HESI Comprehensive Exit
Exam 1 and Retake
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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
Rationale (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
Rationale (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
Rationale (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
Rationale 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
Rationale (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
Rationale (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
Rationale (Confidentiality is the nurse's primary responsibility and is
Exam 1 and Retake
Questions and answers with
Rationale | Graded A+ |
Verified Answers | Latest
Version | Brand New Version!
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
Rationale (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
Rationale (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
Rationale (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
Rationale 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
Rationale (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
Rationale (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
Rationale (Confidentiality is the nurse's primary responsibility and is
