HESI Comprehensive Exit Exam 1 (And Rationale)
Questions and Verified Answers
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?
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness. Correct Answer: D
(Neurological vital signs include serial assessments of TPR, blood pressure, and components of the
Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. 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. The other assessment data choices are late signs of
altered cerebral function.)
A nurse is planning to teach self-care measures to a female client about prevention of yeast infections.
Which instructions should the nurse provide?
a. Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and comfortable.
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts. Correct Answer: D
(A common genital tract infection in females is candidiasis, which is an overgrowth of the normal
vaginal flora of Candida albicans that thrives in an environment that is warm and moist and is
perpetuated by tight-fitting clothing, underwear, or pantyhose made of nonabsorbent materials. The
client should wear clothing that is loose fitting and absorbent, such as cotton underwear, and avoid using
bubble-bath or bath salts which further irritate sensitive genital tissue. Douching is not recommended
because it can irritate vaginal tissue, alter pH, and contribute to fungal growth. While increasing dietary
fiber intake encourages healthy, nutritional guidelines, it is not the focus of the teaching. Cotton, not
nylon undergarments, provide absorbancy and reduce moisture in the perineal area.)
,A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important
for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room. Correct Answer: D
(Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to
a negative pressure air-flow room. Although isolation gowns and isolation carts should be implemented
for clients in isolation with contact precautions, it is most important that air flow from the room is
minimized when the client has TB. The respirator mask should be implemented when the client leaves
the isolation environment.)
The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health
clinic. Which individual has the greatest nutritional and energy demands?
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child. Correct Answer: A
A pregnant woman's metabolic demands are 20 to 24% more than the basic metabolic rate. The other
clients require only 15 to 20% more than the basic metabolic rate.
What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-
hour period?
a. Team nursing.
b. Primary nursing.
c. Case management.
,d. Functional nursing. Correct Answer: B
(Primary nursing is a model of delivery of care where a nurse is accountable for planning care for clients
around the clock. Functional nursing is a care delivery model that provides client care by assignment of
functions or tasks. Team nursing is a care delivery model where assignments to a group of clients are
provided by a mixed-staff team. Case management is the delivery of care that uses a collaborative process
of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health
needs and promote quality cost-effective outcomes.)
Which approach should the nurse use when preparing a toddler for a procedure?
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
c. Plan a teaching session to last about 20 minutes.
d. Show equipment but prevent child from handling it. Correct Answer: A
(Imitation is one of the most distinguishing characteristics of toddler play, so demonstration of a
procedure on a doll enables a non-threatening, dramatic experience that can help prepare the toddler for
the actual procedure. The primary developmental task in toddlerhood is acquiring a sense of autonomy,
so giving choices whenever possible to a toddler is recommended, not avoiding asking the toddler to
make a choice. Since the toddler's attention span is short, teaching sessions should be brief and can be
repeated 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 daughter of a local politician. When the nurse approaches a
man who is reading the names on the hall doors, he identifies himself as a reporter for the local
newspaper and requests information about the client's status. Which standard of nursing practice should
the nurse use to respond?
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality. Correct Answer: D
(Confidentiality is the nurse's primary responsibility and is supported by HIPAA, which mandates that
personal information is not disclosed and access to sensitive client information is limited. Caring involves
, the nurse's concern about how the client experiences the world. Veracity is the nurse's duty to tell the
truth and not deceive others. Advocacy is support of the client's best interests.)
A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat,
low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him
part of their meals. What intervention should the nurse implement?
a. Remove the client from the table and have him sit alone.
b. Send the client back to his room and do not allow him to eat.
c. Report the behavior to the on-call psychologist immediately.
d. Confront the client about the consequences of the behavior. Correct Answer: D
(The nurse should provide a reality check by helping the client realize that there are consequences to his
behavior. Removing the client from the room or table does not help the client realize that his behavior is
manipulative and harmful to himself as well as others. This behavior needs to be documented, but does
not need to be reported immediately.)
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. Cushing syndrome.
c. Multiple sclerosis.
d. Addison's disease. Correct Answer: A
(This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease, which is an
autoimmune condition affecting the thyroid. Cushing syndrome, multiple sclerosis, or Addison's disease
are not associated with these symptoms.)
Which information should the nurse give a client with chronic kidney disease (CKD)?
a. Restrict calcium-rich foods.
b. Obtain monthly B12 injections.
