HESI PN MENTAL HEALTH PROCTORED EXAM (15 VERSIONS)(LATEST-2021)

1.




Afterqassessingqaqpqatient,
f qaqnurseqdevelopsqaqstandardqformalqnursingqdiagn osis.qWhatqisqtheqrationale

orqtheqnurse’sqacti ons?
1
a. Toqformqaqlanguageqthatqcanqbeqencodedqonlyqbyqnurse
s
b. Toqdistinguishqthe nurse’sqroleqfromqtheqphysician’sqrol
e

, c. Toqdevelopqclinicalqjudgmentqbasedqonqother’sqintuition

d. Toqhelpqnursesqfocusqonqtheqscopeqofqmedicalqpractice



ANS:qB
Theqstandardqformalqnursingqdiagnosisqservesqseveralqpurposes.qNursingqdiagnosesqdistinguishqtheqnurse’sq
roleqfromqthatqofqtheqphysician/healthqcareqproviderqandqhelpqnursesqfocusqonqtheqscopeqofqnursingqpracticeq
(notqmedical)qwhileqfosteringqtheqdevelopmentqofqnursingqknowledge.qAqnursingqdiagnosisqprovidesqtheqpr
eciseqdefinitionqthatqgivesqallqmembersqofqtheqhealthqcareqteamqaqcommonqlanguageqforqunderstandingqtheq
patient’sqneeds.qAqdiagnosisqisqaqclinicalqjudgmentqbasedqonqinformation.
2. Whichqdiagnosisqwillqtheqnurseqdocumentqinqaqpatient’sqcareqplanqthatqisqNANDA-Iqapproved?

a. Soreqthroat

b. Acuteqpain

c. Sleepqapnea

d. Heartqfailure



ANS:qB
AcuteqpainqisqtheqonlyqNANDA-
Iqapprovedqdiagnosisqlisted.qSleepqapneaqandqheartqfailureqareqmedicalqdiagnoses,qandqsoreqthroatqi
sqsubjectiveqdata.
3. Aqnurseqdevelopsqaqnursingqdiagnosticqstatementqforqaqpatientqwithqaqmedicalqdiagnosisqofq
pneumoniaqwithqchestqx-
rayqresultsqofqlowerqlobeqinfiltrates.qWhichqnursingqdiagnosisqdidqtheqnurse
write?
a. Ineffectiveqbreathingqpatternqrelatedqtoqpneumonia

b. Riskqforqinfectionqrelatedqtoqchestqx-rayqprocedure

c. Riskqforqdeficientqfluidqvolumeqrelatedqtoqdehydration

Impairedqgasqexchangeqrelatedqtoqalveolar-capillaryqmembrane

d. changes

ANS:qD
Theqrelatedqtoqfactorqofqalveolar-
capillaryqmembraneqchangesqisqaccuratelyqwrittenqbecauseqitqisqaqpatientqresponseqtoqtheqdiseaseqprocessqofq
pneumoniaqthatqtheqnurseqcanqtreat.qTheqrelatedqtoqfactorqshouldqbeqtheqcauseqofqtheqproblemq(nursingqdiagn
osis)qthatqaqnurseqcanqaddress.qTheqrelatedqtoqfactorsqofqdehydrationqandqpneumoniaqareqallqmedicalqdiagno
sesqthatqtheqnurseqcannotqchange.qAqdiagnosticqtestqorqaqchronicqdysfunctionqisqnotqanqetiologyqorqaqconditio
nqthatqaqnursingqinterventionqisqableqtoqtreat.
4. Theqnurseqisqreviewingqaqpatient’sqplanqofqcare,qwhichqincludesqtheqnursingqdiagnosticqstatem
ent,qImpairedqphysicalqmobilityqrelatedqtoqtibialqfractureqasqevidencedqbyqpatient’sqinabilityqtoqambul
ate.qWhichqpartqofqtheqdiagnosticqstatementqdoesqtheqnurseqneedqtoqrevise?
a. Etiology

b. Nursingqdiagnosis

c. Collaborativeq problem

d. Definingqcharacteristic



ANS:qA 2
Theqetiology,qorqrelatedqtoqfactor,qofqtibialqfractureqisqaqmedicalqdiagnosisqandqneedsqtoqbeqrevised.qThe

