EVOLVE HESI RN PSYCHIATRIC-MENTAL
HEALTH EXIT EXAM
,1. A male client is admitted to the mental health unit because he was feeling depressed
about the loss of his wife and job. The client has a history of alcohol dependency and
admits that he was drinking alcohol 12 hours ago. His temperature is 100.0 F, pulse is
100, and blood pressure is 142/100. The nurse plans to give the client lorazepam (Ativan)
based on which priority nursing diagnosis?
a. Risk for injury related to suicidal ideation.
b. Risk for injury related to alcohol detoxification.
c. Knowledge deficit related to ineffective coping.
d. Health seeking behaviors related to personal crisis.
2. 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. Obtain objective data such as x-rays before reporting suspicions.
b. Confirm suspicions of abuse with the physician.
c. Report any case of suspected child abuse.
d. Document injuries to confirm suspected abuse.
3. A child is brought to the emergency room with a broken arm. Because of other injuries,
the nurse suspects the child may be a victim of abuse. When the nurse tries to give the
child an injection, the child's mother becomes very loud and shouts, "I won't leave my
son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the
mother's statements?
a. She is regressing to an earlier behavior pattern.
b. She is sublimating her anger.
c. She is projecting her feelings onto the nurse.
d. She is suppressing her fear.
4. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he
can go for a walk on the grounds of the treatment center. When he is told that his
privileges do not include walking on the grounds, the client becomes verbally abusive.
Which approach should the nurse take?
a. Ask the staff to escort the client to his room.
, b. Have the client ask his physician to change his privileges.
c. Remind the client of the importance of following the rules.
d. Disregard the client's inappropriate verbal outburst.
5. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication
should the nurse anticipate administering to a client who is exhibiting benzodiazepine
withdrawal symptoms?
a. Perphenazine (Trilafon).
b. Diphenylhydramine (Benadryl).
c. Chlordiazepoxide (Librium).
d. Isocarboxazid (Marplan).
6. A client is receiving substitution therapy during withdrawal from benzodiazepines.
Which expected outcome statement has the highest priority when planning nursing
care?
a. Client will not demonstrate cross addiction.
b. Co-dependent behaviors will be decreased.
c. Excessive CNS stimulation will be reduced.
d. Client's level of consciousness will increase.
7. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband
states that she has been reluctant to leave home for the last six months. The client has not
gone to work for a month and has been terminated from her job. She has not left the house
since that time. This client is displaying symptoms of which disorder?
a. Claustrophobia.
b. Acrophobia.
c. Agoraphobia.
d. Necrophobia.
8. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve
dinner trays to other clients on a psychiatric unit. What action should the nurse take?
a. Encourage the client's self motivation by asking her to pass trays for the rest of
HEALTH EXIT EXAM
,1. A male client is admitted to the mental health unit because he was feeling depressed
about the loss of his wife and job. The client has a history of alcohol dependency and
admits that he was drinking alcohol 12 hours ago. His temperature is 100.0 F, pulse is
100, and blood pressure is 142/100. The nurse plans to give the client lorazepam (Ativan)
based on which priority nursing diagnosis?
a. Risk for injury related to suicidal ideation.
b. Risk for injury related to alcohol detoxification.
c. Knowledge deficit related to ineffective coping.
d. Health seeking behaviors related to personal crisis.
2. 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. Obtain objective data such as x-rays before reporting suspicions.
b. Confirm suspicions of abuse with the physician.
c. Report any case of suspected child abuse.
d. Document injuries to confirm suspected abuse.
3. A child is brought to the emergency room with a broken arm. Because of other injuries,
the nurse suspects the child may be a victim of abuse. When the nurse tries to give the
child an injection, the child's mother becomes very loud and shouts, "I won't leave my
son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the
mother's statements?
a. She is regressing to an earlier behavior pattern.
b. She is sublimating her anger.
c. She is projecting her feelings onto the nurse.
d. She is suppressing her fear.
4. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he
can go for a walk on the grounds of the treatment center. When he is told that his
privileges do not include walking on the grounds, the client becomes verbally abusive.
Which approach should the nurse take?
a. Ask the staff to escort the client to his room.
, b. Have the client ask his physician to change his privileges.
c. Remind the client of the importance of following the rules.
d. Disregard the client's inappropriate verbal outburst.
5. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication
should the nurse anticipate administering to a client who is exhibiting benzodiazepine
withdrawal symptoms?
a. Perphenazine (Trilafon).
b. Diphenylhydramine (Benadryl).
c. Chlordiazepoxide (Librium).
d. Isocarboxazid (Marplan).
6. A client is receiving substitution therapy during withdrawal from benzodiazepines.
Which expected outcome statement has the highest priority when planning nursing
care?
a. Client will not demonstrate cross addiction.
b. Co-dependent behaviors will be decreased.
c. Excessive CNS stimulation will be reduced.
d. Client's level of consciousness will increase.
7. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband
states that she has been reluctant to leave home for the last six months. The client has not
gone to work for a month and has been terminated from her job. She has not left the house
since that time. This client is displaying symptoms of which disorder?
a. Claustrophobia.
b. Acrophobia.
c. Agoraphobia.
d. Necrophobia.
8. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve
dinner trays to other clients on a psychiatric unit. What action should the nurse take?
a. Encourage the client's self motivation by asking her to pass trays for the rest of
