Question

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the emergency department, and is transferred to the neurological unit to be monitored for symptoms of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

Answer 1

Correct Answers:

Altered consciousness within the first 24 hours after injury.

Rationale :

🔴 An epidural hematoma is usually caused by bleeding between the skull and dura mater, most commonly from rupture of the middle meningeal artery after trauma to the temporal area of the skull.

🔴 Clients often experience a brief loss of consciousness followed by a lucid interval, during which they appear temporarily stable and alert.

🔴 As bleeding continues and intracranial pressure rises, the client rapidly develops decreased level of consciousness, confusion, drowsiness, headache, vomiting, and neurologic deterioration, often within hours of the injury.

🔴 Early altered consciousness within the first 24 hours is therefore a classic indication of a developing epidural hematoma and requires emergency intervention.

🔴 Without rapid treatment, the expanding hematoma can lead to brain herniation, respiratory arrest, and death.

🔴 Prompt neurosurgical evaluation and CT imaging are critical because epidural hematomas are neurosurgical emergencies.

❌ Headache and pupillary changes 48 hours after head injury.

❌ Headache and pupillary changes can occur with increased intracranial pressure, but epidural hematomas usually deteriorate more rapidly than 48 hours after injury.

❌ Delayed neurologic findings are more consistent with other intracranial complications such as subdural hematoma.

❌ Cushing reflex and cerebral edema after 24 hours.

❌ Cushing reflex (bradycardia, widened pulse pressure, and irregular respirations) is a late sign of severely increased intracranial pressure.

❌ Epidural hematoma is more classically associated with rapid decline in consciousness before late-stage Cushing responses develop.

❌ Fever, nuchal rigidity and opisthotonos within hours.

❌ Fever, neck rigidity, and opisthotonos are more suggestive of meningeal irritation or severe neurologic infection such as meningitis.

❌ These are not classic hallmark findings of epidural hematoma following head trauma.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

"What experience do you have performing this task?"

Rationale :

🔵 When delegating care, the nurse is responsible for ensuring the UAP is competent and experienced in performing the specific task safely.

🔵 Asking about actual experience helps the nurse assess the UAP’s ability to perform the task correctly in real clinical situations.

🔵 A person may have received training but still lack sufficient hands-on practice or confidence with the procedure.

🔵 Safe delegation requires the nurse to evaluate whether the task matches the UAP’s demonstrated skills and competency level.

🔵 This question directly addresses client safety because it helps determine whether additional supervision or instruction is needed.

🔵 Delegation decisions should always consider the client’s condition, task complexity, required skill level, and the UAP’s experience.

❌ “How long have you been working as a UAP?”

❌ Length of employment does not necessarily indicate competence with a specific task.

❌ A UAP may have worked for many years but still have limited experience performing certain procedures.

❌ “Where did you work before coming to this unit?”

❌ Previous work location alone does not determine whether the UAP can safely perform the delegated task.

❌ The nurse must specifically assess competency related to the actual procedure being delegated.

❌ “Did you receive training in performing this task?”

❌ Training is important, but training alone does not guarantee safe or competent performance.

❌ The nurse should assess practical experience and demonstrated ability, not just whether training occurred.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers

Blank 1 Correct Option: sleeping difficulty
Blank 2 Correct Option: nightmares

Rationale :

✅ Blank 1: Sleeping difficulty

🔵 The client reports insomnia, which is a subjective symptom because it is based on what the client says they are experiencing.

🔵 Sleeping difficulty is highly concerning in this client because it is occurring with suicidal ideation, anxiety, alcohol use, withdrawal, trauma history, and PTSD-like symptoms.

🔵 Poor sleep can worsen emotional distress, reduce coping ability, increase irritability, and intensify suicidal thoughts.

🔵 In trauma-related disorders, insomnia is common because the client may feel unsafe, hyperalert, or unable to relax enough to sleep.

✅ Blank 2: Nightmares

🔵 The client reports frequent nightmares, which are also subjective because only the client can describe this experience.

🔵 Nightmares are strongly associated with post-traumatic stress disorder (PTSD), especially after exposure to combat, injury, death, or life-threatening events.