, nursingqdiagnosisqisqappropriateqbecauseqtheqpatientqisqunableqtoqambulate.qAqcollaborativeqproblemqisqanqa
ctualqorqpotentialqphysiologicalqcomplicationqthatqnursesqmonitorqtoqdetectqtheqonsetqofqchangesqinqaqpatien
t’sqhealthqstatus;qthereqisqnoqcollaborativeqproblemqlisted.qTheqdefiningqcharacteristicq(subjectiveqandqobject
iveqdataqthatqsupportqtheqdiagnosis)qisqappropriateqforqImpairedqphysicalqmobility.
5. Aqnurseqisqusingqassessmentqdataqgatheredqaboutqaqpatientqandqcombiningqcriticalqthinking

toqdevelopqaqnursingqdiagnosis.qWhatqisqtheqnurseqdoing?
a. Assigningqclinicalqcues

b. Definingqcharacteristics

c. Diagnosticqreasoning

d. Diagnosticqlabeling



ANS:qC
Diagnosticqreasoningqisqdefinedqasqaqprocessqofqusingqtheqassessmentqdataqgatheredqaboutqaqpatientqtoqlo
gicallyqexplainqaqclinicalqjudgment,qinqthisqcaseqaqnursingqdiagnosis.qDefiningqcharacteristicsqareqassess
mentqfindingsqthatqsupportqtheqnursingqdiagnosis.qDefiningqcharacteristicsqareqtheqsubjectiveqandqobjecti
veqclinicalqcues,qwhichqaqnurseqgathersqintentionallyqandqunintentionally.qTheqnurseqorganizesqallqofqtheq
patient’sqdataqintoqmeaningfulqandqusableqdataqclusters,qwhichqleadqtoqaqdiagnosticqconclusion.
Diagnosticqlabelingqisqsimplyqtheqnameqofqtheqdiagnosis.



6. Aqpatientqpresentsqtoqtheqemergencyqdepartmentqfollowingqaqmotorqvehicleqcrashqandqsuffer
sqaqrightqfemurqfracture.qTheqlegqisqstabilizedqinqaqfullqlegqcast.qOtherwise,qtheqpatientqhasqnoqother
qmajorqinjuries,qisqinqgoodqhealth,qandqreportsqonlyqmoderateqdiscomfort.qWhichqisqtheqmostqperti

nentqnursingqdiagnosisqtheqnurseqwillqincludeqinqtheqplanqofqcare?
a. Posttraumaqsyndrome

b. Constipation

c. Acuteqpain

d. Anxiety



ANS:qC
Basedqonqtheqassessmentqdataqprovided,qtheqonlyqsupportiveqevidenceqforqoneqofqtheqdiagnosisqoptionsqisq“
Reportsqonlyqmoderateqdiscomfort,”qwhichqwouldqsupportqAcuteqpain.qNoqsupportiveqevidenceqisqprovided
qforqanyqofqtheqotherqdiagnoses.qTheqpatientqmayqindeedqdevelopqsignsqorqsymptomsqofqtheqotherqproblems,q

butqsupportiveqdataqareqpresentlyqlackingqinqtheqprovidedqinformation.
7. Theqnurseqisqreviewingqaqpatient’sqdatabaseqforqsignificantqchangesqandqdiscoversqthatqtheqp
atientqhasqnotqvoidedqinqoverq8qhours.qTheqpatient’sqkidneyqfunctionqlabqresultsqareqabnormal,qandq
theqpatient’sqoralqintakeqhasqsignificantlyqdecreasedqsinceqpreviousqshifts.qWhichqstepqofqtheqnursin
g

processqshouldqtheqnurseqproceedqtoqafterqthisqreview?
a. Diagnosis

b. Planning

c. Implementation

d. Evaluation
3

ANS:qA