, HESI Exit V5
1. The nurse has just admitted a client with severe depression. From which focus should the
nurse identify a priority nursing diagnosis?
A Nutrition
B Elimination
C Activity
D Safety
Correct Answer: D
Rationale: Safety is the priority for a client with severe depression due to the risk of self-harm
or suicide. The client may have suicidal ideation, which requires immediate intervention.
Nutrition (A), elimination (B), and activity (C) are important but do not present the same
immediate life-threatening risk .
2. The nurse enters the room as a 3-year-old child is having a generalized seizure. Which
intervention should the nurse do FIRST?
A Clear the area of any hazards
B Place the child on the side
C Restrain the child
D Give the prescribed anticonvulsant
Correct Answer: B
Rationale: During a seizure, the priority is to place the child on their side to maintain an open
airway and prevent aspiration. Clearing hazards (A) is also important but the airway is the
priority. Restraining the child (C) is contraindicated as it can cause injury. Giving anticonvulsants
(D) is not the first action during an active seizure .
3. The nurse is reviewing a depressed client's history from an earlier admission. Documentation
of anhedonia is noted. The nurse understands that this finding refers to:
A Reports of difficulty falling and staying asleep
B Expression of persistent suicidal thoughts
C Lack of enjoyment in usual pleasures
D Reduced senses of taste and smell
,Correct Answer: C
Rationale: Anhedonia is the inability to experience pleasure from activities usually found
enjoyable. Difficulty sleeping (A) is insomnia. Suicidal thoughts (B) are suicidal ideation. Reduced
senses (D) are not specifically anhedonia .
4. A client has just returned to the medical-surgical unit following a segmental lung resection.
After assessing the client, the first nursing action would be to:
A Administer pain medication
B Suction excessive tracheobronchial secretions
C Assist client to turn, deep breathe and cough
D Monitor oxygen saturation
Correct Answer: B
Rationale: After lung resection, maintaining a patent airway is the priority. Excessive secretions
can obstruct the airway and impair gas exchange. Suctioning should be performed first. Pain
medication (A) may be needed but does not address the immediate airway concern. Turning,
coughing, and deep breathing (C) are important but suctioning takes priority. Monitoring oxygen
saturation (D) is part of assessment but does not address the underlying issue .
5. While assessing a client in an outpatient facility with a panic disorder, the nurse completes a
thorough health history and physical exam. Which finding is most significant for this client?
A Compulsive behavior
B Sense of impending doom
C Fear of flying
D Predictable episodes
Correct Answer: B
Rationale: A sense of impending doom is a hallmark symptom of panic disorder. Compulsive
behavior (A) is associated with OCD. Fear of flying (C) is a specific phobia. Panic attacks are
typically unpredictable (D) .
6. A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this
child enters the hospital room for the first time, the toddler runs to the mother, clings to her,
and begins to cry. What would be the initial action by the nurse?
, A Arrange to change client care assignments
B Explain that this behavior is expected
C Discuss the appropriate use of "time-out"
D Explain that the child needs extra attention
Correct Answer: B
Rationale: This behavior is typical for a hospitalized toddler experiencing stranger anxiety.
Explaining that this behavior is expected helps the mother understand that it is normal.
Changing assignments (A) is unnecessary. Time-out (C) is not appropriate. Extra attention (D)
may be needed but explaining the behavior is the initial action .
7. A 15-year-old client with a lengthy confining illness is at risk for altered growth and
development of which task?
A Loss of control
B Insecurity
C Dependence
D Lack of trust
Correct Answer: C
Rationale: Adolescence is a time of developing independence. A lengthy confining illness may
promote dependence on caregivers, interfering with this developmental task. Loss of control
(A), insecurity (B), and lack of trust (D) are also risks but dependence is the primary
developmental concern .
8. Which playroom activities should the nurse organize for a small group of 7-year-old
hospitalized children?
A Sports and games with rules
B Finger paints and water play
C "Dress-up" clothes and props
D Chess and television programs
Correct Answer: A
Rationale: School-age children (6-12 years) enjoy organized games with rules. Finger paints (B)
and dress-up (C) are more appropriate for younger children. Chess (D) may be too advanced for
some 7-year-olds .
