HESI RN
HESI Exit Exam RN Capstone
1. Which client is at greatest risk for developing delirium?
- A. An adult client who cannot sleep due to pain.
- B. An older client who attempted suicide 1 month ago.
- C. A young adult taking antipsychotic medications twice daily.
- D. A middle-aged woman using supplemental oxygen.
Correct answer: B
Rationale: The correct answer is B. Older adults who have attempted suicide are at higher risk for developing delirium, especially in the context of underlying mental health conditions. Choice A is incorrect as sleep disturbances due to pain may lead to discomfort but not necessarily delirium. Choice C is incorrect as taking antipsychotic medications, if managed well, does not inherently increase the risk of delirium. Choice D is incorrect as using supplemental oxygen alone does not significantly increase the risk of developing delirium.
2. A client admitted to the ICU with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) has developed osmotic demyelination. What is the first intervention the nurse should implement?
- A. Evaluate the client's swallowing ability.
- B. Reorient the client frequently.
- C. Patch one eye to minimize confusion.
- D. Perform range of motion exercises.
Correct answer: A
Rationale: The correct answer is to evaluate the client's swallowing ability. Osmotic demyelination can cause dysphagia, putting the client at risk for aspiration. Assessing swallowing function is crucial to prevent complications such as aspiration pneumonia. Reorienting the client frequently (Choice B) is more suitable for confusion related to conditions like delirium. Patching one eye (Choice C) is a technique used for diplopia or double vision, not specifically indicated for osmotic demyelination. Performing range of motion exercises (Choice D) may be beneficial for preventing complications of immobility but is not the priority intervention for osmotic demyelination.
3. Carolina is surprised when her patient does not show for a regularly scheduled appointment. When contacted, the patient states, 'I don't need to come see you anymore. I have found a therapy app on my phone that I love.' How should Carolina respond to this news?
- A. That sounds exciting, would you be willing to visit and show me the app?
- B. At this time, there is no real evidence that the app can replace our therapy.
- C. I am not sure that is a good idea right now; we are so close to progress.
- D. Why would you think that is a better option than meeting with me?
Correct answer: A
Rationale: Carolina should respond with choice A as it shows interest and willingness to understand the patient's new approach. By asking the patient to show the app, Carolina demonstrates openness to exploring the patient's perspective and the technology they find helpful. Choice B is incorrect as it appears dismissive, failing to acknowledge the patient's autonomy in choosing an alternative therapy method. Choice C is also inappropriate as it undermines the patient's decision-making and progress achieved so far. Choice D comes off as confrontational and judgmental, which could lead to the patient feeling defensive and less likely to engage in a constructive conversation.
4. A nurse is developing a community health education program focused on preventing childhood obesity. Which intervention should be prioritized?
- A. Creating a school-based exercise program
- B. Distributing educational pamphlets on healthy eating
- C. Organizing a community health fair
- D. Partnering with local restaurants to offer healthy meal options
Correct answer: A
Rationale: The correct answer is A: Creating a school-based exercise program. This intervention directly addresses the need to increase physical activity among children, a crucial aspect in preventing childhood obesity. While distributing educational pamphlets on healthy eating (choice B) can be beneficial, promoting physical activity through a structured program is more effective in combating obesity. Organizing a community health fair (choice C) may raise awareness but may not lead to sustained behavior change like a structured exercise program. Partnering with local restaurants to offer healthy meal options (choice D) addresses nutrition but does not directly impact physical activity levels, which are essential in obesity prevention.
5. A client who has a history of bipolar disorder is recovering from a manic episode and is now experiencing depressive symptoms. Which action should the nurse take first?
- A. Assess the client for suicidal ideation.
- B. Provide a detailed schedule of daily activities.
- C. Discuss the importance of medication adherence.
- D. Encourage the client to engage in group therapy.
Correct answer: A
Rationale: Assessing for suicidal ideation is the priority when a client with bipolar disorder is transitioning from a manic episode to a depressive phase. Suicidal ideation is a critical concern during depressive episodes, and ensuring the client's safety is the top priority. Providing a detailed schedule of daily activities (Choice B) may be helpful but is not the immediate priority over assessing for suicidal ideation. Discussing the importance of medication adherence (Choice C) and encouraging group therapy (Choice D) are essential components of care but are secondary to ensuring the client's safety in the context of potential suicidal ideation.