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Rn Hesi Proctored Exit Exam- MCPHS
Total Questions : 127
Showing 10 questions, Sign in for moreThe nurse is caring for an older client with severe obstructive sleep apnea (OSA) who is reluctant to wear a bi-level positive airway pressure (BIPAP) mask. Which condition has been identified that is often associated with OSA?
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP?
A 24-year-old male client presents to the clinic with reports of feeling unwell, lacking energy, and often feeling like not going to work, and he has missed five days of work in the past two weeks. The client informs about loss of appetite and that he has not been making healthy food choices. He also reports disruptive sleep habits and an inability to sleep at night and that he wants to sleep a great deal during the day.
1000
The client reports general malaise, fatigue, and decreased appetite. His skin is pale in color. He denies pain or discomfort. The client is withdrawn, soft spoken, and does not offer information without being prompted. The client reports a six pack of beer daily for the last eight months.
- Temperature: 98° F (36.6" C) orally
- Heart rate: 68 beats/minute
- Respirations: 16 breaths/minute
- Blood pressure: 110/72 mm Hg
- Oxygen saturation: 98% on room air
- Height: 5 feet, 9 inches (175.26 cm)
- Weight: 120 pounds (54.43 kg)
- Body mass index (BMI): 17.7 kg/m2 (normal 18 to 24.9 kg/m2)
1000
- Complete a Mental status exam (MSE)
- Obtain blood for a complete blood count (CBC), thyroxine, and thyroid stimulating hormone (TSH)
Patient Data
The client has not been seen in the clinic for several months and did not follow up after having annual laboratory testing done nine months ago as requested by the healthcare provider (HCP).
Which factor(s) is/are the most important for the nurse to include in an initial assessment of the client? Select all that apply.
A 24-year-old male client presents to the clinic with reports of feeling unwell, lacking energy, and often feeling like not going to work, and he has missed five days of work in the past two weeks. The client informs about loss of appetite and that he has not been making healthy food choices. He also reports disruptive sleep habits and an inability to sleep at night and that he wants to sleep a great deal during the day.
1000
The client reports general malaise, fatigue, and decreased appetite. His skin is pale in color. He denies pain or discomfort. The client is withdrawn, soft spoken, and does not offer information without being prompted. The client reports a six pack of beer daily for the last eight months.
- Temperature: 98° F (36.6" C) orally
- Heart rate: 68 beats/minute
- Respirations: 16 breaths/minute
- Blood pressure: 110/72 mm Hg
- Oxygen saturation: 98% on room air
- Height: 5 feet, 9 inches (175.26 cm)
- Weight: 120 pounds (54.43 kg)
- Body mass index (BMI): 17.7 kg/m2 (normal 18 to 24.9 kg/m2)
1000
Complete a Mental status exam (MSE)
Obtain blood for a complete blood count (CBC), thyroxine, and thyroid stimulating hormone (TSH)
Patient data
Click to highlight the information that should inform the nurse about the client's mental health.
During the initial assessment, the nurse observes the client has poor hygiene and has dried food on his mouth with food stains on his clothing. He reports living his near job. He reports trouble sleeping. He reports smoking one-half pack of cigarettes a day. He denies pain. He denies thoughts of self-harm or thoughts of suicide.
Explanation
Rationale for correct choices:
- The nurse observes the client has poor hygiene: In mental health, a decline in personal grooming is often a primary indicator of depression, cognitive impairment, or a lack of energy/motivation to care for oneself.
- Has dried food on his mouth with food stains on his clothing: This is a specific objective observation of "self-neglect." It suggests the client has lost interest in social norms or lacks the executive function to maintain a clean appearance.
- He reports trouble sleeping: Sleep disturbances (insomnia or hypersomnolence) are hallmark symptoms of many mental health disorders, including major depressive disorder and anxiety.
- He denies thoughts of self-harm or thoughts of suicide: While this is a negative finding, it is a critical component of the mental health assessment used to determine the client’s safety and risk level.
Rationale for incorrect choices:
- Living near his job: This is a demographic/environmental detail and does not inherently reflect mental health status.
- Smoking one-half pack of cigarettes: While this is a health-related behavior (substance use), in the context of a primary mental health screen, hygiene and safety/suicide risk are more immediate indicators of psychological state.
- Denying pain: This is a physical (physiological) assessment finding.
A 24-year-old male client presents to the clinic with reports of feeling unwell, lacking energy, and often feeling like not going to work, and he has missed five days of work in the past two weeks. The client informs about loss of appetite and that he has not been making healthy food choices. He also reports disruptive sleep habits and an inability to sleep at night and that he wants to sleep a great deal during the day.
1000
The client reports general malaise, fatigue, and decreased appetite. His skin is pale in color. He denies pain or discomfort. The client is withdrawn, soft spoken, and does not offer information without being prompted. The client reports a six pack of beer daily for the last eight months.
- Temperature: 98° F (36.6" C) orally
- Heart rate: 68 beats/minute
- Respirations: 16 breaths/minute
- Blood pressure: 110/72 mm Hg
- Oxygen saturation: 98% on room air
- Height: 5 feet, 9 inches (175.26 cm)
- Weight: 120 pounds (54.43 kg)
- Body mass index (BMI): 17.7 kg/m2 (normal 18 to 24.9 kg/m2)
1000
Complete a Mental status exam (MSE)
Obtain blood for a complete blood count (CBC), thyroxine, and thyroid stimulating hormone (TSH)
Patient Data
For each nursing action, click to indicate whether the action is a therapeutic communication or a nontherapeutic communication. Each row must have only one response option selected.
