NSG-322 PRACTICE HESI Q AND A
Thevbnursevbcompletesvbanvbemergencyvbadmissionvbofvbavbmalevbclientvbwithvbschizophreniavbwhovbhasvbn
otvbbeenvbtakingvbhisvbantipsychoticvbmedications.vbThevbclientvbisvbpacing,vbisvbextremelyvbirritable,vbandvbh
asvbavbbloodvbpressurevbofvb146/96.vbWhatvbisvbthevbpriorityvbnursingvbaction?vb-vbanswer--
Reevaluatevbthevbclient'svbbloodvbpressurevbinvbanvbhour.
AvbyoungvbadultvbfemalevbclientvbwithvbpanicvbdisordervbarrivesvbinvbthevbEmergencyvbCentervbwithvbavb4-
dayvbhistoryvbofvbchestvbpainvbthatvbbeganvbwhenvbhervbboyfriendvbleftvbher.vbInitialvbassessmentvbrevealsvbn
ormalvbcardiopulmonaryvbfindings.vbWhichvbinformationvbisvbmostvbimportantvbforvbthevbnursevbtovbobtain?vb-
vbanswer--Drugsvbtakenvbinvblastvb7vbdays.
Avbfemalevbclientvbcomesvbtovbanvboutpatientvbtherapyvbappointmentvbintoxicated.vbThevbspousevbtellsvbthevb
nurse,vb"Therevbwasn'tvbanythingvbIvbcouldvbdovbtovbstopvbhervbdrinkingvbthisvbmorning."vbWhatvbinterventionv
bshouldvbthevbnursevbtakevbatvbthisvbtime?vb-vbanswer--
Tellvbthevbclientvbthatvbtherapyvbcannotvbtakevbplacevbwhilevbshevbisvbintoxicated.
Thevbnursevbisvbplanningvbcarevbforvbavbclientvbwithvbmajorvbdepressionvbwhovbisvbadmittedvbtovbthevbunitvbafte
rvbavbrecentvbsuicidevbattempt.vbWhichvbinterventionvbhasvbthevbhighestvbpriorityvbforvbinclusionvbinvbthisvbclien
t'svbplanvbofvbcare?vb-vbanswer--Searchvbthevbclient'svbpersonalvbbelongings.
Avbmalevbclientvbisvbbroughtvbtovbthevbemergencyvbdepartmentvbbyvbavbpolicevbofficer,vbwhovbreportsvbthevbcli
entvbwasvb"disturbingvbthevbpeace"vbbyvbrunningvbnakedvbinvbthevbstreet,vbstrikingvboutvbatvbothers,vbandvbsma
shingvbcarvbwindows.vbWhichvbbehaviorsvbshouldvbthevbclientvbdemonstratevbtovbdeterminevbifvbhevbshouldvb
bevbevaluatedvbforvbinvoluntaryvbcommitment?vb(Choosevballvbthatvbapply.)vb-vbanswer--
Threatsvbtovbkillvbhisvbfriend,vbhearsvbvoicesvbtellingvbhimvbtovbkillvbhimself,vbreportsvbhevbhasvbnotvbneededvbav
bbathvbinvb4vbmonthsvbandvbsaysvbhevbhasvbnotvbeatenvbinvb3vbdays.
Thevbnursevbisvbcaringvbforvbanvbadultvbmalevbclientvbwithvbcatatonicvbschizophreniavbwhovbisvbmutevbandvbmo
tionless.vbWhatvbisvbthevbpriorityvbnursingvbproblem?vb-vbanswer--
Highvbriskvbforvbfluidvbandvbelectrolytevbimbalance.
Atvbthevbendvbofvbavbgroupvbtherapyvbsession,vbavbclientvbwhovbisvbhospitalizedvbforvbpsychosisvbfallsvbtovbthevb
floorvbwhenvbattemptingvbtovbstand.vbWhatvbinterventionvbshouldvbthevbnursevbimplementvbfirst?vb-vbanswer--
Askvbavbgroupvbmembervbtovbseekvbhelp.
Whichvbnursingvbinterventionvbshouldvbthevbnursevbimplementvbwithvbparentsvbwhovbexperiencevbavbfetalvbde
misevbandvbexpressvbthevbwishvbnotvbtovbseevbthevbbaby?vb-vbanswer--
Keepvbthevbbodyvbavailablevbforvbavbfewvbhoursvbinvbcasevbtheyvbchangevbtheirvbminds.
