Hesi Psych Mental Health Exit Exam
The nurse is giving preop instructions to a 14-year-old scheduled to correct a
spinal curvature. Which statement best demonstrates that learning has taken
place?
I understand I will be in a body cast and I will show you how you taught me
to turn.
To take the vital signs of a 4-month-old child which order will give the most
accurate results?
Respiratory rate, heart rate, rectal temperature
AN otoscope exam of a child's ear reveals a tympanic membrane that is
pearly gray, slightly bulging and not movable. What action should the nurse
take next?
Ask the child if he has had a cold, runny nose or any ear pain lately
Which restraint should be used for a toddler after a cleft palate repair?
Elbow
What preoperative nursing intervention should be included in the plan of
care for an infant with pyloric stenosis?
Observe for projectile vomiting
A six-month-old returns from surgery with elbow restraints in place. What
nursing intervention should be included when caring for any restrained child?
remove restraints one at a time and provide range of motion exercise
,A two-year-old with Down Syndrome is brought to the clinic for his regular
physical exam. The nurse knows which problem is frequently associated with
Down Syndrome?
Congenital Heart Disease
When assessing a child with asthma the nurse should expect intercostal
retractions during
inspiration
When planning the care for a child who has had a cleft lip repair, the nurse
knows that crying should be minimized because it
stresses the suture line
A client with a productive cough has obtained a sputum specimen for culture
as instructed. What action is the best initial nursing action?
Administer the first dose of prescribed antibiotic therapy
A client is brought to the Emergency Department by ambulance in cardiac
arrest with CPR in progress. The client is intubated and receiving 100% O2
per ambu bag. The nurse determines the client is cyanotic, cold, and
diaphoretic. Which assessment is most important to obtain?
deep tendon reflexes
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone
(SIADH), a client develops pontine myselinolysis. Which intervention should
the nurse implement first?
Reorientate client to his room
A male client with heart failure (HF) calls the clinic and reports he cannot put
his shoes on because they are too tight. Which additional information should
the nurse obtain?
Has his weight changed in the last several days
,An older adult with a long history of COPD is admitted with progressive
shortness of breath and a persistent cough. She is anxious and is
complaining of a dry mouth. Which intervention should the nurse implement?
Apply a high flow venturi mask
A client with a history of asthma and bronchitis arrives at the clinic with SOB,
productive cough with thickened tenacious mucous and the inability to walk
up a flight of stairs without experiencing breathlessness. Which action is
important for the nurse to instruct the client about self-care?
Increase the daily intake of oral fluids to to liquefy secretions
A cardiac catheterization of a client with heart disease indicates the following
blockages 95% LAD 99% proximal circumflex and 95% proximal RCA. The
client later asks the nurse "what does all that mean for me"
3 main arteries have major blockages with only 1 to 5% of blood flow getting
through to the heart muscle
The nurse is caring for a client with a lower left pulmonary abscess which
position should the nurse instruct the client to maintain
left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct
and is unable to eat or drink without nausea and vomiting. Which finding
should the nurse report to the healthcare provider
yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse
performs a neuro assessment every 4 hours. which assessment finding
warrants immediate intervention by the nurse?
Increasing Anxiety
, The nurse is providing preoperative education for a Jewish client scheduled
to receive a xenograft to promote burn healing. Which info should the nurse
provide this client?
The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requests
assistance to reposition. The wound dehiscence and eviscerates. The nurse
moistens an available sterile dressing and places it over the wound which
intervention should the nurse implement next?
prepare the client to return to the operating room
A client with carcinoma of the lung is complaining of weakness and has a
serum sodium level of 117 mEq/L. Which nursing problem should the nurse
include in this client's plan of care?
Fluid volume excess
A female client enters the clinic and insists on being seen. She is weak,
nervous, and reports a racing heart beat and recent weight loss of 15
pounds. After ruling out substance withdrawal, the healthcare provider
suspects hyperthyroidism and admits her for further testing. Which action
should the nurse implement?
space the clients care to provide periods of rest
The nurse is teaching the client with glomerulonephritis about self care
which dietary recommendations should the nurse encourage the client to
follow?
restrict intake by limiting meats and other high protein foods
An overweight, young adult male who was recently diagnosed with type 2
diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is
feeling very weak and jittery. Which actions should the nurse implement?
