HESI Comprehensive Exam A Practice Questions & Answers.
1. A nurse is assessing the skin of an immobilized patient. What will the nurse do?
a. Assess the skin every 4 hours.
b. Limit the amount of fluid intake.
c. Use a standardized tool such as the Braden Scale.
d. Have special times for inspection so as to not interrupt routine care.
ANS: C
Consistently use a standardized tool, such as the Braden Scale. This identifies
patients with a high risk for impaired skin integrity. Skin assessment can be as often
as every hour. Limiting fluids can lead to dehydration, increasing skin breakdown.
Observe the skin often during routine care.
2. The nurse is caring for an older-adult patient with a diagnosis of urinary tract
infection (UTI). Upon assessment the nurse finds the patient confused and
agitated. How will the nurse interpret these assessment findings?
a. These are normal signs of aging.
b. These are early signs of dementia.
c. These are purely psychological in origin.
d. These are common manifestation with UTIs.
ANS: D
The primary symptom of compromised older patients with an acute urinary tract
infection or fever is confusion. Acute confusion in older adults is not normal; a
thorough nursing assessment is the priority. With the diagnosis of urinary tract
infection, these are not early signs of dementia and they are not purely
psychological.
3. A patient has damage to the cerebellum. Which disorder is most important for the
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, nurse to assess?
a. Imbalance
b. Hemiplegia
c. Muscle sprain
d. Lower extremity paralysis
ANS: A
Damage to the cerebellum causes problems with balance, and motor impairment is
directly related to the amount of destruction of the motor strip. A stroke can lead to
hemiplegia. Direct trauma to the musculoskeletal system results in bruises,
contusions, sprains, and fractures. A complete transection of the spinal cord can
lead to lower extremity paralysis.
4. Which patient will cause the nurse to select a nursing diagnosis of Impaired
physical mobility for a care plan?
a. A patient who is completely immobile
b. A patient who is not completely immobile
c. A patient at risk for single-system involvement
d. A patient who is at risk for multisystem problems
ANS: B
The diagnosis of Impaired physical mobility applies to the patient who has some
limitation but is not completely immobile. The diagnosis of Risk for disuse
syndrome applies to the patient who is immobile and at risk for multisystem
problems because of inactivity. Beyond these diagnoses, the list of potential
diagnoses is extensive because immobility affects multiple body systems.
5. The patient has the nursing diagnosis of Impaired physical mobility related
to pain in the left shoulder. Which priority action will the nurse take?
a. Encourage the patient to do self-care.
b. Keep the patient as mobile as possible.
c. Encourage the patient to perform ROM.
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1. A nurse is assessing the skin of an immobilized patient. What will the nurse do?
a. Assess the skin every 4 hours.
b. Limit the amount of fluid intake.
c. Use a standardized tool such as the Braden Scale.
d. Have special times for inspection so as to not interrupt routine care.
ANS: C
Consistently use a standardized tool, such as the Braden Scale. This identifies
patients with a high risk for impaired skin integrity. Skin assessment can be as often
as every hour. Limiting fluids can lead to dehydration, increasing skin breakdown.
Observe the skin often during routine care.
2. The nurse is caring for an older-adult patient with a diagnosis of urinary tract
infection (UTI). Upon assessment the nurse finds the patient confused and
agitated. How will the nurse interpret these assessment findings?
a. These are normal signs of aging.
b. These are early signs of dementia.
c. These are purely psychological in origin.
d. These are common manifestation with UTIs.
ANS: D
The primary symptom of compromised older patients with an acute urinary tract
infection or fever is confusion. Acute confusion in older adults is not normal; a
thorough nursing assessment is the priority. With the diagnosis of urinary tract
infection, these are not early signs of dementia and they are not purely
psychological.
3. A patient has damage to the cerebellum. Which disorder is most important for the
135
, nurse to assess?
a. Imbalance
b. Hemiplegia
c. Muscle sprain
d. Lower extremity paralysis
ANS: A
Damage to the cerebellum causes problems with balance, and motor impairment is
directly related to the amount of destruction of the motor strip. A stroke can lead to
hemiplegia. Direct trauma to the musculoskeletal system results in bruises,
contusions, sprains, and fractures. A complete transection of the spinal cord can
lead to lower extremity paralysis.
4. Which patient will cause the nurse to select a nursing diagnosis of Impaired
physical mobility for a care plan?
a. A patient who is completely immobile
b. A patient who is not completely immobile
c. A patient at risk for single-system involvement
d. A patient who is at risk for multisystem problems
ANS: B
The diagnosis of Impaired physical mobility applies to the patient who has some
limitation but is not completely immobile. The diagnosis of Risk for disuse
syndrome applies to the patient who is immobile and at risk for multisystem
problems because of inactivity. Beyond these diagnoses, the list of potential
diagnoses is extensive because immobility affects multiple body systems.
5. The patient has the nursing diagnosis of Impaired physical mobility related
to pain in the left shoulder. Which priority action will the nurse take?
a. Encourage the patient to do self-care.
b. Keep the patient as mobile as possible.
c. Encourage the patient to perform ROM.
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