HESI Comprehensive Exam
A child is brought to the emergency department by ambulance after swallowing several
capsules of acetaminophen. What statement by the nurse indicates a need for further
information?
"We need to administer the antidote N-acetyl cysteine and dilute it in juice or soda."
"A loading dose of N-acetyl cysteine has to be followed by maintenance doses." Incorrect
"We need to give N-acetyl cysteine before we do gastric lavage with activated charcoal."
"If the child is unconscious, we must do gastric lavage with activated charcoal to decrease
the absorption of acetaminophen." - ANS-"We need to give N-acetyl cysteine before we do
gastric lavage with activated charcoal."
Rationale: There is a need for further information if the nurse states, "We need to give
N-acetyl cysteine before we do gastric lavage with activated charcoal." Activated charcoal
with lavage is done if the child is unconscious, but N-acetyl cysteine cannot be used
because activated charcoal inactivates the antidote. If given orally, it can be diluted in juice
or soda, and a loading dose of N-acetyl cysteine must be followed by maintenance doses.
\A child who has just been found to have scoliosis will need to wear a thoracolumbosacral
orthotic (TLSO) brace, and the nurse provides information to the mother about the brace.
Which statement by the mother indicates a need for further information?
"My child will need to do exercises."
"My child needs to wear the brace 18 to 23 hours per day."
"Wearing the brace is really important in curing the scoliosis."
"I need to check my child's skin under the brace to be sure it doesn't break down." -
ANS-"Wearing the brace is really important in curing the scoliosis."
Rationale: Scoliosis is a lateral curvature of the spine. There is a need for further information
when the mother says, "Wearing the brace is really important in curing the scoliosis." Bracing
is not curative of scoliosis but may slow the progression of the curvature to allow skeletal
growth and maturation. A brace needs to be worn 18 to 23 hours a day, but it may be
removed at night for sleep if this is prescribed. To be more cosmetically acceptable, a brace
is usually worn under loose-fitting clothing. Back exercises are important in maintaining and
strengthening the abdominal and spinal muscles. The child's skin must be meticulously
monitored for signs of breakdown.
\A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse
prepares the room for the child and places a sign at the child's bedside. What does this sign
tell staff to avoid?
Palpating the abdomen
Taking temperatures rectally
Turning the child to the right side
Measuring blood pressure in the right arm - ANS-Palpating the abdomen
,Rationale: The nurse would place a sign at the child's bedside warning against palpation of
the child's abdomen. Wilms' tumor, or nephroblastoma, is the most common renal tumor in
children. Arising from the renal parenchyma of the kidney, this tumor grows very rapidly. It
may be unilateral and localized or bilateral and sometimes involves metastasis to other
organs. The tumor mass should not be palpated because of the risk that the protective
capsule will rupture. Excessive manipulation can result in seeding of the tumor and the
spread of cancerous cells. Taking temperatures rectally, turning the child to the right side,
and measuring blood pressure in the right arm are interventions that do not need to be
avoided.
\A child with growth hormone deficiency will be receiving somatropin. The nurse provides
information to the mother about the medication. Which of the following laboratory values
does the nurse tell the mother will require monitoring?
Creatinine
Hemoglobin
Blood urea nitrogen (BUN)
Thyroid-stimulating hormone (TSH) - ANS-Thyroid-stimulating hormone (TSH)
Rationale: TSH is the laboratory value the nurse tells the mother to monitor. Somatropin is a
growth hormone. One adverse reaction to somatropin is hypothyroidism. Thyroid function is
assessed before treatment and periodically thereafter. Creatinine and BUN are used to
evaluate renal function, and hemoglobin reflects hematologic activity.
\A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that
the first day of her last menstrual period (LMP) was September 25, 2017. Using Nagele's
rule, what item of client information is needed for the nurse to accurately determine
estimated date of delivery (EDD)?
