HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_azk226
D
The nurse is monitoring neurological vi- (Neurological vital signs include seri-
tal signs for a male client who lost con- al assessments of TPR, blood pres-
sciousness after falling and hitting his sure, and components of the Glasgow
head. Which assessment finding is the coma scale (GCS), which includes ver-
earliest and most sensitive indication of bal, musculoskeletal, and pupillary re-
altered cerebral function? sponses. A change in the client's lev-
a. Unequal pupils. el of consciousness, as indicated by re-
b. Loss of central reflexes. sponses to commands during the GCS,
c. Inability to open the eyes. is the first and the most sensitive sign
d. Change in level of consciousness. of change in cerebral function. The other
assessment data choices are late signs
of altered cerebral function.)
D
(A common genital tract infection in fe-
males is candidiasis, which is an over-
growth of the normal vaginal flora of
Candida albicans that thrives in an en-
A nurse is planning to teach self-care
vironment that is warm and moist and
measures to a female client about pre-
is perpetuated by tight-fitting clothing,
vention of yeast infections. Which in-
underwear, or pantyhose made of non-
structions should the nurse provide?
absorbent materials. The client should
a. Use a douche preparation no more
wear clothing that is loose fitting and
than once a month.
absorbent, such as cotton underwear,
b. Increase daily intake of fiber and leafy
and avoid using bubble-bath or bath salts
green vegetables.
which further irritate sensitive genital tis-
c. Select nylon underwear that is
sue. Douching is not recommended be-
loose-fitting, white, and comfortable.
cause it can irritate vaginal tissue, al-
d. Avoid tight-fitting clothing and do not
ter pH, and contribute to fungal growth.
use bubble-bath or bath salts.
While increasing dietary fiber intake en-
courages healthy, nutritional guidelines,
it is not the focus of the teaching. Cot-
ton, not nylon undergarments, provide
absorbancy and reduce moisture in the
perineal area.)
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_azk226
D
A client who has active tuberculosis (TB)
(Active tuberculosis requires implemen-
is admitted to the medical unit. What ac-
tation of airborne precautions, so the
tion is most important for the nurse to
client should be assigned to a negative
implement?
pressure air-flow room. Although isola-
tion gowns and isolation carts should be
a. Place an isolation cart in the hallway.
implemented for clients in isolation with
b. Fit the client with a respirator mask.
contact precautions, it is most important
c. Don a clean gown for client care.
that air flow from the room is minimized
d. Assign the client to a negative air-flow
when the client has TB. The respirator
room.
mask should be implemented when the
client leaves the isolation environment.)
The nurse is planning to conduct nutri-
tional assessments and diet teaching to A
clients at a family health clinic. Which in-
dividual has the greatest nutritional and A pregnant woman's metabolic demands
energy demands? are 20 to 24% more than the basic meta-
a. A pregnant woman. bolic rate. The other clients require only
b. A teenager beginning puberty. 15 to 20% more than the basic metabolic
c. A 3-month-old infant. rate.
d. A school-aged child.
B
(Primary nursing is a model of delivery
of care where a nurse is accountable
What nursing delivery of care provides for planning care for clients around the
the nurse to plan and direct care of a clock. Functional nursing is a care de-
group of clients over a 24-hour period? livery model that provides client care by
a. Team nursing. assignment of functions or tasks. Team
b. Primary nursing. nursing is a care delivery model where
c. Case management. assignments to a group of clients are pro-
d. Functional nursing. vided by a mixed-staff team. Case man-
agement is the delivery of care that uses
a collaborative process of assessment,
planning, facilitation, and advocacy for
options and services to meet an individ-
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_azk226
ual's health needs and promote quality
cost-effective outcomes.)
A
(Imitation is one of the most distinguish-
ing characteristics of toddler play, so
Which approach should the nurse use demonstration of a procedure on a doll
when preparing a toddler for a proce- enables a non-threatening, dramatic ex-
dure? perience that can help prepare the tod-
dler for the actual procedure. The prima-
a. Demonstrate the procedure using a ry developmental task in toddlerhood is
doll. acquiring a sense of autonomy, so giving
b. Avoid asking the child to make choic- choices whenever possible to a toddler
es. is recommended, not avoiding asking the
c. Plan a teaching session to last about toddler to make a choice. Since the tod-
20 minutes. dler's attention span is short, teaching
d. Show equipment but prevent child sessions should be brief and can be re-
from handling it. peated for reinforcement. Showing the
equipment before its use helps relieve
anxiety, but the child should be allowed to
handle some of the equipment to prevent
frustration and alleviate fear.)
