BSN HESI 366 RN Exit Exam V3 Nightingale Q&A with Rationale
2026\2027 Update
A nurse is admitting a client with a diagnosis of anorexia nervosa to the mental health
unit. Which of the following characteristics is a hallmark of this disorder? -
ANSWER✔✔Personal relationships tend to become more superficial and distant.
Rationale: As anorexia nervosa develops, personal relationships tend to become more
superficial and distant. Social contacts are avoided because of the fear of being invited
to eat and being discovered. The client is preoccupied with food and meal planning
(especially for others), his or her own caloric intake throughout the day, and ways to
avoid eating. Anorexic persons are likely to become very emaciated and do not
maintain a near-normal body weight.
A client with the diagnosis of schizophrenia is unable to speak, although nothing is
wrong with the organs of communication. The nurse plans care knowing that this
condition is referred to as: - ANSWER✔✔Mutism
Rationale: Mutism is absence of verbal speech. The client does not communicate
verbally, despite intact physical structural ability to speak. Verbigeration is the
purposeless repetition of words or phrases. Pressured speech refers to rapidity of
speech, reflecting the client's racing thoughts. Poverty of speech means diminished
amounts of speech or monotonic replies.
A client tells the nurse, "I am a queen. I'm mean, and I gleam." The nurse recognizes
,this as an example of: - ANSWER✔✔Clang associations
Rationale: Clang associations often take the form of rhyming. Repetition of words or
phrases that are similar in sound (rhyming) but in no other way is one of the patterns of
altered thought and language noted in schizophrenia. Echolalia is an involuntary
parrotlike repetition of words spoken by others. Tangential speech is characterized by a
tendency to digress from an original topic of discussion in which a common word
connects two unrelated thoughts. Loosened associations are a sign of disordered
thought processes in which the person speaks with frequent changes of subject and the
content is only obliquely related, if at all, to the subject matter.
A client is severely injured, sustaining a full-thickness circumferential burn to the left
leg, after passing out as a result of drinking alcohol and falling into a fire while on a
camping trip. In report, the nurse is told that the client has just signed consent for
amputation of the limb and that the procedure is scheduled for tomorrow. While
caring for the client, the nurse notes that the client is upset and withdrawn. What is the
most appropriate nursing action at this time? - ANSWER✔✔Reflecting back to the
client that he appears upset
Rationale: Reflection statements tend to elicit deeper awareness of feelings. In
addition, reflecting to the client that he or she appears upset validates the perception
that the client is upset. Letting the client have some time alone to grieve the impending
loss of the limb is premature; the client needs support at this time. Informing the
physician of the client's depression and requesting medication to assist the client in
coping with the diagnosis is also an example of initiating an intervention prematurely.
Reminding the client that the injury was a result of alcohol abuse and referring him for
counseling is inappropriate and a block to communication.
A male client reports difficulty concentrating, outbursts of anger, and a feeling of being
keyed up all the time and states that peer relations are poor. He then tells the nurse
,that the symptoms started after his best friend was killed in the terrorist attack at the
World Trade Center. The nurse suspects that the client is experiencing: -
ANSWER✔✔Post-traumatic stress disorder
Rationale: Post-traumatic stress disorder (PTSD) is a response to an event that would
be markedly distressing to almost anyone. Characteristic symptoms include a sustained
level of anxiety, difficulty sleeping, irritability, difficulty concentrating, and outbursts of
anger. Social phobia and panic disorder are characterized by specific fear of an object
or situation. Obsessive-compulsive disorder involves some repetitive thought or
behavior.
A client in skeletal traction says to the nurse, "I can't get any help with my care! I call
and call, but the nurses never answer my light. Last night one of them told me she had
other patients besides me! I'm very sick, but the nurses don't care!" Which response by
the nurse would be therapeutic? - ANSWER✔✔"It's hard to be in bed and have to ask
for help. You call for a nurse who never seems to come?"
Rationale: In the correct option, the nurse displays empathy while sharing perceptions.
