HESI Comprehensive Exit Exam 1 (And Rationale)
Key Concepts in Nursing Practice
1. Neurological Assessment
Topic: Monitoring Altered Cerebral Function
Scenario: A male client lost consciousness after a fall and head injury.
Question: Which assessment finding is the earliest and most sensitive indication of altered
cerebral function?
Options:
o a. Unequal pupils.
o b. Loss of central reflexes.
o c. Inability to open the eyes.
o d. Change in level of consciousness.
Rationale:
o Neurological vital signs include serial assessments of TPR, blood pressure, and
components of the Glasgow Coma Scale (GCS).
o The GCS assesses verbal, musculoskeletal, and pupillary responses.
o 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.
o The other assessment data choices (unequal pupils, loss of central reflexes, inability to
open eyes) are considered late signs of altered cerebral function.
2. Prevention of Yeast Infections
Topic: Self-Care Measures for Yeast Infection Prevention
Client: A female client receiving instructions on preventing yeast infections.
Question: Which instructions should the nurse provide?
Options:
o a. Use a douche preparation no more than once a month.
o b. Increase daily intake of fiber and leafy green vegetables.
o c. Select nylon underwear that is loose-fitting, white, and comfortable.
o d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts.
Rationale:
o Candidiasis is a common genital tract infection in females, an overgrowth of Candida
albicans.
o This fungus thrives in a warm and moist environment.
, o Tight-fitting clothing, nonabsorbent underwear (like nylon), and pantyhose can perpetuate
this environment.
o Key Instructions:
Wear loose-fitting and absorbent clothing, such as cotton underwear.
Avoid using bubble-bath or bath salts, as these can irritate sensitive genital tissue.
o Important Considerations:
Douching is not recommended as it can irritate vaginal tissue, alter pH, and
contribute to fungal growth.
While increased dietary fiber is healthy, it is not the primary focus for preventing
yeast infections.
Cotton, not nylon, undergarments provide absorbency and reduce moisture.
3. Tuberculosis Management
Topic: Nursing Care for Active Tuberculosis
Client: A client with active tuberculosis (TB) admitted to the medical unit.
Question: What action is most important for the nurse to implement?
Options:
o a. Place an isolation cart in the hallway.
o b. Fit the client with a respirator mask.
o c. Don a clean gown for client care.
o d. Assign the client to a negative air-flow room.
Rationale:
o Active tuberculosis requires strict airborne precautions.
o The most critical action is to assign the client to a negative pressure air-flow room. This
minimizes the spread of airborne particles.
o While isolation gowns and carts are important for contact precautions, they are secondary
to air-flow management for TB.
o A respirator mask should be implemented when the client leaves the isolation
environment to prevent transmission.
4. Nutritional and Energy Demands
Topic: Individuals with Greatest Nutritional Needs
Question: Which individual has the greatest nutritional and energy demands?
Options:
o a. A pregnant woman.
o b. A teenager beginning puberty.
o c. A 3-month-old infant.
o d. A school-aged child.
Rationale:
, o A pregnant woman's metabolic demands increase by 20 to 24% above the basic
metabolic rate to support fetal growth and maternal physiological changes.
o Teenagers beginning puberty, infants, and school-aged children require increased nutrition,
but their metabolic demands are typically 15 to 20% above the basic metabolic rate.
5. Nursing Delivery of Care Models
Topic: Models of Nursing Care Delivery
Question: Which nursing delivery of care provides the nurse to plan and direct care of a group of
clients over a 24-hour period?
Options:
o a. Team nursing.
o b. Primary nursing.
o c. Case management.
o d. Functional nursing.
Rationale:
o Primary nursing is a model where a nurse is accountable for planning and coordinating
care for assigned clients around the clock, across all shifts.
o Functional nursing: Care is delivered by assigning specific tasks to different staff
members.
o Team nursing: A team of nursing personnel, including RNs, LPNs/LVNs, and UAPs, care
for a group of clients.
o Case management: A collaborative process of assessment, planning, facilitation, and
advocacy to meet individual health needs and promote cost-effective outcomes.
6. Preparing Toddlers for Procedures
Topic: Communicating with Toddlers about Procedures
Question: Which approach should the nurse use when preparing a toddler for a procedure?
Options:
o a. Demonstrate the procedure using a doll.
o b. Avoid asking the child to make choices.
o c. Plan a teaching session to last about 20 minutes.
o d. Show equipment but prevent child from handling it.
