HESI RN
HESI RN Exit Exam 2023
1. A female client with major depressive disorder tells the nurse she feels worthless and can't see how her life will ever get better. What is the best response by the nurse?
- A. I can understand how you feel. Tell me more about what's been going on.
- B. You're going through a tough time. Let's discuss what makes you feel this way.
- C. You sound very hopeless right now. Are you thinking about harming yourself?
- D. It's difficult to see the light when you're feeling this way, but I'm here to help you.
Correct answer: C
Rationale: Choice C is the best response because it directly addresses the client's expressed hopelessness and assesses the risk for self-harm. When a client with major depressive disorder expresses feeling worthless and unable to see improvement, it is essential to assess suicidal ideation to ensure their safety. Choices A, B, and D provide empathy and support, which are important but addressing suicidal ideation is the priority in this situation.
2. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
- A. Assign an RN to supervise a nursing assistant for skin care
- B. Assign a nursing assistant to help the client with self-care activities
- C. Delegate complete care to an unlicensed assistive personnel
- D. Supervise a nursing assistant for skin care
Correct answer: D
Rationale: In this scenario, the best care assignment for the client with a skin tear and hematoma is to supervise a nursing assistant for skin care. This ensures proper wound care while utilizing the skills of the nursing assistant effectively. Assigning an RN to supervise the nursing assistant is appropriate as it provides the necessary expertise for wound care supervision. Delegating complete care to an unlicensed assistive personnel may not be suitable for a client with specific wound care needs. Helping the client with self-care activities may not directly address the urgent need for proper wound care in this situation.
3. A female client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, Nurse Tyzz notes that the client is agitated, irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with which problem?
- A. Depression
- B. Neuropathy
- C. Hypoglycemia
- D. Hyperthyroidism
Correct answer: A
Rationale: The correct answer is A: Depression. Depression is a common psychological manifestation in clients with Cushing's syndrome. In this scenario, the client's symptoms of agitation, irritability, poor memory, loss of appetite, and disheveled appearance are indicative of depressive symptoms rather than neuropathy, hypoglycemia, or hyperthyroidism. Neuropathy typically presents with sensory changes and motor deficits, which are not described in the scenario. Hypoglycemia would manifest with symptoms such as diaphoresis, tremors, and confusion, which are not mentioned. Hyperthyroidism symptoms include weight loss, heat intolerance, and palpitations, which are not consistent with the client's presentation.
4. A male client admitted three days ago with respiratory failure is intubated, and 40% oxygen per facemask is initiated. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?
- A. Exhibits adequate tissue perfusion
- B. Remains free of injury
- C. Remains free of infection
- D. Maintains effective breathing pattern
Correct answer: D
Rationale: Successful extubation relies on the patient's ability to maintain an effective breathing pattern. This indicates that the patient can adequately oxygenate and ventilate without the need for mechanical support. Monitoring tissue perfusion, preventing infection, and ensuring safety are important but not directly related to the immediate criteria for successful extubation. Tissue perfusion, injury prevention, and infection control are crucial aspects of overall patient care but are not the primary factors to consider when evaluating readiness for extubation.
5. The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
- A. Elicit a positive scarf sign on the affected side.
- B. Observe for an asymmetrical Moro (startle) reflex.
- C. Watch for swelling of fingers on the affected side.
- D. Note paralysis of the affected extremity and muscles.
Correct answer: B
Rationale: Crepitus in a newborn's chest following vaginal delivery may indicate a clavicle fracture. Observing for an asymmetrical Moro reflex is essential because it can indicate potential nerve damage or fracture, which may be associated with the crepitus identified during the examination.