Anvbadultvbfemalevbwhovbisvbmarriedvbandvbworksvbfull-
timevbinvbavbfactoryvbhasvbbeenvbabsentvbfromvbworkvbforvbthreevbdaysvbatvbavbtimevbonvbseveralvboccasions.vb
Eachvbtimevbshevbreturnsvbtovbwork,vbshevbwearsvbdarkvbglassesvbtovbcovervbfacialvbbruising.vbHervbsuperviso
rvbrefersvbhervbtovbthevboccupationalvbhealthvbnurse.vbWhatvbassessmentvbquestionvbshouldvbthevbnursevbuse
?vb-vbanswer--Howvbdidvbthisvbhappenvbtovbyou?
, Avbclientvbonvbthevbmentalvbhealthvbunitvbreportsvbconcernsvbaboutvbweightvbgainvbasvbavbresultvbofvbtakingvbdi
valproexvb(Depakote)vbandvbrequestsvbassistancevbtovbfillvboutvbavbmenu.vbThevbnursevbshouldvbinitiatevbavbre
ferralvbtovbwhichvbhealthcarevbteamvbmember?vb-vbanswer--Dietician.
Thevbnursevbisvbplanningvbthevbcarevbforvbavbclientvbbasedvbonvbthevbpsychoanalyticalvbmodel.vbWhichvbinterv
entionvbshouldvbthevbnursevbincludevbinvbthevbplanvbofvbcare?vb-vbanswer--
Focusvbonvbthevbclient'svbpositivevborvbnegativevbfeelingsvbtowardvbthevbnurse.
AvbwomanvbadmittedvbtovbthevbEmergencyvbDepartmentvbisvbbleedingvbprofuselyvbfromvbavbpatchvbwherevbh
airvbwasvblostvbfromvbhervbscalp.vbShevbisvbaccompaniedvbbyvbhervbhusbandvbwhovbtellsvbthevbnursevbthatvbhisv
bwifevbcaughtvbhervbhairvbonvbthevbrailingvbandvbpulledvbitvboutvbwhenvbshevbfellvbdownvbthevbstairs.vbThevbhusb
andvbisvbsolicitousvbofvbhisvbwifevbandvbquicklyvbanswersvbquestionsvbonvbhervbbehalf.vbHevbattemptsvbtovbco
mfortvbhisvbwifevbbyvbsayingvbtovbher,vb"Ivbamvbrightvbherevbwithvbyou,vbdear.vbNothingvbcanvbkeepvbusvbapart."v
bWhatvbisvbthevbpriorityvbnursingvbintervention?vb-vbanswer--
Requirevbthevbhusbandvbtovbleavevbthevbcubiclevbwhilevbthevbclientvbisvbbeingvbtreated.
Avbfemalevbclientvbwithvbseverevbdepressionvbisvbgivenvbinformationvbaboutvbthevbrisks,vbbenefits,vbalternativ
es,vbandvbexpectedvboutcomesvbofvbelectroconvulsivevbtherapyvb(ECT)vbandvbsignsvbthevbinformedvbconsen
tvbforvbtreatment.vbAftervbthevbclient'svbfamilyvbleaves,vbthevbclientvbtellsvbthevbnurse,vb"Ivbsignedvbthevbpapersvb
becausevbmyvbhusbandvbtoldvbmevbIvbwillvbbevbdeportedvbifvbmyvbdepressionvbisvbnotvbcured."vbWhatvbinforma
tionvbshouldvbthevbnursevbreportvbtovbthevbhealthcarevbprovider?vb-vbanswer--
Thevbclient'svbconsentvbmayvbhavevbbeenvbcoerced.
Avbmalevbclientvbwithvbseverevborthopedicvbinjuriesvbfollowingvbavbmotorvbvehiclevbcollisionvbisvbirritable,vbang
ry,vbandvbbelittlesvbthevbnurses.vbWhilevbavbnursevbisvbchangingvbthevbdressingvbovervbavblaceration,vbthevbclie
ntvbscreams,vb"Don'tvbtouchvbme!
vbYou'revbsovbstupidvbthatvbyou'llvbmakevbitvbworse!"vbWhichvbinterventionvbisvbbestvbforvbthevbnursevbtovbimple
ment?vb-vbanswer--Providevbinformationvbaboutvbinfectionvbprevention.
