1|Page
HESI Critical care exit exam ACTUAL VERIFIED
QUESTIONS AND CORRECT DETAILED ANSWERS
LATEST UPDATE.pdf
A 6-year-old child is alert but quiet when brought to the
emergency center with periorbital ecchymosis and
ecchymosis behind the ears. The nurse suspects potential
child abuse and continues to assess the child for
additional manifestations of a basilar skull fracture. What
assessment finding would be consistent with a basilar
skull fracture?
A. Hematemesis and abdominal distention.
B. Asymmetry of the face and eye movements.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and mo - Answer-Rhinorrhoea or
otorrhoea with Halo sign.
RATIONALE:
Raccoon eyes (periorbital ecchymosis) and Battle's sign
(ecchymosis behind the ear over the
mastoid process) are both signs of a basilar skull fracture,
so the nurse should assess for possible
meningeal tears that manifest as a Halo sign with CSF
leakage from the ears or nose (D). (A) is
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consistent with orbital fractures. (B) occurs with wrenching
traumas of the shoulder or arm
fractures. (C) occurs with blunt abdominal injuries.
The nurse is assessing a client who complains of weight
loss, racing heart rate, and difficulty
sleeping. The nurse determines the client has moist skin
with fine hair, prominent eyes, lid
retraction, and a staring expression. These findings are
consistent with which disorder?
A. Grave's disease.
B. Multiple sclerosis.
C. Addison's disease.
D. Cushing syndrome. - Answer-Grave's disease
RATIONALE:
This client is exhibiting symptoms associated with
hyperthyroidism or Grave's disease (A),
which is an autoimmune condition affecting the thyroid. (B,
C, and D) are not associated with
these symptoms.
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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. A nystagmus on the left.
B. Exophthalmos on the right.
C. Ptosis on the left eyelid.
D. Astigmatism on the right. - Answer-Ptosis on the left
eyelid
Rationale: Ptosis is the term to describe an eyelid droop
that covers a large portion of the iris (A), which
may result from oculomotor nerve or eyelid muscle
disorder. (B) is characterized by rapid,
rhythmic movement of both eyes. (C) is a distortion of the
lens of the eye, causing decreased
visual acuity. (D) is a term used to describe a protrusion of
the eyeballs that occurs with
hyperthyroidism.
The nurse is assessing a child's weight and height during
a clinic visit prior to starting school.
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The nurse plots the child's weight on the growth chart and
notes that the child's weight is in the
95th percentile for the child's height. What action should
the nurse take?
A. Question the type and quantity of foods eaten in a
typical day.
B. Encourage giving two additional snacks each day to the
child.
C. Recommend a daily intake of at least four glasses of
whole milk.
D. Assess for signs of poor - Answer-A. Question the type
and quantity of foods eaten in a typical day.
RATIONALE:
The child is overweight for height, so assessment of the
child's daily diet (C) should be
determined. The child does not need (A or B), both of
which will increase the child's weight.
Poor nutrition (D) is commonly seen in underweight
children, not overweight.
A child is receiving maintenance intravenous (IV) fluids at
the rate of 1000 mL for the first 10
HESI Critical care exit exam ACTUAL VERIFIED
QUESTIONS AND CORRECT DETAILED ANSWERS
LATEST UPDATE.pdf
A 6-year-old child is alert but quiet when brought to the
emergency center with periorbital ecchymosis and
ecchymosis behind the ears. The nurse suspects potential
child abuse and continues to assess the child for
additional manifestations of a basilar skull fracture. What
assessment finding would be consistent with a basilar
skull fracture?
A. Hematemesis and abdominal distention.
B. Asymmetry of the face and eye movements.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and mo - Answer-Rhinorrhoea or
otorrhoea with Halo sign.
RATIONALE:
Raccoon eyes (periorbital ecchymosis) and Battle's sign
(ecchymosis behind the ear over the
mastoid process) are both signs of a basilar skull fracture,
so the nurse should assess for possible
meningeal tears that manifest as a Halo sign with CSF
leakage from the ears or nose (D). (A) is
,2|Page
consistent with orbital fractures. (B) occurs with wrenching
traumas of the shoulder or arm
fractures. (C) occurs with blunt abdominal injuries.
The nurse is assessing a client who complains of weight
loss, racing heart rate, and difficulty
sleeping. The nurse determines the client has moist skin
with fine hair, prominent eyes, lid
retraction, and a staring expression. These findings are
consistent with which disorder?
A. Grave's disease.
B. Multiple sclerosis.
C. Addison's disease.
D. Cushing syndrome. - Answer-Grave's disease
RATIONALE:
This client is exhibiting symptoms associated with
hyperthyroidism or Grave's disease (A),
which is an autoimmune condition affecting the thyroid. (B,
C, and D) are not associated with
these symptoms.
,3|Page
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. A nystagmus on the left.
B. Exophthalmos on the right.
C. Ptosis on the left eyelid.
D. Astigmatism on the right. - Answer-Ptosis on the left
eyelid
Rationale: Ptosis is the term to describe an eyelid droop
that covers a large portion of the iris (A), which
may result from oculomotor nerve or eyelid muscle
disorder. (B) is characterized by rapid,
rhythmic movement of both eyes. (C) is a distortion of the
lens of the eye, causing decreased
visual acuity. (D) is a term used to describe a protrusion of
the eyeballs that occurs with
hyperthyroidism.
The nurse is assessing a child's weight and height during
a clinic visit prior to starting school.
, 4|Page
The nurse plots the child's weight on the growth chart and
notes that the child's weight is in the
95th percentile for the child's height. What action should
the nurse take?
A. Question the type and quantity of foods eaten in a
typical day.
B. Encourage giving two additional snacks each day to the
child.
C. Recommend a daily intake of at least four glasses of
whole milk.
D. Assess for signs of poor - Answer-A. Question the type
and quantity of foods eaten in a typical day.
RATIONALE:
The child is overweight for height, so assessment of the
child's daily diet (C) should be
determined. The child does not need (A or B), both of
which will increase the child's weight.
Poor nutrition (D) is commonly seen in underweight
children, not overweight.
A child is receiving maintenance intravenous (IV) fluids at
the rate of 1000 mL for the first 10
