HESI Comprehensive Exam/
Neurological & Sensory
Assessment
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?
→ D. Change in level of consciousness
A 6-year-old child is alert but quiet when brought to the emergency
center with periorbital ecchymosis and ecchymosis behind the ears.
What assessment finding would be consistent with a basilar skull
fracture?
→ D. Rhinorrhea or otorrhea with Halo sign
The nurse is assessing a client and identifies the presence of petechiae.
Which documentation best describes this finding?
→ A. Purplish-red pinpoint lesions of the skin
,The nurse is assessing an older client and determines that the client's
left upper eyelid droops, covering more of the iris than the right eyelid.
Which description should the nurse use to document this finding?
→ A. Ptosis on the left eyelid
To assess a client's pupillary response to accommodation, a nurse
should perform which activity?
→ D. Ask the client to look at a distant object and then at an object held
10 cm from the nose
Infectious Disease & Isolation
A client who has active tuberculosis (TB) is admitted to the medical
unit. What action is most important for the nurse to implement?
→ D. Assign the client to a negative air-flow room
A child with bacterial conjunctivitis receives a prescription for
erythromycin eye drops. Which information is most important for the
nurse to include in the teaching plan?
→ D. Avoid sharing towels and washcloths with siblings
Women's Health & OB
A nurse is planning to teach self-care measures to a female client about
prevention of yeast infections. Which instructions should the nurse
provide?
,→ D. Avoid tight-fitting clothing and do not use bubble-bath or bath
salts
Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a
client's fundus is 3 cm above the umbilicus, boggy, and located to the
right of midline. Which action should the nurse take first?
→ B. Palpate above the symphysis for the bladder
The clinic nurse identifies an elevation in the results of the triple marker
screening test for a client who is in the first trimester of pregnancy.
Which action should the nurse prepare the client for?
→ B. Preparing for other diagnostic testing
Which finding should the nurse identify as an early clinical
manifestation of neonatal encephalopathy related to
hyperbilirubinemia?
→ C. Lethargy or irritability
The nurse is teaching an adolescent girl with scoliosis about a
Milwaukee brace which her healthcare provider has prescribed. Which
instruction would be accurate?
→ A. Remove the brace one hour each day for bathing only
Cardiac & Respiratory
, The nurse obtains a heart rate of 92 and a blood pressure of 110/76
prior to administering a scheduled dose of verapamil (Calan) for a client
with atrial flutter. Which action should the nurse implement?
→ A. Administer the dose as prescribed
A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial
infarction. The nurse determines the client's apical pulse is 65 beats per
minute. What action should the nurse implement next?
→ C. Administer the medication
Following major abdominal surgery, a male client's ABGs reveal PaO₂ 95
mmHg and PaCO₂ 50 mmHg. He is reluctant to move or deep breathe.
What action should the nurse implement?
→ B. Encourage the use of an incentive spirometer
Endocrine
The nurse is assessing a client who complains of weight loss, racing
heart rate, and difficulty sleeping. Findings include moist skin, fine hair,
prominent eyes, and lid retraction. These findings are consistent with
which disorder?
→ A. Grave's disease
A client is admitted with Type 2 diabetes mellitus and influenza. Which
categories of illness should the nurse develop goals for?
→ C. One chronic and one acute illness
Neurological & Sensory
Assessment
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?
→ D. Change in level of consciousness
A 6-year-old child is alert but quiet when brought to the emergency
center with periorbital ecchymosis and ecchymosis behind the ears.
What assessment finding would be consistent with a basilar skull
fracture?
→ D. Rhinorrhea or otorrhea with Halo sign
The nurse is assessing a client and identifies the presence of petechiae.
Which documentation best describes this finding?
→ A. Purplish-red pinpoint lesions of the skin
,The nurse is assessing an older client and determines that the client's
left upper eyelid droops, covering more of the iris than the right eyelid.
Which description should the nurse use to document this finding?
→ A. Ptosis on the left eyelid
To assess a client's pupillary response to accommodation, a nurse
should perform which activity?
→ D. Ask the client to look at a distant object and then at an object held
10 cm from the nose
Infectious Disease & Isolation
A client who has active tuberculosis (TB) is admitted to the medical
unit. What action is most important for the nurse to implement?
→ D. Assign the client to a negative air-flow room
A child with bacterial conjunctivitis receives a prescription for
erythromycin eye drops. Which information is most important for the
nurse to include in the teaching plan?
→ D. Avoid sharing towels and washcloths with siblings
Women's Health & OB
A nurse is planning to teach self-care measures to a female client about
prevention of yeast infections. Which instructions should the nurse
provide?
,→ D. Avoid tight-fitting clothing and do not use bubble-bath or bath
salts
Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a
client's fundus is 3 cm above the umbilicus, boggy, and located to the
right of midline. Which action should the nurse take first?
→ B. Palpate above the symphysis for the bladder
The clinic nurse identifies an elevation in the results of the triple marker
screening test for a client who is in the first trimester of pregnancy.
Which action should the nurse prepare the client for?
→ B. Preparing for other diagnostic testing
Which finding should the nurse identify as an early clinical
manifestation of neonatal encephalopathy related to
hyperbilirubinemia?
→ C. Lethargy or irritability
The nurse is teaching an adolescent girl with scoliosis about a
Milwaukee brace which her healthcare provider has prescribed. Which
instruction would be accurate?
→ A. Remove the brace one hour each day for bathing only
Cardiac & Respiratory
, The nurse obtains a heart rate of 92 and a blood pressure of 110/76
prior to administering a scheduled dose of verapamil (Calan) for a client
with atrial flutter. Which action should the nurse implement?
→ A. Administer the dose as prescribed
A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial
infarction. The nurse determines the client's apical pulse is 65 beats per
minute. What action should the nurse implement next?
→ C. Administer the medication
Following major abdominal surgery, a male client's ABGs reveal PaO₂ 95
mmHg and PaCO₂ 50 mmHg. He is reluctant to move or deep breathe.
What action should the nurse implement?
→ B. Encourage the use of an incentive spirometer
Endocrine
The nurse is assessing a client who complains of weight loss, racing
heart rate, and difficulty sleeping. Findings include moist skin, fine hair,
prominent eyes, and lid retraction. These findings are consistent with
which disorder?
→ A. Grave's disease
A client is admitted with Type 2 diabetes mellitus and influenza. Which
categories of illness should the nurse develop goals for?
→ C. One chronic and one acute illness