Thevbnursevbisvbassessingvbavbclientvbwithvbavbhistoryvbofvbborderlinevbpersonalityvbdisorder.vbWhichvbquestio
nvbshouldvbthevbnursevbincludevbinvbthevbassessment?vb-vbanswer--
Dovbyouvbfrequentlyvbhavevbtempervbtantrums?
Duringvbthevbadmissionvbofvbavbmalevbclientvbtovbthevbmentalvbhealthvbunit,vbthevbclientvbtellsvbthevbnursevbthatv
bhevbhadvbavbpanicvbattackvbtodayvbandvbranvboutvbofvbthevbphysician'svboffice.vbWhichvbquestionvbisvbmostvbim
portantvbforvbthevbnursevbtovbaskvbthisvbclient?vb-vbanswer--
Havevbyouvbhadvbanyvbthoughtsvbofvbhurtingvbyourself?
Thevbdaughtervbofvbanvboldervbmalevbclientvbtellsvbthevbnursevbthatvbhervbfathervbisvbbecomingvbincreasinglyvbf
orgetful.vbWhichvbfindingvbindicatesvbthatvbthevbclientvbneedsvbfurthervbevaluationvbofvbcognitivevbfunction?vb-
vbanswer--Cannotvbmentallyvbretracevbobjectsvbthatvbwerevbrecentlyvbmisplaced.
Whichvbactionvbshouldvbthevbnursevbimplementvbfirstvbforvbavbclientvbexperiencingvbalcoholvbwithdrawal?vb-
vbanswer--Preparevbthevbenvironmentvbtovbpreventvbself-injury.
Thevbnursevbisvbcaringvbforvbavbclientvbwhovbreceivedvbthevbfirst-
timevbelectroconvulsivevbtherapyvb(ECT)vbavbhalfvbhourvbago.vbWhichvbactionvbshouldvbthevbnursevbimpleme
ntvbfirst?vb-vbanswer--Monitorvbvitalvbsigns.
Thevbclientvbwithvbdepressionvbasksvbthevbnurse,vb"vbWhatvbarevbneurotransmitters?
vbMyvbdoctorvbthinksvbmyvbproblemvbmayvblievbwithvbthevbneurotransmittersvbinvbmyvbbrain."vbWhatvbinformati
Thevbnursevbcompletesvbanvbemergencyvbadmissionvbofvbavbmalevbclientvbwithvbschizophreniavbwhovbhasvbn
otvbbeenvbtakingvbhisvbantipsychoticvbmedications.vbThevbclientvbisvbpacing,vbisvbextremelyvbirritable,vbandvbh
asvbavbbloodvbpressurevbofvb146/96.vbWhatvbisvbthevbpriorityvbnursingvbaction?vb-vbanswer--
Reevaluatevbthevbclient'svbbloodvbpressurevbinvbanvbhour.
AvbyoungvbadultvbfemalevbclientvbwithvbpanicvbdisordervbarrivesvbinvbthevbEmergencyvbCentervbwithvbavb4-
dayvbhistoryvbofvbchestvbpainvbthatvbbeganvbwhenvbhervbboyfriendvbleftvbher.vbInitialvbassessmentvbrevealsvbn
ormalvbcardiopulmonaryvbfindings.vbWhichvbinformationvbisvbmostvbimportantvbforvbthevbnursevbtovbobtain?vb-
vbanswer--Drugsvbtakenvbinvblastvb7vbdays.
Avbfemalevbclientvbcomesvbtovbanvboutpatientvbtherapyvbappointmentvbintoxicated.vbThevbspousevbtellsvbthevb
nurse,vb"Therevbwasn'tvbanythingvbIvbcouldvbdovbtovbstopvbhervbdrinkingvbthisvbmorning."vbWhatvbinterventionv
bshouldvbthevbnursevbtakevbatvbthisvbtime?vb-vbanswer--
Tellvbthevbclientvbthatvbtherapyvbcannotvbtakevbplacevbwhilevbshevbisvbintoxicated.
Thevbnursevbisvbplanningvbcarevbforvbavbclientvbwithvbmajorvbdepressionvbwhovbisvbadmittedvbtovbthevbunitvbafte
rvbavbrecentvbsuicidevbattempt.vbWhichvbinterventionvbhasvbthevbhighestvbpriorityvbforvbinclusionvbinvbthisvbclien
t'svbplanvbofvbcare?vb-vbanswer--Searchvbthevbclient'svbpersonalvbbelongings.