🔵 The client’s nightmares connect with other PTSD findings such as avoidance of military-related triggers, hypervigilance, exaggerated startle response, emotional withdrawal, guilt, and intrusive trauma memories.

🔵 Frequent nightmares can increase sleep deprivation and emotional instability, making suicide risk even more serious.

Why the other options do not fit the blanks

❌ Alcohol on breath

🔴 Alcohol odor is an objective finding because the nurse can directly observe or smell it.

🔴 It is concerning because alcohol can increase impulsivity and suicide risk, but it is not a subjective symptom.

❌ Blood pressure of 144/92 mm Hg

🔴 This is an objective vital sign, not a subjective symptom.

🔴 It may reflect anxiety, stress, alcohol use, or physiologic arousal, but it is measured by the nurse.

❌ Hypervigilance

🔴 Hypervigilance is an objective behavioral finding in this case because the nurse observes the client constantly surveying the environment and being easily startled.

🔴 It is very consistent with PTSD, but it does not fit the phrase “subjective symptoms.”

❌ Latency of response

🔴 Latency of response means a delay before answering questions.

🔴 This would be an objective communication finding observed by the nurse, not something the client reports.

❌ Respirations of 20

🔴 Respirations of 20/min are an objective vital sign and are within the expected adult range.

🔴 This finding does not indicate a subjective trauma-related symptom.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers

Feelings of guilt [ Major depressive disorder ; Posttraumatic stress disorder ]
Lack of interest [ Major depressive disorder ]
Avoidance [ Posttraumatic stress disorder ]
Nightmares [ Posttraumatic stress disorder ]
Sleep disturbance [ Major depressive disorder ; Generalized anxiety disorder ; Posttraumatic stress disorder ]
Suicidal ideation [ Major depressive disorder ]

Rationale :

Feelings of guilt

✅ Major depressive disorder: Feelings of worthlessness or excessive guilt are classic depressive symptoms. This client says she feels worthless and cannot understand why her life was spared.

✅ PTSD: Survivor guilt is also common after trauma, especially after combat exposure or witnessing deaths of comrades.

Lack of interest

✅ Major depressive disorder: Loss of interest or pleasure is called anhedonia. The client reports no interest or pleasure in activities and has become withdrawn.

Avoidance

✅ PTSD: Avoidance is a core PTSD symptom. The client avoids platoon members and avoids driving near a military base because these trigger memories of the trauma.

Nightmares

✅ PTSD: Recurrent nightmares are a trauma re-experiencing symptom. Her nightmares are linked with combat trauma and the explosion.

Sleep disturbance

✅ Major depressive disorder: Depression commonly causes insomnia or excessive sleeping.

✅ Generalized anxiety disorder: Anxiety can cause difficulty falling asleep because of excessive worry and hyperarousal.

✅ PTSD: PTSD often causes sleep problems due to nightmares, hypervigilance, and feeling unsafe.

Suicidal ideation

✅ Major depressive disorder: Suicidal thoughts are a serious depressive symptom. This client has active suicidal ideation with a specific plan and access to a loaded handgun, making this an emergency safety concern.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers

Blank 1 Correct Option: epinephrine
Blank 2 Correct Option: increased alertness and less pleasure in activities

Rationale :

✅ Blank 1: Epinephrine

🔵 Epinephrine is part of the body’s fight-or-flight stress response.

🔵 In PTSD, the nervous system can stay overly activated even when the person is no longer in danger.

🔵 Elevated epinephrine contributes to hypervigilance, exaggerated startle response, anxiety, rapid heart rate, increased blood pressure, and difficulty sleeping.

🔵 This matches the client’s findings: she is constantly surveying the environment, easily startled, anxious, sleepless, and tachycardic.

✅ Blank 2: Increased alertness and less pleasure in activities

🔵 Increased epinephrine keeps the client in a state of heightened alertness, as if danger is still present.

🔵 This can make the client feel tense, restless, easily startled, and unable to relax.

🔵 Chronic stress activation can also reduce enjoyment and emotional connection, contributing to withdrawal and lack of pleasure in activities.

🔵 This fits the client’s PTSD and depressive findings: hypervigilance, avoidance, withdrawal, and loss of interest.

