HESI MILESTONE 2 2026 STUDY GUIDE
COMPLETE NURSING FUNDAMENTALS AND
PRACTICE QUESTIONS
◉ The schizophrenic client insists that he is returning to his
apartment, although the
healthcare provider informed him that he will be moving to a
boarding home. What is
the most important nursing diagnosis for discharge planning?
Answer: Ineffective denial related to situational anxiety
◉ The nurse is interviewing a client with schizophrenia. Which
client behavior requires
immediate intervention? Answer: Muscle twitches in the back and
neck
◉ 32-year-old male client is admitted with paranoid schizophrenia
Answer: Reassure the client that he is safe and should rest.
◉ What is schizophrenia? Answer: it is a chemical imbalance in the
brain that causes disorganized thinking:
Dx: 2 or more S&S for over 6 mo
,(Positive= delusions, hallucinations, disorganized speech or
Negative= 6 A's Anhedonia, Flat Affect, Apathy, Anergia,
Algogia, Avolition)
-Establish rapport and trust, ask about hallucinations, distract,
lower environmental
stimuli, monitor suicidal ideation, 1st or 2nd generation antipsych
◉ grief process/ therapeutic response Answer: A. Encourage client
to express anger in a supportive, nonthreatening environment.
B. Discourage rumination.
C. Assist client in giving up idealized perception of deceased; point
out
misrepresentations.
D. Encourage interaction with others.
E. Assist client with identification of support systems.
F. Consult spiritual leader as indicated by client need and preference.
G. Assist client toward a comfortable, peaceful death.
◉ A resident of a long-term care facility, who has moderate
dementia, is having
difficulty eating in the dining room. The client becomes frustrated
when dropping
utensils on the floor and then refuses to eat. What action should the
nurse
,implement? Answer: Encourage finger foods, distraction, speak
therapeutically
◉ 2 days after admission from alcohol withdrawal what should the
nurse do? Answer: Monitor HR and BP
◉ which action should the nurse implement first for a client
experiencing alcohol
withdrawal? Answer: prepare the environment to prevent self
injury: self
◉ A patient won't take oral meds that is going through alcohol
withdrawal. The nurse
starts giving saline lock per alcohol protocol and thiamine. What do
you tell them that
it will help with recovery? Answer: Thiamine will replenish alcohol
effects on the body (something to do with iron)
◉ A client comes in after being in a car accident and is experiencing
alcohol withdrawal,
magnesium level of 1.1, cardiac dysrhythmias. What would you give
first? Answer: Magnesium
, ◉ Patient having to get treated for benzodiazepine and methadone
overdose. What do
you use? Answer: Narcan
◉ When preparing to administer a domestic violence screening tool
to a female client,
which statement should the nurse provide? Answer: all clients are
screened for domestic abuse because it is common in our society
◉ a mental health care worker caring for a client with escalating
aggressive behavior.
What action by the mental healthcare worker wards immediate
interventions? Answer: -attempting to physically restrain patient
◉ Violence handling Answer: - Engage in dialogue to prevent
escalation, intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate
need for meds,
be consistent
◉ a 30 year old sales manager tells the nurse "i am thinking
about a job change. i don't feel like i am living
COMPLETE NURSING FUNDAMENTALS AND
PRACTICE QUESTIONS
◉ The schizophrenic client insists that he is returning to his
apartment, although the
healthcare provider informed him that he will be moving to a
boarding home. What is
the most important nursing diagnosis for discharge planning?
Answer: Ineffective denial related to situational anxiety
◉ The nurse is interviewing a client with schizophrenia. Which
client behavior requires
immediate intervention? Answer: Muscle twitches in the back and
neck
◉ 32-year-old male client is admitted with paranoid schizophrenia
Answer: Reassure the client that he is safe and should rest.
◉ What is schizophrenia? Answer: it is a chemical imbalance in the
brain that causes disorganized thinking:
Dx: 2 or more S&S for over 6 mo
,(Positive= delusions, hallucinations, disorganized speech or
Negative= 6 A's Anhedonia, Flat Affect, Apathy, Anergia,
Algogia, Avolition)
-Establish rapport and trust, ask about hallucinations, distract,
lower environmental
stimuli, monitor suicidal ideation, 1st or 2nd generation antipsych
◉ grief process/ therapeutic response Answer: A. Encourage client
to express anger in a supportive, nonthreatening environment.
B. Discourage rumination.
C. Assist client in giving up idealized perception of deceased; point
out
misrepresentations.
D. Encourage interaction with others.
E. Assist client with identification of support systems.
F. Consult spiritual leader as indicated by client need and preference.
G. Assist client toward a comfortable, peaceful death.
◉ A resident of a long-term care facility, who has moderate
dementia, is having
difficulty eating in the dining room. The client becomes frustrated
when dropping
utensils on the floor and then refuses to eat. What action should the
nurse
,implement? Answer: Encourage finger foods, distraction, speak
therapeutically
◉ 2 days after admission from alcohol withdrawal what should the
nurse do? Answer: Monitor HR and BP
◉ which action should the nurse implement first for a client
experiencing alcohol
withdrawal? Answer: prepare the environment to prevent self
injury: self
◉ A patient won't take oral meds that is going through alcohol
withdrawal. The nurse
starts giving saline lock per alcohol protocol and thiamine. What do
you tell them that
it will help with recovery? Answer: Thiamine will replenish alcohol
effects on the body (something to do with iron)
◉ A client comes in after being in a car accident and is experiencing
alcohol withdrawal,
magnesium level of 1.1, cardiac dysrhythmias. What would you give
first? Answer: Magnesium
, ◉ Patient having to get treated for benzodiazepine and methadone
overdose. What do
you use? Answer: Narcan
◉ When preparing to administer a domestic violence screening tool
to a female client,
which statement should the nurse provide? Answer: all clients are
screened for domestic abuse because it is common in our society
◉ a mental health care worker caring for a client with escalating
aggressive behavior.
What action by the mental healthcare worker wards immediate
interventions? Answer: -attempting to physically restrain patient
◉ Violence handling Answer: - Engage in dialogue to prevent
escalation, intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate
need for meds,
be consistent
◉ a 30 year old sales manager tells the nurse "i am thinking
about a job change. i don't feel like i am living