Client has never had an abortion
Client has regular 28-day menstrual cycle
Client was 14 years old when menses first started
Client's menstrual periods never last longer than 3 days - ANS-Client has regular 28-day
menstrual cycle
Rationale: Accurate use of Nagele's rule is used to calculate the EDD. It requires that the
woman have a regular 28-day menstrual cycle.
\A client arrives in the emergency department and tells the nurse that he/she is experiencing
tingling in both hands and is unable to move his/her fingers. The client states that he/she has
been unable to work because of the problem. During the psychosocial assessment, the
client reports that 2 days earlier his/her partner said he/she wanted a separation and that
he/she would have to support self financially. What problem does the nurse conclude that
this client is exhibiting signs/symptoms compatible with?
Severe anxiety
Conversion disorder
Posttraumatic stress disorder (PTSD)
Obsessive-compulsive disorder - ANS-Conversion disorder
,Rationale: Conversion disorder is characterized by the presence of one or more
signs/symptoms suggesting a neurological problem that cannot be attributed to a medical
disorder. Psychological factors such as stress and conflict are associated with the onset or
exacerbation of the sign/symptom. A person with severe anxiety may focus on a particular
detail or many scattered details. The person may have difficulty noticing what is going on in
the environment, even when it is pointed out by another. Learning and problem-solving are
not possible at this level of anxiety, and the client may be dazed and confused. PTSD is
characterized by repeated re-experiencing of a highly traumatic event that involved actual or
threatened death or serious injury to self or others to which the individual responded with
intense fear, helplessness, or horror. Obsessions are thoughts, impulses, or images that
persist and recur so that they cannot be dismissed from the mind. Compulsions are ritualistic
behaviors that an individual feels driven to perform in an attempt to reduce anxiety.
\A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are
performed because the primary health care provider suspects iron-deficiency anemia. After
reviewing the laboratory results, which finding indicative of this type of anemia does the
nurse expect to note?.
An increased RBC count
An increased hematocrit level
An increased hemoglobin level
Microcytic red blood cells (RBCs) - ANS-Microcytic red blood cells (RBCs)
Rationale: The nurse expects to note a low RBC count and microcytic (small) RBCs. In
iron-deficiency anemia, laboratory testing will reveal low hemoglobin and hematocrit levels.
In iron-deficiency anemia, iron stores are depleted first, followed by hemoglobin stores.
\A client calls the emergency department and tells the nurse that he may have come in
contact with poison ivy while trimming bushes in his yard. What does the nurse tell the client
to immediately do?
Contact the primary health care provider
Report to the emergency department for treatment
Get into the shower and rinse the skin for at least 15 minutes
Go to the drugstore, purchase an over-the-counter topical corticosteroid, and rub it into the
exposed skin - ANS-Get into the shower and rinse the skin for at least 15 minutes
Rationale: If contact with poison ivy is suspected, signs/symptoms may be averted by
immediately rinsing the skin for 15 minutes with running water to remove the resin before
skin penetration occurs. Persons walking or working in areas where poison ivy grows should
protect the skin by wearing appropriate clothing. The client is also instructed to remove
clothing carefully to avoid skin contact. Although a topical over-the-counter corticosteroid
may relieve some of the discomfort of the poison ivy rash, this is not the action that needs to
be taken immediately. Contacting the primary health care provider and coming to the
emergency department for treatment are unnecessary.
\A client diagnosed with adenocarcinoma of the ovary is scheduled to undergo
chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral
salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy?
Select all that apply.