❌ Acetylcholine

🔴 Acetylcholine is mainly involved in muscle movement, memory, learning, and parasympathetic activity.

🔴 It is not the primary stress chemical responsible for PTSD-related hypervigilance.

❌ Cortisol

🔴 Cortisol is a stress hormone that can affect immunity, metabolism, and healing.

🔴 Elevated cortisol is more closely linked with effects such as impaired healing process, not the best match for this PTSD statement.

❌ Dopamine

🔴 Dopamine is involved in reward, motivation, movement, and pleasure.

🔴 Dopamine imbalance may affect mood and pleasure, but it is not the main cause of the client’s increased alertness and fight-or-flight symptoms.

❌ Inability to contextualize life occurrences

🔴 This is more related to impaired processing of traumatic memories and difficulty integrating the event into normal memory.

🔴 It is not the best direct effect of elevated epinephrine.

❌ Impaired healing process

🔴 Impaired healing is more strongly associated with prolonged high cortisol levels.

🔴 It does not best explain the client’s hypervigilance and increased alertness.

❌ Memory suppression

🔴 Memory suppression can occur with trauma-related dissociation or avoidance.

🔴 It is not the main expected effect of elevated epinephrine.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers

Monitor suicidal ideation. [ indicated ]
Assess for pattern of bowel movements. [ indicated ]
Watch for hypotension. [ not indicated ]
Offer frequent sips of fluids. [ indicated ]
Weigh client weekly. [ indicated ]

Rationale :

✅ Monitor suicidal ideation

🔷 Sertraline is an SSRI antidepressant, and clients must be monitored closely for worsening depression or suicidal thoughts, especially when therapy is first started or the dose is changed.

🔷 This client is already at high suicide risk because she wrote a suicide note, had a loaded handgun nearby, and states she wants to end her life.

🔷 Antidepressants can improve energy before mood fully improves, which can increase the risk that a client may act on suicidal thoughts.

🔷 The nurse should perform frequent safety checks, maintain suicide precautions, remove harmful objects, and report any worsening suicidal ideation immediately.

✅ Assess for pattern of bowel movements

🔷 Sertraline can cause gastrointestinal effects, including diarrhea, nausea, abdominal discomfort, or changes in bowel habits.

🔷 Assessing the client’s baseline bowel pattern helps the nurse identify medication-related changes after therapy begins.

🔷 Diarrhea can contribute to dehydration, electrolyte imbalance, and poor medication tolerance if severe.

🔷 The nurse should monitor bowel frequency, stool consistency, hydration status, and report persistent or severe GI symptoms.

❌ Watch for hypotension

🔷 This is not the priority expected monitoring concern for sertraline.

🔷 Sertraline is not primarily associated with significant hypotension like some antihypertensives, alpha blockers, or sedating psychotropic medications.

🔷 This client’s blood pressure is actually elevated at 164/96 mm Hg, likely related to anxiety, hyperarousal, alcohol use, or acute stress.

🔷 The nurse should monitor vital signs as part of overall care, but hypotension is not a key sertraline-specific intervention.

✅ Offer frequent sips of fluids

🔷 Sertraline can cause dry mouth, nausea, and decreased comfort with oral intake.

🔷 Offering frequent sips of fluids helps relieve dry mouth and supports hydration.

🔷 Adequate fluid intake is also important if the client develops GI adverse effects such as diarrhea.

🔷 The nurse should encourage fluids as tolerated while continuing to assess for nausea, vomiting, diarrhea, or signs of dehydration.

✅ Weigh client weekly

🔷 SSRIs such as sertraline can affect appetite and weight over time.

🔷 This client already reports poor mood, withdrawal, and lack of interest, which can reduce appetite and nutritional intake.

🔷 Weekly weights help identify clinically significant weight loss or gain early.

🔷 Monitoring weight is also useful because depression, alcohol use, and medication effects can all influence nutrition and overall health status.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Get annual flu and pneumococcal vaccine polyvalent (PPSV23) vaccines.

Rationale :

🔵 Clients with asthma, chronic bronchitis, and emphysema have chronic respiratory conditions that place them at increased risk for serious respiratory infections.

