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HESI Comprehensive Exit Exam 1 (125 questions and answers (And Rationale)100% guaranteed.
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HESI Comprehensive Exit Exam 1 (125questions and answers (And
Rationale)100% guaranteed
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.
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.
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.)
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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.
,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.
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.
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.
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.
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.
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.
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.
, c. Avoid salt substitutes.
d. Increase daily intake of fiber.
C
(A client with CKD should restrict sodium and potassium dietary intake, and salt
substitutes usually contain potassium, so they should avoid using them.
Hypocalcemia is a complication of CKD and calcium supplements are often needed.
Anemia related to CKD is treated with iron, folic acid, and erythropoietin, not B12
injections. Although increasing fiber is a common dietary recommendation, it not an
essential part of client teaching for CKD.)
A young adult female arrives at the emergency department with a black right eye and
is bleeding from the left side of her head. She reports that her boyfriend has been
abusing her physically. The nurse performs a history and physical examination. How
should the nurse document these findings?
a. Client alleges that her boyfriend beat her up. Client is bleeding from the left side of
the face.
b. Client reports her boyfriend hit her in the eye and on the head. Bruises and
lacerations present on face.
c. Client presents with a right black eye and a cut on the left side of her head that is
bleeding. Reports abusive boyfriend responsible for injuries. Needs referral to a safe
place to stay.
d. Young adult female presents with periorbital ecchymosis on right side, 3 cm
laceration on left parietal area, approximately 1 cm deep with tissue bridging. States
her boyfriend is abusive.
D
(Proper documentation of abuse as reported by the victim is crucial, and the nurse
should document specific and objective data that gives an accurate depiction of the
events without documentation of judgmental inferences. All the other choices lack
specificity and important details related to the event.)
A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of
major depression. The initial nursing care plan includes the goal, "Assist client to
express feelings of anger." Which nursing intervention is most important to include in
the client's plan of care?
a. Teach that anger will subside after two weeks on antidepressants.
b. Ask client to describe triggers of anger.
c. Gather more data about social support.
d. Collaborate with the treatment team about revising the goal.
B
(Depression is associated with feelings of anger, and clients are often not aware of
these feelings. Awareness is the first step in dealing with anger (or any other
feeling), so the nurse's efforts should be directed toward increasing the client's
awareness of feelings. Anger may persist after beginning antidepressant therapy,
and it may not be necessary to revise the goal. Gathering data on social support
systems can assist the client to cope, but it's most important to ask the client to
describe triggers of anger.)
The nurse determines that a client's body weight is 105% above the standardized
height-weight scale. Which related factor should the nurse include in the nursing
problem, "Imbalanced nutrition: more than body requirements?"
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