, Eat foods that are low in fat and protein
Obtain pneumococcal and influenza vaccines
Drink copious amounts of fluid and void frequently
Avoid contact with any individual who has signs/symptoms of a cold
Avoid contact with all individuals other than immediate family members - ANS-Drink copious
amounts of fluid and void frequently
Avoid contact with any individual who has signs/symptoms of a cold
Rationale: Hemorrhagic cystitis is an adverse effect of this medication. The client is
encouraged to drink copious amounts of fluid at least 24 hours before, during, and after
chemotherapy, and avoid contact with individuals who are ill, have a cold, or have recently
received a live-virus vaccine. The client is also encouraged to void frequently to prevent
cystitis. The client is not to receive immunizations without the primary health care provider's
approval, because they could diminish the body's resistance, putting the client at increased
risk for infection. It is not necessary for the client to avoid contact with all individuals other
than immediate family members. The client should, however, avoid contact with individuals
who are ill, have a cold, or have recently received a live-virus vaccine. Encouraging
adequate dietary intake is appropriate, but a low-protein or low-fat diet is not necessary.
\A client diagnosed with advanced chronic kidney disease (CKD) and oliguria has been
taught about sodium and potassium restriction between dialysis treatments. The nurse
determines that the client understands this restriction if the client states that what is
acceptable to use?
Salt substitutes
Herbs and spices
Salt with cooking only
Processed foods as desired - ANS-Herbs and spices
Rationale: Most clients with CKD retain sodium. The client with CKD is instructed not to add
salt at the table or during food preparation. Herbs and spices may be used as an alternative
to salt to enhance the flavor of food. The client with advanced CKD is instructed to limit
potassium intake. The client is also instructed to avoid salt substitutes, many of which are
composed of potassium chloride, if oliguria is present. Processed foods are discouraged
because they are high in sodium.
\A client diagnosed with chronic kidney disease who requires dialysis three times a week for
the rest of his life says to the nurse, "Why should I even bother to watch what I eat and
drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the
client's statement, the nurse determines that the client is experiencing which problem?
Anxiety
Powerlessness
Ineffective coping
Disturbed body image - ANS-Powerlessness
Rationale: Powerlessness is present when a client believes that he or she has no control
over the situation or that his or her actions will not affect an outcome in any significant way.
Anxiety is a vague uneasy feeling of apprehension. Some factors in anxiety include a threat
or perceived threat to physical or emotional integrity or self-concept, changes in role
A child is brought to the emergency department by ambulance after swallowing several
capsules of acetaminophen. What statement by the nurse indicates a need for further
information?
"We need to administer the antidote N-acetyl cysteine and dilute it in juice or soda."
"A loading dose of N-acetyl cysteine has to be followed by maintenance doses." Incorrect
"We need to give N-acetyl cysteine before we do gastric lavage with activated charcoal."
"If the child is unconscious, we must do gastric lavage with activated charcoal to decrease
the absorption of acetaminophen." - ANS-"We need to give N-acetyl cysteine before we do
gastric lavage with activated charcoal."
Rationale: There is a need for further information if the nurse states, "We need to give
N-acetyl cysteine before we do gastric lavage with activated charcoal." Activated charcoal
with lavage is done if the child is unconscious, but N-acetyl cysteine cannot be used
because activated charcoal inactivates the antidote. If given orally, it can be diluted in juice
or soda, and a loading dose of N-acetyl cysteine must be followed by maintenance doses.
\A child who has just been found to have scoliosis will need to wear a thoracolumbosacral
orthotic (TLSO) brace, and the nurse provides information to the mother about the brace.
Which statement by the mother indicates a need for further information?
"My child will need to do exercises."
"My child needs to wear the brace 18 to 23 hours per day."
"Wearing the brace is really important in curing the scoliosis."
"I need to check my child's skin under the brace to be sure it doesn't break down." -
ANS-"Wearing the brace is really important in curing the scoliosis."
Rationale: Scoliosis is a lateral curvature of the spine. There is a need for further information
when the mother says, "Wearing the brace is really important in curing the scoliosis." Bracing
is not curative of scoliosis but may slow the progression of the curvature to allow skeletal
growth and maturation. A brace needs to be worn 18 to 23 hours a day, but it may be
removed at night for sleep if this is prescribed. To be more cosmetically acceptable, a brace
is usually worn under loose-fitting clothing. Back exercises are important in maintaining and
strengthening the abdominal and spinal muscles. The child's skin must be meticulously
monitored for signs of breakdown.
