Exam Evolve HESI Questions and Correct Verified
Answers with Rationales||Latest Version!!!Graded A+
A 45-year-old male client tells the nurse that he used to believe that he
was Jesus Christ, but now he knows he is not. Which response is best
for the nurse to make?
A. "Did you really believe you were Jesus Christ?"
B. "I think you're getting well."
C. "Others have had similar thoughts when under stress."
D. "Why did you think you were Jesus Christ?"
C. "Others have had similar thoughts when under stress."
(C) offers support by assuring the client that others have suffered as
he has (also the principle on which Alcoholics Anonymous acts). (A)
is belittling. (B) is making an inappropriate judgment. You may have
narrowed your choices to (C and D). However, you should eliminate
(D) because it is a "why" question, and the client does not know why!
A nurse working in the emergency room of a children's hospital
admits a child whose injuries could have resulted from abuse. Which
statement most accurately describes the nurse's responsibility in cases
of suspected child abuse?
A. The nurse should obtain objective data such as x-rays before
reporting suspicions to the authorities.
B. The nurse should confirm any suspicions of child abuse with the
healthcare provider before reporting to the authorities.
C. The nurse should report any case of suspected child abuse to the
nurse in charge.
D. The nurse should note in the client's record any suspicions of child
abuse so that a history of such suspicions can be tracked.
C. The nurse should report any case of suspected child abuse to the
nurse in charge.
It is the nurse's legal responsibility to report all suspected cases of
child abuse. Notifying the charge nurse starts the legal reporting
process (C).
pg. 1
,A client who is being treated with lithium carbonate for bipolar
disorder develops diarrhea, vomiting, and drowsiness. What action
should the nurse take?
A. Notify the healthcare provider immediately and prepare for
administration of an antidote.
B. Notify the healthcare provider of the symptoms prior to the next
administration of the drug.
C. Record the symptoms as normal side effects and continue
administration of the prescribed dosage.
D. Hold the medication and refuse to administer additional amounts
of the drug.
B. Notify the healthcare provider of the symptoms prior to the next
administration of the drug.
Early side effects of lithium carbonate (occurring with serum lithium
levels below 2.0 mEq per liter) generally follow a progressive pattern
beginning with diarrhea, vomiting, drowsiness, and muscular
weakness. At higher levels, ataxia, tinnitus, blurred vision, and large
dilute urine output may occur. (B) is the best choice. Although these
are expected symptoms, the healthcare provider should be notified
prior to the next administration of the drug. (A, C, and D) would not
reflect good nursing judgment.
A client on the psychiatric unit appears to imitate a certain nurse on
the unit. The client seeks out this particular nurse and imitates the
nurse's mannerisms. The nurse knows that the client is using which
defense mechanism?
A. Sublimation.
B. Identification.
C. Introjection.
D. Repression.
B. Identification.
Identification (B) is an attempt to be like someone or emulate the
personality traits of another. (A) is substituting an unacceptable
feeling for one that is more socially acceptable. (C) is incorporating
the values or qualities of an admired person or group into one's own
pg. 2
,ego structure. (D) is the involuntary exclusion of painful thoughts or
memories from one's awareness.
The nurse is planning the care for a 32-year-old male client with acute
depression. Which nursing intervention would be best in helping this
client deal with his depression?
A. Ensure that the client's day is filled with group activities.
B. Assist the client in exploring feelings of shame, anger, and guilt.
C. Allow the client to initiate and determine activities of daily living.
D. Encourage the client to explore the rationale for his depression.
B. Assist the client in exploring feelings of shame, anger, and guilt.
Depression is associated with feelings of shame, anger, and guilt.
Exploring such feelings is an important nursing intervention for the
depressed client (B). If the client's day is filled with group activities
(A) he might not have the opportunity to explore these feelings. (C) is
a good intervention for the chronically depressed client who exhibits
vegetative signs of depression. (D) is essentially asking the client
"why" he is depressed--avoid "whys" disguised as "rationale."
An anxious client expressing a fear of people and open places is
admitted to the psychiatric unit. What is the most effective way for the
nurse to assist this client?
A. Plan an outing within the first week of admission.
B. Distract her whenever she expresses her discomfort about being
with others.
C. Confront her fears and discuss the possible causes of these fears.
D. Accompany her outside for an increasing amount of time each day.
D. Accompany her outside for an increasing amount of time each day.
The process of gradual desensitization by controlled exposure to the
situation which is feared (D), is the treatment of choice in phobic
reactions. (A and C) are far too aggressive for the initial treatment
period and could even be considered hostile. (B) promotes denial of
the problem, and gives the client the message that discussion of the
phobia is not permitted.
pg. 3
, A client with bipolar disorder on the mental health unit becomes loud,
and shouts at one of the nurses, "You fat tub of lard! Get something
done around here!" What is the best initial action for the nurse to
take?
A. Have the orderly escort the client to his room.
B. Tell the client his healthcare provider will be notified if he
continues to be verbally abusive.
C. Redirect the client's energy by asking him to tidy the recreation
room.
D. Call the healthcare provider to obtain a prescription for a sedative.
C. Redirect the client's energy by asking him to tidy the recreation
room.
Distracting the client, or redirecting his energy (C), prevents further
escalation of the inappropriate behavior. (A) could result in escalating
the abuse and unnecessarily involve another staff member in the
abusive situation. (B) is a threat and is using a health team member
(healthcare provider) as the threat. (D) may be indicated if the
behavior escalates, but, at this time, the best initial action is (C).
A 35-year-old male client who has been hospitalized for two weeks
for chronic paranoia continues to state that someone is trying to steal
his clothing. The most appropriate action for the nurse to take is to
A. encourage the client to actively participate in assigned activities on
the unit.
B. place a lock on the client's closet.
C. ignore the client's paranoid ideation to extinguish these behaviors.
D. explain to the client that his suspicions are false.
A. encourage the client to actively participate in assigned activities on
the unit.
Diverting the client's attention from paranoid ideation and
encouraging him to complete assignments can be helpful in assisting
him to develop a positive self-image (A). The client's problem is not
security, and (B) actually supports his paranoid ideation. (C) is not
correct because ignoring the client's symptoms may lower his self-
esteem. The nurse should not argue with the client about his delusions
pg. 4