🔵 Influenza and pneumococcal infections can worsen lung function and trigger severe complications such as pneumonia, respiratory failure, COPD exacerbations, hospitalization, and death.

🔵 Annual influenza vaccination and pneumococcal vaccination are among the most important preventive measures to reduce respiratory infection risk in these clients.

🔵 Vaccination helps decrease illness severity, reduce hospital admissions, and improve long-term respiratory health outcomes.

🔵 The nurse should reinforce that vaccination is especially important for older adults, smokers, and clients with chronic lung disease or weakened immunity.

🔵 Preventive vaccination is considered a major evidence-based intervention in respiratory disease management.

❌ Use nasal or cough tissues followed by handwashing at all times.

❌ Good hand hygiene and respiratory etiquette are important methods for reducing infection transmission.

❌ However, vaccination provides broader and more effective protection against serious respiratory infections in high-risk clients.

❌ Ensure supplemental oxygen and respiratory medications are available at all times.

❌ Respiratory medications and oxygen may be necessary for symptom management in some clients.

❌ This intervention focuses more on treatment readiness rather than the most important preventive healthcare measure.

❌Avoid large crowded areas during the colder months of the year.

❌ Avoiding crowded areas may reduce exposure to respiratory infections.

❌ However, this strategy alone is less effective and less comprehensive than receiving recommended vaccinations.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Apply the cream to the iliac crest and cover one hour prior to the procedure.

Rationale :

🟣 Lidocaine-prilocaine topical cream is a local anesthetic used to numb the skin before painful procedures such as bone marrow aspiration, lumbar puncture, or IV insertion.

🟣 The cream must be applied in advance, usually about 1 hour before the procedure, to allow enough time for adequate skin anesthesia to occur.

🟣 Covering the cream with an occlusive dressing helps improve absorption and keeps the medication in place over the intended site.

🟣 Bone marrow aspiration in children is commonly performed at the posterior iliac crest, so the cream should be applied directly to that area.

🟣 Proper timing of the anesthetic improves comfort, reduces procedural pain, and decreases anxiety associated with invasive procedures.

🟣 The nurse should also assess the skin for irritation or allergy before application and remove the cream according to protocol before the procedure begins.

❌ Administer a sedative and anxiolytic agent before applying the cream.

❌ Sedation may sometimes be prescribed separately for bone marrow aspiration, but it is not required before applying the topical anesthetic cream.

❌ The priority nursing action specific to this medication is correct application and timing before the procedure.

❌ Use ice to numb the skin and then apply the cream at the injection site.

❌ Ice is not necessary before applying lidocaine-prilocaine cream.

❌ Cooling the skin may interfere with circulation and potentially reduce medication absorption.

❌ Position with a pillow under the iliac crest to secure the cream application.

❌ Positioning may be needed later during the procedure, but it is not the key action required before the anesthetic takes effect.

❌ Correct timing and occlusive coverage are more important for effective topical anesthesia.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race.

Rationale :

🔴 A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race.

🔴 This client needs the most RN care hours because electrolyte disturbances can quickly cause serious complications such as cardiac dysrhythmias, seizures, muscle weakness, confusion, and shock.

🔴 Ongoing nausea and vomiting can worsen fluid and electrolyte imbalance, making frequent assessment and intervention necessary.

🔴 A central venous catheter requires skilled RN monitoring because it carries risks for infection, air embolism, bleeding, and catheter-related complications.

🔴 This client is the most physiologically unstable and requires close monitoring, IV therapy management, lab review, and rapid response to changes.

❌ An 82-year-old client with Alzheimer’s disease and a newly fractured femur who has an indwelling urinary catheter and soft wrist restraints applied.

❌ This client needs safety monitoring, pain control, skin checks, catheter care, and restraint assessment.

❌ However, some supportive care can be shared with assistive personnel under RN supervision, while the runner’s electrolyte instability and central line require more direct RN care.

❌ A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline lock PIV.

❌ This client requires respiratory assessment and oxygen monitoring, but the description does not show acute instability.

❌ Oxygen by nasal cannula and a saline lock are less complex than central line care with active electrolyte disturbance.

❌ A 34-year-old admitted today after an emergency appendectomy who has a PIV and indwelling urinary catheter.