Rationale:
o Imitation is a key characteristic of toddler play. Demonstrating a procedure on a doll
provides a non-threatening and dramatic experience, aiding preparation.
o Toddlers are developing a sense of autonomy; offering choices whenever possible is
recommended.
o Toddlers have a short attention span; teaching sessions should be brief and repeated.
o Showing equipment helps reduce anxiety, and allowing the child to handle some
equipment can alleviate fear and frustration.
, 7. Standards of Nursing Practice: Confidentiality
Topic: Maintaining Client Confidentiality
Scenario: A nurse is approached by a reporter seeking information about a client who is the
daughter of a local politician.
Question: Which standard of nursing practice should the nurse use to respond?
Options:
o a. Caring.
o b. Veracity.
o c. Advocacy.
o d. Confidentiality.
Rationale:
o Confidentiality is the nurse's primary ethical and legal responsibility, supported by
HIPAA.
o It mandates that personal health information is not disclosed and access is limited.
o Caring: Involves the nurse's empathy and concern for the client's experience.
o Veracity: The duty to tell the truth.
o Advocacy: Supporting the client's best interests.
8. Managing Manipulative Behavior
Topic: Interventions for Antisocial Personality Disorder
Client: A morbidly obese male client with antisocial personality disorder attempting to get other
clients to give him food.
Question: What intervention should the nurse implement?
Options:
o a. Remove the client from the table and have him sit alone.
o b. Send the client back to his room and do not allow him to eat.
o c. Report the behavior to the on-call psychologist immediately.
o d. Confront the client about the consequences of the behavior.
Rationale:
o The nurse should provide a reality check by helping the client understand the
consequences of his manipulative behavior.
o Removing the client or restricting meals doesn't address the underlying behavior.
o While documentation is necessary, immediate reporting is not indicated for this specific
behavior.
9. Recognizing Hyperthyroidism
Topic: Clinical Manifestations of Thyroid Disorders
Client: A client presenting with weight loss, racing heart rate, and difficulty sleeping.
Assessment Findings: Moist skin with fine hair, prominent eyes, lid retraction, and a staring
expression.
Key Concepts in Nursing Practice
1. Neurological Assessment
Topic: Monitoring Altered Cerebral Function
Scenario: A male client lost consciousness after a fall and head injury.
Question: Which assessment finding is the earliest and most sensitive indication of altered
cerebral function?
Options:
o a. Unequal pupils.
o b. Loss of central reflexes.
o c. Inability to open the eyes.
o d. Change in level of consciousness.
Rationale:
o Neurological vital signs include serial assessments of TPR, blood pressure, and
components of the Glasgow Coma Scale (GCS).
o The GCS assesses verbal, musculoskeletal, and pupillary responses.
o 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.
o The other assessment data choices (unequal pupils, loss of central reflexes, inability to
open eyes) are considered late signs of altered cerebral function.
2. Prevention of Yeast Infections
Topic: Self-Care Measures for Yeast Infection Prevention
Client: A female client receiving instructions on preventing yeast infections.
Question: Which instructions should the nurse provide?
Options:
o a. Use a douche preparation no more than once a month.
o b. Increase daily intake of fiber and leafy green vegetables.
o c. Select nylon underwear that is loose-fitting, white, and comfortable.
o d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts.
Rationale:
o Candidiasis is a common genital tract infection in females, an overgrowth of Candida
albicans.
o This fungus thrives in a warm and moist environment.
, o Tight-fitting clothing, nonabsorbent underwear (like nylon), and pantyhose can perpetuate
this environment.
o Key Instructions:
Wear loose-fitting and absorbent clothing, such as cotton underwear.
Avoid using bubble-bath or bath salts, as these can irritate sensitive genital tissue.
o Important Considerations:
Douching is not recommended as it can irritate vaginal tissue, alter pH, and
contribute to fungal growth.
While increased dietary fiber is healthy, it is not the primary focus for preventing
yeast infections.
Cotton, not nylon, undergarments provide absorbency and reduce moisture.
3. Tuberculosis Management
Topic: Nursing Care for Active Tuberculosis
Client: A client with active tuberculosis (TB) admitted to the medical unit.
Question: What action is most important for the nurse to implement?