Explanation
- Point out misfortunes of other people: This is nontherapeutic because it minimizes the client’s feelings and may make them feel misunderstood or dismissed.
- Discuss client's appearance and daily activities: This is therapeutic as it helps establish rapport and encourages conversation in a non-threatening way.
- Inform client of medication times: This is therapeutic because it provides necessary information, promotes understanding, and supports adherence to care.
- Allow client to verbalize feelings: This is therapeutic as it encourages emotional expression and supports a trusting nurse-client relationship.
A 24-year-old male client presents to the clinic with reports of feeling unwell, lacking energy, and often feeling like not going to work, and he has missed five days of work in the past two weeks. The client informs about loss of appetite and that he has not been making healthy food choices. He also reports disruptive sleep habits and an inability to sleep at night and that he wants to sleep a great deal during the day.
1000
The client reports general malaise, fatigue, and decreased appetite. His skin is pale in color. He denies pain or discomfort. The client is withdrawn, soft spoken, and does not offer information without being prompted. The client reports a six pack of beer daily for the last eight months.
- Temperature: 98° F (36.6" C) orally
- Heart rate: 68 beats/minute
- Respirations: 16 breaths/minute
- Blood pressure: 110/72 mm Hg
- Oxygen saturation: 98% on room air
- Height: 5 feet, 9 inches (175.26 cm)
- Weight: 120 pounds (54.43 kg)
- Body mass index (BMI): 17.7 kg/m2 (normal 18 to 24.9 kg/m2)
1000
Complete a Mental status exam (MSE)
Obtain blood for a complete blood count (CBC), thyroxine, and thyroid stimulating hormone (TSH)
Patient Data
The client has been diagnosed with depression by the healthcare provider (HCP). Prescriptions are received for discharge. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.
The nurse instructs the client that sertraline can cause
Explanation
Rationale for correct choices:
• Dry mouth: Sertraline, a selective serotonin reuptake inhibitor (SSRI), commonly causes mild anticholinergic side effects such as dry mouth. This occurs due to decreased salivary secretion and is a frequent, non-serious adverse effect seen in clients taking antidepressants.
• Sips of water: Taking frequent sips of water is an appropriate and effective way to relieve dry mouth. It helps maintain oral moisture and comfort without causing harm or interfering with medication therapy.
Rationale for incorrect choices:
• Hypernatremia: SSRIs like sertraline are more commonly associated with hyponatremia (low sodium), especially in older adults, not hypernatremia. Therefore, this is incorrect.
• Elevated blood pressure: Sertraline does not typically cause hypertension. Some antidepressants (like SNRIs) may increase blood pressure, but SSRIs generally do not.
• Frequent rest: This intervention is more appropriate for managing fatigue, not dry mouth.
• Elevation of legs: This is used for edema or circulation issues and has no role in managing dry mouth.
A 24-year-old male client presents to the clinic with reports of feeling unwell, lacking energy, and often feeling like not going to work, and he has missed five days of work in the past two weeks. The client informs about loss of appetite and that he has not been making healthy food choices. He also reports disruptive sleep habits and an inability to sleep at night and that he wants to sleep a great deal during the day.
1000
The client reports general malaise, fatigue, and decreased appetite. His skin is pale in color. He denies pain or discomfort. The client is withdrawn, soft spoken, and does not offer information without being prompted. The client reports a six pack of beer daily for the last eight months.
- Temperature: 98° F (36.6" C) orally
- Heart rate: 68 beats/minute
- Respirations: 16 breaths/minute
- Blood pressure: 110/72 mm Hg
- Oxygen saturation: 98% on room air
- Height: 5 feet, 9 inches (175.26 cm)
- Weight: 120 pounds (54.43 kg)
- Body mass index (BMI): 17.7 kg/m2 (normal 18 to 24.9 kg/m2)
1000
Complete a Mental status exam (MSE)
Obtain blood for a complete blood count (CBC), thyroxine, and thyroid stimulating hormone (TSH)
Patient Data
The client returns to the clinic for his four week follow up appointment.
Which 3 statements made by the client indicate his depression is improving?
A 24-year-old male client presents to the clinic with reports of feeling unwell, lacking energy, and often feeling like not going to work, and he has missed five days of work in the past two weeks. The client informs about loss of appetite and that he has not been making healthy food choices. He also reports disruptive sleep habits and an inability to sleep at night and that he wants to sleep a great deal during the day.
1000
The client reports general malaise, fatigue, and decreased appetite. His skin is pale in color. He denies pain or discomfort. The client is withdrawn, soft spoken, and does not offer information without being prompted. The client reports a six pack of beer daily for the last eight months.
- Temperature: 98° F (36.6" C) orally
- Heart rate: 68 beats/minute
- Respirations: 16 breaths/minute
- Blood pressure: 110/72 mm Hg
- Oxygen saturation: 98% on room air
- Height: 5 feet, 9 inches (175.26 cm)
- Weight: 120 pounds (54.43 kg)
- Body mass index (BMI): 17.7 kg/m2 (normal 18 to 24.9 kg/m2)
1000
Complete a Mental status exam (MSE)
Obtain blood for a complete blood count (CBC), thyroxine, and thyroid stimulating hormone (TSH)
Patient Data
The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?
A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae type b (Hib) conjugate vaccine. Which instruction should the nurse provide?
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