Questions and Verified Answers
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?
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness. Correct Answer: D
(Neurological vital signs include serial assessments of TPR, blood pressure, and components of the
Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. 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. The other assessment data choices are late signs of
altered cerebral function.)
A nurse is planning to teach self-care measures to a female client about prevention of yeast infections.
Which instructions should the nurse provide?
a. Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and comfortable.
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts. Correct Answer: D
(A common genital tract infection in females is candidiasis, which is an overgrowth of the normal
vaginal flora of Candida albicans that thrives in an environment that is warm and moist and is
perpetuated by tight-fitting clothing, underwear, or pantyhose made of nonabsorbent materials. The
client should wear clothing that is loose fitting and absorbent, such as cotton underwear, and avoid using
bubble-bath or bath salts which further irritate sensitive genital tissue. Douching is not recommended
because it can irritate vaginal tissue, alter pH, and contribute to fungal growth. While increasing dietary
fiber intake encourages healthy, nutritional guidelines, it is not the focus of the teaching. Cotton, not
nylon undergarments, provide absorbancy and reduce moisture in the perineal area.)
,A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important
for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room. Correct Answer: D
(Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to
a negative pressure air-flow room. Although isolation gowns and isolation carts should be implemented
for clients in isolation with contact precautions, it is most important that air flow from the room is
minimized when the client has TB. The respirator mask should be implemented when the client leaves
the isolation environment.)
The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health
clinic. Which individual has the greatest nutritional and energy demands?
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child. Correct Answer: A
A pregnant woman's metabolic demands are 20 to 24% more than the basic metabolic rate. The other
clients require only 15 to 20% more than the basic metabolic rate.
What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-
hour period?
a. Team nursing.
b. Primary nursing.
c. Case management.
,d. Functional nursing. Correct Answer: B
(Primary nursing is a model of delivery of care where a nurse is accountable for planning care for clients
around the clock. Functional nursing is a care delivery model that provides client care by assignment of
functions or tasks. Team nursing is a care delivery model where assignments to a group of clients are
provided by a mixed-staff team. Case management is the delivery of care that uses a collaborative process
of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health
needs and promote quality cost-effective outcomes.)
Which approach should the nurse use when preparing a toddler for a procedure?
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
c. Plan a teaching session to last about 20 minutes.
d. Show equipment but prevent child from handling it. Correct Answer: A
(Imitation is one of the most distinguishing characteristics of toddler play, so demonstration of a
procedure on a doll enables a non-threatening, dramatic experience that can help prepare the toddler for
the actual procedure. The primary developmental task in toddlerhood is acquiring a sense of autonomy,
so giving choices whenever possible to a toddler is recommended, not avoiding asking the toddler to
make a choice. Since the toddler's attention span is short, teaching sessions should be brief and can be
repeated 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 daughter of a local politician. When the nurse approaches a
man who is reading the names on the hall doors, he identifies himself as a reporter for the local
newspaper and requests information about the client's status. Which standard of nursing practice should
the nurse use to respond?
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality. Correct Answer: D
(Confidentiality is the nurse's primary responsibility and is supported by HIPAA, which mandates that
personal information is not disclosed and access to sensitive client information is limited. Caring involves
, the nurse's concern about how the client experiences the world. Veracity is the nurse's duty to tell the
truth and not deceive others. Advocacy is support of the client's best interests.)
A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat,
low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him
part of their meals. What intervention should the nurse implement?
a. Remove the client from the table and have him sit alone.
b. Send the client back to his room and do not allow him to eat.
c. Report the behavior to the on-call psychologist immediately.
d. Confront the client about the consequences of the behavior. Correct Answer: D
(The nurse should provide a reality check by helping the client realize that there are consequences to his
behavior. Removing the client from the room or table does not help the client realize that his behavior is
manipulative and harmful to himself as well as others. This behavior needs to be documented, but does
not need to be reported immediately.)
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. Cushing syndrome.
c. Multiple sclerosis.
d. Addison's disease. Correct Answer: A
(This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease, which is an
autoimmune condition affecting the thyroid. Cushing syndrome, multiple sclerosis, or Addison's disease
are not associated with these symptoms.)
Which information should the nurse give a client with chronic kidney disease (CKD)?
a. Restrict calcium-rich foods.
b. Obtain monthly B12 injections.