❌ This postoperative client needs routine assessments for pain, infection, intake/output, and surgical complications.

❌ However, a stable post-appendectomy client with a PIV and catheter is less complex than a client with electrolyte imbalance, vomiting, and a central venous catheter.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

A schizophrenic client who has been taking antipsychotics for 2 weeks.

Rationale :

🔵 A schizophrenic client who has been taking antipsychotics for 2 weeks.

🔵 This is the best assignment for a newly hired UAP because the client is likely more stable than the others.

🔵 After 2 weeks of antipsychotic therapy, symptoms such as agitation, hallucinations, and disorganized behavior may begin improving.

🔵 A UAP can assist with basic care, observation, hygiene, meals, ambulation, and reporting changes to the nurse.

🔵 The RN remains responsible for assessment, medication evaluation, teaching, and clinical judgment.

❌ A bipolar client who is receiving lithium and is dressed in a sexually provocative manner.

❌ This client may be showing signs of mania, including poor judgment, impulsivity, and sexually inappropriate behavior.

❌ The client requires close RN assessment, boundary-setting, safety monitoring, and evaluation for lithium effectiveness or toxicity.

❌ A teenager who was admitted during the night following a suicide attempt.

❌ This client is high risk and requires close suicide precautions and skilled psychiatric assessment.

❌ A newly hired UAP should not be assigned to a recently suicidal client because safety risk is too high.

❌ A client who is experiencing frequent auditory and visual hallucinations.

❌ Frequent hallucinations can increase risk for fear, agitation, unsafe behavior, or response to internal stimuli.

❌ This client needs RN assessment, therapeutic communication, medication evaluation, and safety monitoring.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Prescription	indicated	not indicated
Monitor suicidal ideation.
Assess for pattern of bowel movements.
Watch for hypotension.
Offer frequent sips of fluids.
Weigh client weekly.

HESI EXIT 2026 -April Exam

No.

2 :
When delegating a task to an unlicensed assistive personnel (UAP) newly assigned to a nursing unit, which question is most important for the nurse to ask the UAP?

3 :
Patient Data

Correct Answers

4 :
The nurse reviews the clinical findings.

Correct Answers

5 :
The nurse calms the client and deescalates the situation.

Correct Answers

6 :
Patient data

Correct Answers

7 :
The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

8 :
A 10-year-old child with leukemia is scheduled for a bone marrow aspiration. Lidocaine 2.5%-prilocaine 2.5%, a topical anesthetic cream is prescribed. Which action should the nurse implement prior to the procedure?

9 :
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

10 :
Which client is best to assign to a newly hired unlicensed assistive personnel (UAP) on a psychiatric unit?

Connect With Us

HESI EXIT 2026 -April Exam

No.

2 : When delegating a task to an unlicensed assistive personnel (UAP) newly assigned to a nursing unit, which question is most important for the nurse to ask the UAP?

3 : Patient Data

Correct Answers

4 : The nurse reviews the clinical findings.

Correct Answers

5 : The nurse calms the client and deescalates the situation.

Correct Answers

6 : Patient data

Correct Answers

7 : The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

8 : A 10-year-old child with leukemia is scheduled for a bone marrow aspiration. Lidocaine 2.5%-prilocaine 2.5%, a topical anesthetic cream is prescribed. Which action should the nurse implement prior to the procedure?

9 : The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

10 : Which client is best to assign to a newly hired unlicensed assistive personnel (UAP) on a psychiatric unit?

2 :
When delegating a task to an unlicensed assistive personnel (UAP) newly assigned to a nursing unit, which question is most important for the nurse to ask the UAP?

3 :
Patient Data

4 :
The nurse reviews the clinical findings.

5 :
The nurse calms the client and deescalates the situation.

6 :
Patient data

7 :
The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

8 :
A 10-year-old child with leukemia is scheduled for a bone marrow aspiration. Lidocaine 2.5%-prilocaine 2.5%, a topical anesthetic cream is prescribed. Which action should the nurse implement prior to the procedure?

9 :
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

10 :
Which client is best to assign to a newly hired unlicensed assistive personnel (UAP) on a psychiatric unit?