Sharing perceptions allows the client to validate the nurse's understanding of what the
client is feeling and thinking. It opens the door for the client to share concerns, fears,
and anxieties. In stating, "You poor thing! I'm so sorry this happened to you. That nurse
should be reported!" the nurse is sympathetic but inappropriate regarding the negative
comment about another nurse. In stating, "I think you're being very impatient. The
nurses work very hard and come as quickly as they can," the nurse is assertive and
defending the nursing staff. In stating, "I can hear your anger. That nurse had no right
to speak to you that way. I will report her to the director. It won't happen again," the
nurse expresses the client's frustration by labeling the client's feelings as angry and
expresses disapproval of the nursing staff.
A nurse is caring for a hospitalized client with an alcohol abuse disorder. In reviewing
, the client's discharge outcomes, the most positive outcome is that the client states that
he or she will: - ANSWER✔✔Continue to attend Alcoholics Anonymous meetings
Rationale: All of the outcomes deserve support by the nurse, but the option, continue
to attend Alcoholics Anonymous (AA) meetings, will help the client abstain from alcohol
and provide the client with a support group. This is the most positive outcome.
A 30-year-old client says to the nurse, "I want to die. I think about it a lot, but I don't
know how in the world to do it." On the basis of the client's statement, the nurse
determines that: - ANSWER✔✔The risk for suicide exists and continued assessment is
needed
Rationale: The words "I want to die" indicate a suicide risk warranting continued
assessment. Any language indicating a desire for self-harm must be viewed as serious.
This question presents no data indicating a history of self-harm. The other options are
incorrect interpretations.
Family members awaiting the outcome of a suicide attempt are tearful. Which
response by the nurse would be most therapeutic to the family at this time? -
ANSWER✔✔A "I can see that you are worried."
Rationale: The correct response involves the use of the therapeutic technique of
clarifying. In stating, "You have nothing worry about," the nurse provides false
reassurance. In stating, "You can see your loved one soon," the nurse focuses on an
important issue at an inappropriate time (family members are tearful). In stating,
"Everything possible is being done," the nurse uses clichés and false reassurance.
Which of the following steps should be included in the care of a 13-year-old
2026\2027 Update
A nurse is admitting a client with a diagnosis of anorexia nervosa to the mental health
unit. Which of the following characteristics is a hallmark of this disorder? -
ANSWER✔✔Personal relationships tend to become more superficial and distant.
Rationale: As anorexia nervosa develops, personal relationships tend to become more
superficial and distant. Social contacts are avoided because of the fear of being invited
to eat and being discovered. The client is preoccupied with food and meal planning
(especially for others), his or her own caloric intake throughout the day, and ways to
avoid eating. Anorexic persons are likely to become very emaciated and do not
maintain a near-normal body weight.
A client with the diagnosis of schizophrenia is unable to speak, although nothing is
wrong with the organs of communication. The nurse plans care knowing that this
condition is referred to as: - ANSWER✔✔Mutism
Rationale: Mutism is absence of verbal speech. The client does not communicate
verbally, despite intact physical structural ability to speak. Verbigeration is the
purposeless repetition of words or phrases. Pressured speech refers to rapidity of
speech, reflecting the client's racing thoughts. Poverty of speech means diminished
amounts of speech or monotonic replies.
A client tells the nurse, "I am a queen. I'm mean, and I gleam." The nurse recognizes
,this as an example of: - ANSWER✔✔Clang associations
Rationale: Clang associations often take the form of rhyming. Repetition of words or
phrases that are similar in sound (rhyming) but in no other way is one of the patterns of
altered thought and language noted in schizophrenia. Echolalia is an involuntary
parrotlike repetition of words spoken by others. Tangential speech is characterized by a
tendency to digress from an original topic of discussion in which a common word
connects two unrelated thoughts. Loosened associations are a sign of disordered
thought processes in which the person speaks with frequent changes of subject and the
content is only obliquely related, if at all, to the subject matter.
