and positioning the client so that the damaged part of the
visual field faces the door are incorrect because the client depends on and needs to use
the intact portion of the visual field for sensory input. The client is taught to move the head
from side to side (scan) to compensate for a diminished visual field. Scanning is also
important when the client is eating.
A nurse has provided information about exercise to a client with a diagnosis of degenerative
joint disease (osteoarthritis). Which type of exercise does the nurse tell the client to avoid?
High-impact exercise
Swimming and water exercise
Daily range-of-motion exercises
Regular exercise with warm-up and cool-down sessions - CORRECT ANS- -High-impact
exercise
,Rationale: Vigorous or high-impact exercise may exacerbate signs/symptoms and may be
damaging to articulating surfaces within joints. These type of exercises should be avoided
by clients with osteoarthritis. Osteoarthritis is a joint disorder marked by joint pain that is
worse after high-impact exercise or when the affected person puts weight on the joint and
is relieved by rest. The other options are helpful activities/exercises in promoting joint
mobility.
A client diagnosed with schizophrenia says to the nurse, "I decided not to take my
medication because it can't help. I am the only one who can help me." Which nursing
response is therapeutic in this situation?
"Only you can help?"
"You decided not to take your medication?"
"If you can make that observation, you probably don't need your medication any longer."
"Your doctor wants you to continue this medication because it's helping you. Do you recall
needing to be hospitalized because you stopped your medication?" - CORRECT ANS- -
"Your doctor wants you to continue this medication because it's helping you. Do you recall
needing to be hospitalized because you stopped your medication?"
Rationale: Noncompliance with antipsychotic medication is one of the reasons clients with
schizophrenia have relapses. The nurse should give a response to the schizophrenic client
that will help the client identify the causes of relapse. The therapeutic response by the
nurse is, "Your doctor wants you to continue this medication because it's helping you. Do
you recall needing to be hospitalized because you stopped your medication?" In asking,
"Only you can help?" the nurse is employing restating, which can be therapeutic but is not
useful in this client's situation. "You decided not to take your medication?" is another
example of restating. In stating, "If you can make this observation, you probably don't need
your medication any longer," the nurse is using an illogical, judgmental, and biased
response that is not therapeutic.
, A nurse prepares to administer digoxin to a client with heart failure. Which vital sign must
be checked before the medication is administered?
Temperature
Respirations
Apical pulse
Blood pressure - CORRECT ANS- -Apical pulse
Rationale: The nurse would count the client's apical heart rate for 60 seconds before giving
the medication. Digoxin is a cardiac glycoside used to treat heart failure and control the
ventricular rate in clients with atrial fibrillation. If the heart rate is slower than 60 beats/min,
the medication is withheld and the primary health care provider notified. Excessive slowing
of the heart rate is one clinical sign of digoxin toxicity. Although the nurse might check other
vital signs, the apical pulse is the most important in this context.
A nurse preparing to administer digoxin to a client calls the laboratory for the result of the
digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports
that the result was 2.0 ng/mL (2.6 nmol/L). On the basis of this result, what should the
nurse do?
Administer the digoxin
Contact the primary health care provider
Wait for the primary health care provider to make rounds and report the result
Check the client's apical heart rate and administer the digoxin if the rate is faster than 60
beats/min - CORRECT ANS- -Contact the primary health care provider
Rationale: The nurse should contact the primary health care provider. The optimal
therapeutic serum level for digoxin is 0.5 to 0.8 ng/mL (0.6 to 1.0 nmol/L). A digoxin
concentration greater than this level indicates toxicity, and requires the nurse to contact
Questions & Detailed Answer Rationales from
Premier Universities for Guaranteed Achievement
A nurse is caring for a client who has had a stroke and is experiencing hemianopsia. Which
measure does the nurse take in the care of the client?
