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HESI Comprehensive Exam
2023
,HESI COMPREHENSIVE EXAM
, two weeks later to evaluate his blood pressure (BP). His BP is
158/106 and he admits that he has not been taking the prescribed
medication because the drugs make him “feel bad”. In explaining
the need for hypertension control, the nurse should stress that an
elevated BP places the client at risk for which pathophysiological
condition?
a- Blindness secondary to cataracts
b- Acute kidney injury due to glomerular damage
c- Stroke secondary to hemorrhage
d- Heart block due to myocardial damage
Rationale: Stroke related to cerebral hemorrhage is major risk for
uncontrolled hypertension.
3. The nurse observes an unlicensed assistive personnel (UAP)
positioning a newly admitted client who has a seizure disorder.
The client is supine and the UAP is placing soft pillows along the
side rails. What action should the nurse implement?
a- Ensure that the UAP has placed the pillows effectively to protect the
client.
b- Instruct the UAP to obtain soft blankets to secure to the side rails
instead of pillows.
, a- Assume responsibility for placing the pillows while the UAP
completes another task.
b- Ask the UAP to use some of the pillows to prop the client in a side
lying position.
Rationale: The nurse should instruct the UAP to pad the side rails with
soft blankest because the use of pillows could result in suffocation and
would need to be removed at the onset of the seizure. The nurse can
delegate paddling the side rails to the UAP
4. An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for the past 12 days. Which assessment
finding requires immediate follow-up?
a- Describes life without purpose
b- Complains of nausea and loss of appetite
c- States is often fatigued and drowsy
d- Exhibits an increase in sweating.
Rationale: Cymbalta is a selective serotonin and norepinephrine
reuptake inhibitor that is known to increase the risk of suicidal
thinking in adolescents and young adults with major depressive
disorder. B, C and D are side effects
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