A client is severely injured, sustaining a full-thickness circumferential burn to the left
leg, after passing out as a result of drinking alcohol and falling into a fire while on a
camping trip. In report, the nurse is told that the client has just signed consent for
amputation of the limb and that the procedure is scheduled for tomorrow. While
caring for the client, the nurse notes that the client is upset and withdrawn. What is the
most appropriate nursing action at this time? - ANSWER✔✔Reflecting back to the
client that he appears upset
Rationale: Reflection statements tend to elicit deeper awareness of feelings. In
addition, reflecting to the client that he or she appears upset validates the perception
that the client is upset. Letting the client have some time alone to grieve the impending
loss of the limb is premature; the client needs support at this time. Informing the
physician of the client's depression and requesting medication to assist the client in
coping with the diagnosis is also an example of initiating an intervention prematurely.
Reminding the client that the injury was a result of alcohol abuse and referring him for
counseling is inappropriate and a block to communication.
A male client reports difficulty concentrating, outbursts of anger, and a feeling of being
keyed up all the time and states that peer relations are poor. He then tells the nurse
,that the symptoms started after his best friend was killed in the terrorist attack at the
World Trade Center. The nurse suspects that the client is experiencing: -
ANSWER✔✔Post-traumatic stress disorder
Rationale: Post-traumatic stress disorder (PTSD) is a response to an event that would
be markedly distressing to almost anyone. Characteristic symptoms include a sustained
level of anxiety, difficulty sleeping, irritability, difficulty concentrating, and outbursts of
anger. Social phobia and panic disorder are characterized by specific fear of an object
or situation. Obsessive-compulsive disorder involves some repetitive thought or
behavior.
A client in skeletal traction says to the nurse, "I can't get any help with my care! I call
and call, but the nurses never answer my light. Last night one of them told me she had
other patients besides me! I'm very sick, but the nurses don't care!" Which response by
the nurse would be therapeutic? - ANSWER✔✔"It's hard to be in bed and have to ask
for help. You call for a nurse who never seems to come?"
Rationale: In the correct option, the nurse displays empathy while sharing perceptions.
Sharing perceptions allows the client to validate the nurse's understanding of what the
client is feeling and thinking. It opens the door for the client to share concerns, fears,
and anxieties. In stating, "You poor thing! I'm so sorry this happened to you. That nurse
should be reported!" the nurse is sympathetic but inappropriate regarding the negative
comment about another nurse. In stating, "I think you're being very impatient. The
nurses work very hard and come as quickly as they can," the nurse is assertive and
defending the nursing staff. In stating, "I can hear your anger. That nurse had no right
to speak to you that way. I will report her to the director. It won't happen again," the
nurse expresses the client's frustration by labeling the client's feelings as angry and
expresses disapproval of the nursing staff.
A nurse is caring for a hospitalized client with an alcohol abuse disorder. In reviewing
, the client's discharge outcomes, the most positive outcome is that the client states that
he or she will: - ANSWER✔✔Continue to attend Alcoholics Anonymous meetings
Rationale: All of the outcomes deserve support by the nurse, but the option, continue
to attend Alcoholics Anonymous (AA) meetings, will help the client abstain from alcohol
and provide the client with a support group. This is the most positive outcome.
A 30-year-old client says to the nurse, "I want to die. I think about it a lot, but I don't
know how in the world to do it." On the basis of the client's statement, the nurse
determines that: - ANSWER✔✔The risk for suicide exists and continued assessment is
needed
Rationale: The words "I want to die" indicate a suicide risk warranting continued
assessment. Any language indicating a desire for self-harm must be viewed as serious.
This question presents no data indicating a history of self-harm. The other options are
incorrect interpretations.
Family members awaiting the outcome of a suicide attempt are tearful. Which
response by the nurse would be most therapeutic to the family at this time? -
ANSWER✔✔A "I can see that you are worried."
Rationale: The correct response involves the use of the therapeutic technique of
clarifying. In stating, "You have nothing worry about," the nurse provides false
reassurance. In stating, "You can see your loved one soon," the nurse focuses on an
important issue at an inappropriate time (family members are tearful). In stating,
"Everything possible is being done," the nurse uses clichés and false reassurance.
Which of the following steps should be included in the care of a 13-year-old