Approaching the client from the side of nonintact vision
Teaching the client to move the head from side to side (scan) when eating
Placing objects needed for self-care within the client's nonintact visual field
Positioning the client in the room so that his nonintact visual field faces the door -
CORRECT ANS- -Teaching the client to move the head from side to side (scan) when eating
Rationale: Hemianopsia is the loss of vision in a portion of the visual field. Approaching the
client from the side of nonintact vision, placing objects needed for self-care within the
client's nonintact visual field, and positioning the client so that the damaged part of the
visual field faces the door are incorrect because the client depends on and needs to use
the intact portion of the visual field for sensory input. The client is taught to move the head
from side to side (scan) to compensate for a diminished visual field. Scanning is also
important when the client is eating.
A nurse has provided information about exercise to a client with a diagnosis of degenerative
joint disease (osteoarthritis). Which type of exercise does the nurse tell the client to avoid?
High-impact exercise
Swimming and water exercise
Daily range-of-motion exercises
Regular exercise with warm-up and cool-down sessions - CORRECT ANS- -High-impact
exercise
,Rationale: Vigorous or high-impact exercise may exacerbate signs/symptoms and may be
damaging to articulating surfaces within joints. These type of exercises should be avoided
by clients with osteoarthritis. Osteoarthritis is a joint disorder marked by joint pain that is
worse after high-impact exercise or when the affected person puts weight on the joint and
is relieved by rest. The other options are helpful activities/exercises in promoting joint
mobility.
A client diagnosed with schizophrenia says to the nurse, "I decided not to take my
medication because it can't help. I am the only one who can help me." Which nursing
response is therapeutic in this situation?
"Only you can help?"
"You decided not to take your medication?"
"If you can make that observation, you probably don't need your medication any longer."
"Your doctor wants you to continue this medication because it's helping you. Do you recall
needing to be hospitalized because you stopped your medication?" - CORRECT ANS- -
"Your doctor wants you to continue this medication because it's helping you. Do you recall
needing to be hospitalized because you stopped your medication?"
Rationale: Noncompliance with antipsychotic medication is one of the reasons clients with
schizophrenia have relapses. The nurse should give a response to the schizophrenic client
that will help the client identify the causes of relapse. The therapeutic response by the
nurse is, "Your doctor wants you to continue this medication because it's helping you. Do
you recall needing to be hospitalized because you stopped your medication?" In asking,
"Only you can help?" the nurse is employing restating, which can be therapeutic but is not
useful in this client's situation. "You decided not to take your medication?" is another
example of restating. In stating, "If you can make this observation, you probably don't need
your medication any longer," the nurse is using an illogical, judgmental, and biased
response that is not therapeutic.
, A nurse prepares to administer digoxin to a client with heart failure. Which vital sign must
be checked before the medication is administered?
Temperature
Respirations
Apical pulse
Blood pressure - CORRECT ANS- -Apical pulse
Rationale: The nurse would count the client's apical heart rate for 60 seconds before giving
the medication. Digoxin is a cardiac glycoside used to treat heart failure and control the
ventricular rate in clients with atrial fibrillation. If the heart rate is slower than 60 beats/min,
the medication is withheld and the primary health care provider notified. Excessive slowing
of the heart rate is one clinical sign of digoxin toxicity. Although the nurse might check other
vital signs, the apical pulse is the most important in this context.
A nurse preparing to administer digoxin to a client calls the laboratory for the result of the
digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports
that the result was 2.0 ng/mL (2.6 nmol/L). On the basis of this result, what should the
nurse do?
Administer the digoxin
Contact the primary health care provider
Wait for the primary health care provider to make rounds and report the result
Check the client's apical heart rate and administer the digoxin if the rate is faster than 60
beats/min - CORRECT ANS- -Contact the primary health care provider
Rationale: The nurse should contact the primary health care provider. The optimal
therapeutic serum level for digoxin is 0.5 to 0.8 ng/mL (0.6 to 1.0 nmol/L). A digoxin
concentration greater than this level indicates toxicity, and requires the nurse to contact