The nurse is caring for a client who is the
D
daughter of a local politician. When the
nurse approaches a man who is reading
(Confidentiality is the nurse's primary re-
the names on the hall doors, he iden-
sponsibility and is supported by HIPAA,
tifies himself as a reporter for the lo-
which mandates that personal informa-
cal newspaper and requests information
tion is not disclosed and access to sen-
about the client's status. Which standard
sitive client information is limited. Caring
of nursing practice should the nurse use
involves the nurse's concern about how
to respond?
the client experiences the world. Veracity
a. Caring.
is the nurse's duty to tell the truth and
b. Veracity.
not deceive others. Advocacy is support
c. Advocacy.
of the client's best interests.)
d. Confidentiality.
A male client diagnosed with antisocial
personality disorder is morbidly obese
and is placed on a low fat, low calorie
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_azk226
diet. At dinner the nurse notes that he is
trying to get other clients on the unit to D
give him part of their meals. What inter-
vention should the nurse implement? (The nurse should provide a reality check
by helping the client realize that there
a. Remove the client from the table and are consequences to his behavior. Re-
have him sit alone. moving the client from the room or table
b. Send the client back to his room and does not help the client realize that his
do not allow him to eat. behavior is manipulative and harmful to
c. Report the behavior to the on-call psy- himself as well as others. This behavior
chologist immediately. needs to be documented, but does not
d. Confront the client about the conse- need to be reported immediately.)
quences of the behavior.
The nurse is assessing a client who com-
plains of weight loss, racing heart rate, A
and difficulty sleeping. The nurse deter-
mines the client has moist skin with fine (This client is exhibiting symptoms as-
hair, prominent eyes, lid retraction, and sociated with hyperthyroidism or Grave's
a staring expression. These findings are disease, which is an autoimmune con-
consistent with which disorder? dition affecting the thyroid. Cushing syn-
a. Grave's disease. drome, multiple sclerosis, or Addison's
b. Cushing syndrome. disease are not associated with these
c. Multiple sclerosis. symptoms.)
d. Addison's disease.
C
(A client with CKD should restrict sodium
and potassium dietary intake, and salt
Which information should the nurse give
substitutes usually contain potassium, so
a client with chronic kidney disease
they should avoid using them. Hypocal-
(CKD)?
cemia is a complication of CKD and calci-
a. Restrict calcium-rich foods.
um supplements are often needed. Ane-
b. Obtain monthly B12 injections.
mia related to CKD is treated with iron,
c. Avoid salt substitutes.
folic acid, and erythropoietin, not B12
d. Increase daily intake of fiber.
injections. Although increasing fiber is a
common dietary recommendation, it not
an essential part of client teaching for
CKD.)
Study online at https://quizlet.com/_azk226
D
The nurse is monitoring neurological vi- (Neurological vital signs include seri-
tal signs for a male client who lost con- al assessments of TPR, blood pres-
sciousness after falling and hitting his sure, and components of the Glasgow
head. Which assessment finding is the coma scale (GCS), which includes ver-
earliest and most sensitive indication of bal, musculoskeletal, and pupillary re-
altered cerebral function? sponses. A change in the client's lev-
a. Unequal pupils. el of consciousness, as indicated by re-
b. Loss of central reflexes. sponses to commands during the GCS,
c. Inability to open the eyes. is the first and the most sensitive sign
d. Change in level of consciousness. of change in cerebral function. The other
assessment data choices are late signs
of altered cerebral function.)
D
(A common genital tract infection in fe-
males is candidiasis, which is an over-
growth of the normal vaginal flora of
Candida albicans that thrives in an en-
A nurse is planning to teach self-care
vironment that is warm and moist and
measures to a female client about pre-
is perpetuated by tight-fitting clothing,
vention of yeast infections. Which in-
underwear, or pantyhose made of non-
structions should the nurse provide?
absorbent materials. The client should
a. Use a douche preparation no more
wear clothing that is loose fitting and
than once a month.
absorbent, such as cotton underwear,
b. Increase daily intake of fiber and leafy
and avoid using bubble-bath or bath salts
green vegetables.
which further irritate sensitive genital tis-
c. Select nylon underwear that is
sue. Douching is not recommended be-
loose-fitting, white, and comfortable.
cause it can irritate vaginal tissue, al-
d. Avoid tight-fitting clothing and do not
ter pH, and contribute to fungal growth.
use bubble-bath or bath salts.
While increasing dietary fiber intake en-
courages healthy, nutritional guidelines,
it is not the focus of the teaching. Cot-
ton, not nylon undergarments, provide
absorbancy and reduce moisture in the
perineal area.)
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_azk226
D
A client who has active tuberculosis (TB)
(Active tuberculosis requires implemen-
is admitted to the medical unit. What ac-
tation of airborne precautions, so the
tion is most important for the nurse to
client should be assigned to a negative
implement?
pressure air-flow room. Although isola-
tion gowns and isolation carts should be
a. Place an isolation cart in the hallway.
implemented for clients in isolation with
b. Fit the client with a respirator mask.
contact precautions, it is most important
c. Don a clean gown for client care.
that air flow from the room is minimized
d. Assign the client to a negative air-flow
when the client has TB. The respirator
room.
mask should be implemented when the
client leaves the isolation environment.)