The nurse is giving preop instructions to a 14-year-old scheduled to correct a
spinal curvature. Which statement best demonstrates that learning has taken
place?
I understand I will be in a body cast and I will show you how you taught me
to turn.
To take the vital signs of a 4-month-old child which order will give the most
accurate results?
Respiratory rate, heart rate, rectal temperature
AN otoscope exam of a child's ear reveals a tympanic membrane that is
pearly gray, slightly bulging and not movable. What action should the nurse
take next?
Ask the child if he has had a cold, runny nose or any ear pain lately
Which restraint should be used for a toddler after a cleft palate repair?
Elbow
What preoperative nursing intervention should be included in the plan of
care for an infant with pyloric stenosis?
Observe for projectile vomiting
A six-month-old returns from surgery with elbow restraints in place. What
nursing intervention should be included when caring for any restrained child?
remove restraints one at a time and provide range of motion exercise
,A two-year-old with Down Syndrome is brought to the clinic for his regular
physical exam. The nurse knows which problem is frequently associated with
Down Syndrome?
Congenital Heart Disease
When assessing a child with asthma the nurse should expect intercostal
retractions during
inspiration
When planning the care for a child who has had a cleft lip repair, the nurse
knows that crying should be minimized because it
stresses the suture line
A client with a productive cough has obtained a sputum specimen for culture
as instructed. What action is the best initial nursing action?
Administer the first dose of prescribed antibiotic therapy
A client is brought to the Emergency Department by ambulance in cardiac
arrest with CPR in progress. The client is intubated and receiving 100% O2
per ambu bag. The nurse determines the client is cyanotic, cold, and
diaphoretic. Which assessment is most important to obtain?
deep tendon reflexes
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone
(SIADH), a client develops pontine myselinolysis. Which intervention should
the nurse implement first?
Reorientate client to his room
A male client with heart failure (HF) calls the clinic and reports he cannot put
his shoes on because they are too tight. Which additional information should
the nurse obtain?
Has his weight changed in the last several days
,An older adult with a long history of COPD is admitted with progressive
shortness of breath and a persistent cough. She is anxious and is
complaining of a dry mouth. Which intervention should the nurse implement?
Apply a high flow venturi mask
A client with a history of asthma and bronchitis arrives at the clinic with SOB,
productive cough with thickened tenacious mucous and the inability to walk
up a flight of stairs without experiencing breathlessness. Which action is
important for the nurse to instruct the client about self-care?
Increase the daily intake of oral fluids to to liquefy secretions
A cardiac catheterization of a client with heart disease indicates the following
blockages 95% LAD 99% proximal circumflex and 95% proximal RCA. The
client later asks the nurse "what does all that mean for me"
3 main arteries have major blockages with only 1 to 5% of blood flow getting
through to the heart muscle
The nurse is caring for a client with a lower left pulmonary abscess which
position should the nurse instruct the client to maintain
left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct
and is unable to eat or drink without nausea and vomiting. Which finding
should the nurse report to the healthcare provider
yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse
performs a neuro assessment every 4 hours. which assessment finding
warrants immediate intervention by the nurse?
Increasing Anxiety
, The nurse is providing preoperative education for a Jewish client scheduled
to receive a xenograft to promote burn healing. Which info should the nurse
provide this client?
The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requests
assistance to reposition. The wound dehiscence and eviscerates. The nurse
moistens an available sterile dressing and places it over the wound which
intervention should the nurse implement next?
prepare the client to return to the operating room
A client with carcinoma of the lung is complaining of weakness and has a
serum sodium level of 117 mEq/L. Which nursing problem should the nurse
include in this client's plan of care?
Fluid volume excess
A female client enters the clinic and insists on being seen. She is weak,
nervous, and reports a racing heart beat and recent weight loss of 15
pounds. After ruling out substance withdrawal, the healthcare provider
suspects hyperthyroidism and admits her for further testing. Which action
should the nurse implement?
space the clients care to provide periods of rest
The nurse is teaching the client with glomerulonephritis about self care
which dietary recommendations should the nurse encourage the client to
follow?
restrict intake by limiting meats and other high protein foods
An overweight, young adult male who was recently diagnosed with type 2
diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is
feeling very weak and jittery. Which actions should the nurse implement?
