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HESI COMPREHENSIVE EXAM | QUESTIONS AND ANSWERS | 100% CORRECT | 2024.
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HESI COMPREHENSIVE EXAM | QUESTIONS AND ANSWERS | 100% CORRECT | 2024. 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 c...

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  • 23 de septiembre de 2024
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HESI COMPREHENSIVE EXAM | QUESTIONS AND ANSWERS |
100% CORRECT | 2024.




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

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 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

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

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

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

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

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

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

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

, 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. nYoung nadult nfemale npresents nwith nperiorbital necchymosis non nright nside, n3 ncm
nlaceration non nleft nparietal narea, napproximately n1 ncm ndeep nwith ntissue nbridging. nStates

nher nboyfriend nis nabusive. n- n nD




A nretired noffice nworker nis nadmitted nto nthe npsychiatric ninpatient nunit nwith na ndiagnosis nof
nmajor ndepression. nThe ninitial nnursing ncare nplan nincludes nthe ngoal, n"Assist nclient nto

nexpress nfeelings nof nanger." nWhich nnursing nintervention nis nmost nimportant nto ninclude nin

nthe nclient's nplan nof ncare?

a. nTeach nthat nanger nwill nsubside nafter ntwo nweeks non nantidepressants.
b. nAsk nclient nto ndescribe ntriggers nof nanger.
c. nGather nmore ndata nabout nsocial nsupport.
d. nCollaborate nwith nthe ntreatment nteam nabout nrevising nthe ngoal. n- n nB

The nnurse ndetermines nthat na nclient's nbody nweight nis n105% nabove nthe nstandardized
nheight-weight nscale. nWhich nrelated nfactor nshould nthe nnurse ninclude nin nthe nnursing

nproblem, n"Imbalanced nnutrition: nmore nthan nbody nrequirements?"

a. nMorbidly nobese.
b. nMarkedly nobese.
c. nInadequate nlifestyle nchanges nin ndiet nand nexercise.
d. nIncreased nmorbidity nand nmortality nrisks. n- n nC

A nchild nis nreceiving nmaintainance nintravenous n(IV) nfluids nat nthe nrate nof n1000 nml nfor nthe
nfirst n10 nkg nof nbody nweight, nplus n50 nml/kg nper nday nfor neach nkilogram nbetween n10 nand

n20. nHow nmany nmilliliters nper nhour nshould nthe nnurse nprogram nthe ninfusion npump nfor na

nchild nwho nweighs n19.5 nkg? n(Enter nnumeric nvalue nonly. nIf nrounding nis nrequired, nround nto

nthe nnearest nwhole nnumber.) n- n n61




A n6-year-old nchild nis nalert nbut nquiet nwhen nbrought nto nthe nemergency ncenter nwith
nperiorbital necchymosis nand necchymosis nbehind nthe nears. nThe nnurse nsuspects npotential

nchild nabuse nand ncontinues nto nassess nthe nchild nfor nadditional nmanifestations nof na

nbasilar nskull nfracture. nWhat nassessment nfinding nwould nbe nconsistent nwith na nbasilar

nskull nfracture?

a. nAsymmetry nof nthe nface nand neye nmovements.
b. nAbnormal nposition nand nmovement nof nthe narm.

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