HESI Comprehensive Exit Exam 1 (And
Rationale)
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.)
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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 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 absorbency 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 basal metabolic rate. The
other clients require only 15 to 20% more than the basal 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.)
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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