Avbmalevbclientvbisvbbroughtvbtovbthevbemergencyvbdepartmentvbbyvbavbpolicevbofficer,vbwhovbreportsvbthevbcli
entvbwasvb"disturbingvbthevbpeace"vbbyvbrunningvbnakedvbinvbthevbstreet,vbstrikingvboutvbatvbothers,vbandvbsma
shingvbcarvbwindows.vbWhichvbbehaviorsvbshouldvbthevbclientvbdemonstratevbtovbdeterminevbifvbhevbshouldvb
bevbevaluatedvbforvbinvoluntaryvbcommitment?vb(Choosevballvbthatvbapply.)vb-vbanswer--
Threatsvbtovbkillvbhisvbfriend,vbhearsvbvoicesvbtellingvbhimvbtovbkillvbhimself,vbreportsvbhevbhasvbnotvbneededvbav
bbathvbinvb4vbmonthsvbandvbsaysvbhevbhasvbnotvbeatenvbinvb3vbdays.
Thevbnursevbisvbcaringvbforvbanvbadultvbmalevbclientvbwithvbcatatonicvbschizophreniavbwhovbisvbmutevbandvbmo
tionless.vbWhatvbisvbthevbpriorityvbnursingvbproblem?vb-vbanswer--
Highvbriskvbforvbfluidvbandvbelectrolytevbimbalance.
Atvbthevbendvbofvbavbgroupvbtherapyvbsession,vbavbclientvbwhovbisvbhospitalizedvbforvbpsychosisvbfallsvbtovbthevb
floorvbwhenvbattemptingvbtovbstand.vbWhatvbinterventionvbshouldvbthevbnursevbimplementvbfirst?vb-vbanswer--
Askvbavbgroupvbmembervbtovbseekvbhelp.
Whichvbnursingvbinterventionvbshouldvbthevbnursevbimplementvbwithvbparentsvbwhovbexperiencevbavbfetalvbde
misevbandvbexpressvbthevbwishvbnotvbtovbseevbthevbbaby?vb-vbanswer--
Keepvbthevbbodyvbavailablevbforvbavbfewvbhoursvbinvbcasevbtheyvbchangevbtheirvbminds.
Anvbadultvbfemalevbwhovbisvbmarriedvbandvbworksvbfull-
timevbinvbavbfactoryvbhasvbbeenvbabsentvbfromvbworkvbforvbthreevbdaysvbatvbavbtimevbonvbseveralvboccasions.vb
Eachvbtimevbshevbreturnsvbtovbwork,vbshevbwearsvbdarkvbglassesvbtovbcovervbfacialvbbruising.vbHervbsuperviso
rvbrefersvbhervbtovbthevboccupationalvbhealthvbnurse.vbWhatvbassessmentvbquestionvbshouldvbthevbnursevbuse
?vb-vbanswer--Howvbdidvbthisvbhappenvbtovbyou?
, Avbclientvbonvbthevbmentalvbhealthvbunitvbreportsvbconcernsvbaboutvbweightvbgainvbasvbavbresultvbofvbtakingvbdi
valproexvb(Depakote)vbandvbrequestsvbassistancevbtovbfillvboutvbavbmenu.vbThevbnursevbshouldvbinitiatevbavbre
ferralvbtovbwhichvbhealthcarevbteamvbmember?vb-vbanswer--Dietician.
Thevbnursevbisvbplanningvbthevbcarevbforvbavbclientvbbasedvbonvbthevbpsychoanalyticalvbmodel.vbWhichvbinterv
entionvbshouldvbthevbnursevbincludevbinvbthevbplanvbofvbcare?vb-vbanswer--
Focusvbonvbthevbclient'svbpositivevborvbnegativevbfeelingsvbtowardvbthevbnurse.
AvbwomanvbadmittedvbtovbthevbEmergencyvbDepartmentvbisvbbleedingvbprofuselyvbfromvbavbpatchvbwherevbh
airvbwasvblostvbfromvbhervbscalp.vbShevbisvbaccompaniedvbbyvbhervbhusbandvbwhovbtellsvbthevbnursevbthatvbhisv
bwifevbcaughtvbhervbhairvbonvbthevbrailingvbandvbpulledvbitvboutvbwhenvbshevbfellvbdownvbthevbstairs.vbThevbhusb
andvbisvbsolicitousvbofvbhisvbwifevbandvbquicklyvbanswersvbquestionsvbonvbhervbbehalf.vbHevbattemptsvbtovbco
mfortvbhisvbwifevbbyvbsayingvbtovbher,vb"Ivbamvbrightvbherevbwithvbyou,vbdear.vbNothingvbcanvbkeepvbusvbapart."v
bWhatvbisvbthevbpriorityvbnursingvbintervention?vb-vbanswer--
Requirevbthevbhusbandvbtovbleavevbthevbcubiclevbwhilevbthevbclientvbisvbbeingvbtreated.