\A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse
prepares the room for the child and places a sign at the child's bedside. What does this sign
tell staff to avoid?
Palpating the abdomen
Taking temperatures rectally
Turning the child to the right side
Measuring blood pressure in the right arm - ANS-Palpating the abdomen
,Rationale: The nurse would place a sign at the child's bedside warning against palpation of
the child's abdomen. Wilms' tumor, or nephroblastoma, is the most common renal tumor in
children. Arising from the renal parenchyma of the kidney, this tumor grows very rapidly. It
may be unilateral and localized or bilateral and sometimes involves metastasis to other
organs. The tumor mass should not be palpated because of the risk that the protective
capsule will rupture. Excessive manipulation can result in seeding of the tumor and the
spread of cancerous cells. Taking temperatures rectally, turning the child to the right side,
and measuring blood pressure in the right arm are interventions that do not need to be
avoided.
\A child with growth hormone deficiency will be receiving somatropin. The nurse provides
information to the mother about the medication. Which of the following laboratory values
does the nurse tell the mother will require monitoring?
Creatinine
Hemoglobin
Blood urea nitrogen (BUN)
Thyroid-stimulating hormone (TSH) - ANS-Thyroid-stimulating hormone (TSH)
Rationale: TSH is the laboratory value the nurse tells the mother to monitor. Somatropin is a
growth hormone. One adverse reaction to somatropin is hypothyroidism. Thyroid function is
assessed before treatment and periodically thereafter. Creatinine and BUN are used to
evaluate renal function, and hemoglobin reflects hematologic activity.
\A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that
the first day of her last menstrual period (LMP) was September 25, 2017. Using Nagele's
rule, what item of client information is needed for the nurse to accurately determine
estimated date of delivery (EDD)?
Client has never had an abortion
Client has regular 28-day menstrual cycle
Client was 14 years old when menses first started
Client's menstrual periods never last longer than 3 days - ANS-Client has regular 28-day
menstrual cycle
Rationale: Accurate use of Nagele's rule is used to calculate the EDD. It requires that the
woman have a regular 28-day menstrual cycle.
\A client arrives in the emergency department and tells the nurse that he/she is experiencing
tingling in both hands and is unable to move his/her fingers. The client states that he/she has
been unable to work because of the problem. During the psychosocial assessment, the
client reports that 2 days earlier his/her partner said he/she wanted a separation and that
he/she would have to support self financially. What problem does the nurse conclude that
this client is exhibiting signs/symptoms compatible with?
Severe anxiety
Conversion disorder
Posttraumatic stress disorder (PTSD)
Obsessive-compulsive disorder - ANS-Conversion disorder
,Rationale: Conversion disorder is characterized by the presence of one or more
signs/symptoms suggesting a neurological problem that cannot be attributed to a medical
disorder. Psychological factors such as stress and conflict are associated with the onset or
exacerbation of the sign/symptom. A person with severe anxiety may focus on a particular
detail or many scattered details. The person may have difficulty noticing what is going on in
the environment, even when it is pointed out by another. Learning and problem-solving are
not possible at this level of anxiety, and the client may be dazed and confused. PTSD is
characterized by repeated re-experiencing of a highly traumatic event that involved actual or
threatened death or serious injury to self or others to which the individual responded with
intense fear, helplessness, or horror. Obsessions are thoughts, impulses, or images that
persist and recur so that they cannot be dismissed from the mind. Compulsions are ritualistic
behaviors that an individual feels driven to perform in an attempt to reduce anxiety.
\A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are
performed because the primary health care provider suspects iron-deficiency anemia. After
reviewing the laboratory results, which finding indicative of this type of anemia does the
nurse expect to note?.