The nurse is planning to conduct nutri-
tional assessments and diet teaching to A
clients at a family health clinic. Which in-
dividual has the greatest nutritional and A pregnant woman's metabolic demands
energy demands? are 20 to 24% more than the basic meta-
a. A pregnant woman. bolic rate. The other clients require only
b. A teenager beginning puberty. 15 to 20% more than the basic metabolic
c. A 3-month-old infant. rate.
d. A school-aged child.
B
(Primary nursing is a model of delivery
of care where a nurse is accountable
What nursing delivery of care provides for planning care for clients around the
the nurse to plan and direct care of a clock. Functional nursing is a care de-
group of clients over a 24-hour period? livery model that provides client care by
a. Team nursing. assignment of functions or tasks. Team
b. Primary nursing. nursing is a care delivery model where
c. Case management. assignments to a group of clients are pro-
d. Functional nursing. vided by a mixed-staff team. Case man-
agement is the delivery of care that uses
a collaborative process of assessment,
planning, facilitation, and advocacy for
options and services to meet an individ-
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_azk226
ual's health needs and promote quality
cost-effective outcomes.)
A
(Imitation is one of the most distinguish-
ing characteristics of toddler play, so
Which approach should the nurse use demonstration of a procedure on a doll
when preparing a toddler for a proce- enables a non-threatening, dramatic ex-
dure? perience that can help prepare the tod-
dler for the actual procedure. The prima-
a. Demonstrate the procedure using a ry developmental task in toddlerhood is
doll. acquiring a sense of autonomy, so giving
b. Avoid asking the child to make choic- choices whenever possible to a toddler
es. is recommended, not avoiding asking the
c. Plan a teaching session to last about toddler to make a choice. Since the tod-
20 minutes. dler's attention span is short, teaching
d. Show equipment but prevent child sessions should be brief and can be re-
from handling it. peated for reinforcement. Showing the
equipment before its use helps relieve
anxiety, but the child should be allowed to
handle some of the equipment to prevent
frustration and alleviate fear.)
The nurse is caring for a client who is the
D
daughter of a local politician. When the
nurse approaches a man who is reading
(Confidentiality is the nurse's primary re-
the names on the hall doors, he iden-
sponsibility and is supported by HIPAA,
tifies himself as a reporter for the lo-
which mandates that personal informa-
cal newspaper and requests information
tion is not disclosed and access to sen-
about the client's status. Which standard
sitive client information is limited. Caring
of nursing practice should the nurse use
involves the nurse's concern about how
to respond?
the client experiences the world. Veracity
a. Caring.
is the nurse's duty to tell the truth and
b. Veracity.
not deceive others. Advocacy is support
c. Advocacy.
of the client's best interests.)
d. Confidentiality.
A male client diagnosed with antisocial
personality disorder is morbidly obese
and is placed on a low fat, low calorie
, HESI Comprehensive Exit Exam 1 (And Rationale)
Study online at https://quizlet.com/_azk226
diet. At dinner the nurse notes that he is
trying to get other clients on the unit to D
give him part of their meals. What inter-
vention should the nurse implement? (The nurse should provide a reality check
by helping the client realize that there
a. Remove the client from the table and are consequences to his behavior. Re-
have him sit alone. moving the client from the room or table
b. Send the client back to his room and does not help the client realize that his
do not allow him to eat. behavior is manipulative and harmful to
c. Report the behavior to the on-call psy- himself as well as others. This behavior
chologist immediately. needs to be documented, but does not
d. Confront the client about the conse- need to be reported immediately.)
quences of the behavior.
The nurse is assessing a client who com-
plains of weight loss, racing heart rate, A
and difficulty sleeping. The nurse deter-
mines the client has moist skin with fine (This client is exhibiting symptoms as-
hair, prominent eyes, lid retraction, and sociated with hyperthyroidism or Grave's
a staring expression. These findings are disease, which is an autoimmune con-
consistent with which disorder? dition affecting the thyroid. Cushing syn-
a. Grave's disease. drome, multiple sclerosis, or Addison's
b. Cushing syndrome. disease are not associated with these
c. Multiple sclerosis. symptoms.)
d. Addison's disease.
C
(A client with CKD should restrict sodium
and potassium dietary intake, and salt
Which information should the nurse give
substitutes usually contain potassium, so
a client with chronic kidney disease
they should avoid using them. Hypocal-
(CKD)?
cemia is a complication of CKD and calci-
a. Restrict calcium-rich foods.
um supplements are often needed. Ane-
b. Obtain monthly B12 injections.
mia related to CKD is treated with iron,
c. Avoid salt substitutes.
folic acid, and erythropoietin, not B12
d. Increase daily intake of fiber.
injections. Although increasing fiber is a
common dietary recommendation, it not
an essential part of client teaching for
CKD.)