Options:
o a. Place an isolation cart in the hallway.
o b. Fit the client with a respirator mask.
o c. Don a clean gown for client care.
o d. Assign the client to a negative air-flow room.
Rationale:
o Active tuberculosis requires strict airborne precautions.
o The most critical action is to assign the client to a negative pressure air-flow room. This
minimizes the spread of airborne particles.
o While isolation gowns and carts are important for contact precautions, they are secondary
to air-flow management for TB.
o A respirator mask should be implemented when the client leaves the isolation
environment to prevent transmission.
4. Nutritional and Energy Demands
Topic: Individuals with Greatest Nutritional Needs
Question: Which individual has the greatest nutritional and energy demands?
Options:
o a. A pregnant woman.
o b. A teenager beginning puberty.
o c. A 3-month-old infant.
o d. A school-aged child.
Rationale:
, o A pregnant woman's metabolic demands increase by 20 to 24% above the basic
metabolic rate to support fetal growth and maternal physiological changes.
o Teenagers beginning puberty, infants, and school-aged children require increased nutrition,
but their metabolic demands are typically 15 to 20% above the basic metabolic rate.
5. Nursing Delivery of Care Models
Topic: Models of Nursing Care Delivery
Question: Which nursing delivery of care provides the nurse to plan and direct care of a group of
clients over a 24-hour period?
Options:
o a. Team nursing.
o b. Primary nursing.
o c. Case management.
o d. Functional nursing.
Rationale:
o Primary nursing is a model where a nurse is accountable for planning and coordinating
care for assigned clients around the clock, across all shifts.
o Functional nursing: Care is delivered by assigning specific tasks to different staff
members.
o Team nursing: A team of nursing personnel, including RNs, LPNs/LVNs, and UAPs, care
for a group of clients.
o Case management: A collaborative process of assessment, planning, facilitation, and
advocacy to meet individual health needs and promote cost-effective outcomes.
6. Preparing Toddlers for Procedures
Topic: Communicating with Toddlers about Procedures
Question: Which approach should the nurse use when preparing a toddler for a procedure?
Options:
o a. Demonstrate the procedure using a doll.
o b. Avoid asking the child to make choices.
o c. Plan a teaching session to last about 20 minutes.
o d. Show equipment but prevent child from handling it.
Rationale:
o Imitation is a key characteristic of toddler play. Demonstrating a procedure on a doll
provides a non-threatening and dramatic experience, aiding preparation.
o Toddlers are developing a sense of autonomy; offering choices whenever possible is
recommended.
o Toddlers have a short attention span; teaching sessions should be brief and repeated.
o Showing equipment helps reduce anxiety, and allowing the child to handle some
equipment can alleviate fear and frustration.
, 7. Standards of Nursing Practice: Confidentiality
Topic: Maintaining Client Confidentiality
Scenario: A nurse is approached by a reporter seeking information about a client who is the
daughter of a local politician.
Question: Which standard of nursing practice should the nurse use to respond?
Options:
o a. Caring.
o b. Veracity.
o c. Advocacy.
o d. Confidentiality.
Rationale:
o Confidentiality is the nurse's primary ethical and legal responsibility, supported by
HIPAA.
o It mandates that personal health information is not disclosed and access is limited.
o Caring: Involves the nurse's empathy and concern for the client's experience.
o Veracity: The duty to tell the truth.
o Advocacy: Supporting the client's best interests.
8. Managing Manipulative Behavior
Topic: Interventions for Antisocial Personality Disorder
Client: A morbidly obese male client with antisocial personality disorder attempting to get other
clients to give him food.
Question: What intervention should the nurse implement?
Options:
o a. Remove the client from the table and have him sit alone.
o b. Send the client back to his room and do not allow him to eat.
o c. Report the behavior to the on-call psychologist immediately.
o d. Confront the client about the consequences of the behavior.
Rationale:
o The nurse should provide a reality check by helping the client understand the
consequences of his manipulative behavior.
o Removing the client or restricting meals doesn't address the underlying behavior.
o While documentation is necessary, immediate reporting is not indicated for this specific
behavior.
9. Recognizing Hyperthyroidism
Topic: Clinical Manifestations of Thyroid Disorders
Client: A client presenting with weight loss, racing heart rate, and difficulty sleeping.
Assessment Findings: Moist skin with fine hair, prominent eyes, lid retraction, and a staring
expression.