Avbfemalevbclientvbwithvbseverevbdepressionvbisvbgivenvbinformationvbaboutvbthevbrisks,vbbenefits,vbalternativ
es,vbandvbexpectedvboutcomesvbofvbelectroconvulsivevbtherapyvb(ECT)vbandvbsignsvbthevbinformedvbconsen
tvbforvbtreatment.vbAftervbthevbclient'svbfamilyvbleaves,vbthevbclientvbtellsvbthevbnurse,vb"Ivbsignedvbthevbpapersvb
becausevbmyvbhusbandvbtoldvbmevbIvbwillvbbevbdeportedvbifvbmyvbdepressionvbisvbnotvbcured."vbWhatvbinforma
tionvbshouldvbthevbnursevbreportvbtovbthevbhealthcarevbprovider?vb-vbanswer--
Thevbclient'svbconsentvbmayvbhavevbbeenvbcoerced.
Avbmalevbclientvbwithvbseverevborthopedicvbinjuriesvbfollowingvbavbmotorvbvehiclevbcollisionvbisvbirritable,vbang
ry,vbandvbbelittlesvbthevbnurses.vbWhilevbavbnursevbisvbchangingvbthevbdressingvbovervbavblaceration,vbthevbclie
ntvbscreams,vb"Don'tvbtouchvbme!
vbYou'revbsovbstupidvbthatvbyou'llvbmakevbitvbworse!"vbWhichvbinterventionvbisvbbestvbforvbthevbnursevbtovbimple
ment?vb-vbanswer--Providevbinformationvbaboutvbinfectionvbprevention.
Thevbnursevbisvbassessingvbavbclientvbwithvbavbhistoryvbofvbborderlinevbpersonalityvbdisorder.vbWhichvbquestio
nvbshouldvbthevbnursevbincludevbinvbthevbassessment?vb-vbanswer--
Dovbyouvbfrequentlyvbhavevbtempervbtantrums?
Duringvbthevbadmissionvbofvbavbmalevbclientvbtovbthevbmentalvbhealthvbunit,vbthevbclientvbtellsvbthevbnursevbthatv
bhevbhadvbavbpanicvbattackvbtodayvbandvbranvboutvbofvbthevbphysician'svboffice.vbWhichvbquestionvbisvbmostvbim
portantvbforvbthevbnursevbtovbaskvbthisvbclient?vb-vbanswer--
Havevbyouvbhadvbanyvbthoughtsvbofvbhurtingvbyourself?
Thevbdaughtervbofvbanvboldervbmalevbclientvbtellsvbthevbnursevbthatvbhervbfathervbisvbbecomingvbincreasinglyvbf
orgetful.vbWhichvbfindingvbindicatesvbthatvbthevbclientvbneedsvbfurthervbevaluationvbofvbcognitivevbfunction?vb-
vbanswer--Cannotvbmentallyvbretracevbobjectsvbthatvbwerevbrecentlyvbmisplaced.
Whichvbactionvbshouldvbthevbnursevbimplementvbfirstvbforvbavbclientvbexperiencingvbalcoholvbwithdrawal?vb-
vbanswer--Preparevbthevbenvironmentvbtovbpreventvbself-injury.
Thevbnursevbisvbcaringvbforvbavbclientvbwhovbreceivedvbthevbfirst-
timevbelectroconvulsivevbtherapyvb(ECT)vbavbhalfvbhourvbago.vbWhichvbactionvbshouldvbthevbnursevbimpleme
ntvbfirst?vb-vbanswer--Monitorvbvitalvbsigns.
Thevbclientvbwithvbdepressionvbasksvbthevbnurse,vb"vbWhatvbarevbneurotransmitters?
vbMyvbdoctorvbthinksvbmyvbproblemvbmayvblievbwithvbthevbneurotransmittersvbinvbmyvbbrain."vbWhatvbinformati