1. The nurse has just admitted a client with severe depression. From which focus should the
nurse identify a priority nursing diagnosis?
A Nutrition
B Elimination
C Activity
D Safety
Correct Answer: D
Rationale: Safety is the priority for a client with severe depression due to the risk of self-harm
or suicide. The client may have suicidal ideation, which requires immediate intervention.
Nutrition (A), elimination (B), and activity (C) are important but do not present the same
immediate life-threatening risk .
2. The nurse enters the room as a 3-year-old child is having a generalized seizure. Which
intervention should the nurse do FIRST?
A Clear the area of any hazards
B Place the child on the side
C Restrain the child
D Give the prescribed anticonvulsant
Correct Answer: B
Rationale: During a seizure, the priority is to place the child on their side to maintain an open
airway and prevent aspiration. Clearing hazards (A) is also important but the airway is the
priority. Restraining the child (C) is contraindicated as it can cause injury. Giving anticonvulsants
(D) is not the first action during an active seizure .
3. The nurse is reviewing a depressed client's history from an earlier admission. Documentation
of anhedonia is noted. The nurse understands that this finding refers to:
A Reports of difficulty falling and staying asleep
B Expression of persistent suicidal thoughts
C Lack of enjoyment in usual pleasures
D Reduced senses of taste and smell
,Correct Answer: C
Rationale: Anhedonia is the inability to experience pleasure from activities usually found
enjoyable. Difficulty sleeping (A) is insomnia. Suicidal thoughts (B) are suicidal ideation. Reduced
senses (D) are not specifically anhedonia .
4. A client has just returned to the medical-surgical unit following a segmental lung resection.
After assessing the client, the first nursing action would be to:
A Administer pain medication
B Suction excessive tracheobronchial secretions
C Assist client to turn, deep breathe and cough
D Monitor oxygen saturation
Correct Answer: B
Rationale: After lung resection, maintaining a patent airway is the priority. Excessive secretions
can obstruct the airway and impair gas exchange. Suctioning should be performed first. Pain
medication (A) may be needed but does not address the immediate airway concern. Turning,
coughing, and deep breathing (C) are important but suctioning takes priority. Monitoring oxygen
saturation (D) is part of assessment but does not address the underlying issue .
5. While assessing a client in an outpatient facility with a panic disorder, the nurse completes a
thorough health history and physical exam. Which finding is most significant for this client?
A Compulsive behavior
B Sense of impending doom
C Fear of flying
D Predictable episodes
Correct Answer: B
Rationale: A sense of impending doom is a hallmark symptom of panic disorder. Compulsive
behavior (A) is associated with OCD. Fear of flying (C) is a specific phobia. Panic attacks are
typically unpredictable (D) .
6. A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this
child enters the hospital room for the first time, the toddler runs to the mother, clings to her,
and begins to cry. What would be the initial action by the nurse?
, A Arrange to change client care assignments
B Explain that this behavior is expected
C Discuss the appropriate use of "time-out"
D Explain that the child needs extra attention
Correct Answer: B
Rationale: This behavior is typical for a hospitalized toddler experiencing stranger anxiety.
Explaining that this behavior is expected helps the mother understand that it is normal.
Changing assignments (A) is unnecessary. Time-out (C) is not appropriate. Extra attention (D)
may be needed but explaining the behavior is the initial action .
7. A 15-year-old client with a lengthy confining illness is at risk for altered growth and
development of which task?
A Loss of control
B Insecurity
C Dependence
D Lack of trust
Correct Answer: C
Rationale: Adolescence is a time of developing independence. A lengthy confining illness may
promote dependence on caregivers, interfering with this developmental task. Loss of control
(A), insecurity (B), and lack of trust (D) are also risks but dependence is the primary
developmental concern .
8. Which playroom activities should the nurse organize for a small group of 7-year-old
hospitalized children?
A Sports and games with rules
B Finger paints and water play
C "Dress-up" clothes and props
D Chess and television programs
Correct Answer: A
Rationale: School-age children (6-12 years) enjoy organized games with rules. Finger paints (B)
and dress-up (C) are more appropriate for younger children. Chess (D) may be too advanced for
some 7-year-olds .