An increased RBC count
An increased hematocrit level
An increased hemoglobin level
Microcytic red blood cells (RBCs) - ANS-Microcytic red blood cells (RBCs)
Rationale: The nurse expects to note a low RBC count and microcytic (small) RBCs. In
iron-deficiency anemia, laboratory testing will reveal low hemoglobin and hematocrit levels.
In iron-deficiency anemia, iron stores are depleted first, followed by hemoglobin stores.
\A client calls the emergency department and tells the nurse that he may have come in
contact with poison ivy while trimming bushes in his yard. What does the nurse tell the client
to immediately do?
Contact the primary health care provider
Report to the emergency department for treatment
Get into the shower and rinse the skin for at least 15 minutes
Go to the drugstore, purchase an over-the-counter topical corticosteroid, and rub it into the
exposed skin - ANS-Get into the shower and rinse the skin for at least 15 minutes
Rationale: If contact with poison ivy is suspected, signs/symptoms may be averted by
immediately rinsing the skin for 15 minutes with running water to remove the resin before
skin penetration occurs. Persons walking or working in areas where poison ivy grows should
protect the skin by wearing appropriate clothing. The client is also instructed to remove
clothing carefully to avoid skin contact. Although a topical over-the-counter corticosteroid
may relieve some of the discomfort of the poison ivy rash, this is not the action that needs to
be taken immediately. Contacting the primary health care provider and coming to the
emergency department for treatment are unnecessary.
\A client diagnosed with adenocarcinoma of the ovary is scheduled to undergo
chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral
salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy?
Select all that apply.
, Eat foods that are low in fat and protein
Obtain pneumococcal and influenza vaccines
Drink copious amounts of fluid and void frequently
Avoid contact with any individual who has signs/symptoms of a cold
Avoid contact with all individuals other than immediate family members - ANS-Drink copious
amounts of fluid and void frequently
Avoid contact with any individual who has signs/symptoms of a cold
Rationale: Hemorrhagic cystitis is an adverse effect of this medication. The client is
encouraged to drink copious amounts of fluid at least 24 hours before, during, and after
chemotherapy, and avoid contact with individuals who are ill, have a cold, or have recently
received a live-virus vaccine. The client is also encouraged to void frequently to prevent
cystitis. The client is not to receive immunizations without the primary health care provider's
approval, because they could diminish the body's resistance, putting the client at increased
risk for infection. It is not necessary for the client to avoid contact with all individuals other
than immediate family members. The client should, however, avoid contact with individuals
who are ill, have a cold, or have recently received a live-virus vaccine. Encouraging
adequate dietary intake is appropriate, but a low-protein or low-fat diet is not necessary.
\A client diagnosed with advanced chronic kidney disease (CKD) and oliguria has been
taught about sodium and potassium restriction between dialysis treatments. The nurse
determines that the client understands this restriction if the client states that what is
acceptable to use?
Salt substitutes
Herbs and spices
Salt with cooking only
Processed foods as desired - ANS-Herbs and spices
Rationale: Most clients with CKD retain sodium. The client with CKD is instructed not to add
salt at the table or during food preparation. Herbs and spices may be used as an alternative
to salt to enhance the flavor of food. The client with advanced CKD is instructed to limit
potassium intake. The client is also instructed to avoid salt substitutes, many of which are
composed of potassium chloride, if oliguria is present. Processed foods are discouraged
because they are high in sodium.
\A client diagnosed with chronic kidney disease who requires dialysis three times a week for
the rest of his life says to the nurse, "Why should I even bother to watch what I eat and
drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the
client's statement, the nurse determines that the client is experiencing which problem?
Anxiety
Powerlessness
Ineffective coping
Disturbed body image - ANS-Powerlessness
Rationale: Powerlessness is present when a client believes that he or she has no control
over the situation or that his or her actions will not affect an outcome in any significant way.
Anxiety is a vague uneasy feeling of apprehension. Some factors in anxiety include a threat
or perceived threat to physical or emotional integrity or self-concept, changes in role
