BSN366 Exam 2 Actual Exam Style V3 |
BSN 366 HESI RN Exit | Nightingale
1. A client is prescribed Lithium carbonate for the treatment of Bipolar I Disorder. Which
serum laboratory value indicates the nurse should withhold the medication and notify the
provider?
A. Lithium level of 1.0 mEq/L
B. Lithium level of 1.2 mEq/L
C. Lithium level of 0.6 mEq/L
D. Lithium level of 1.6 mEq/L
Answer: D
Rationale: A lithium level of 1.6 mEq/L is above the therapeutic range of 0.6 to 1.2 mEq/L
and indicates early toxicity. The nurse should immediately withhold the next dose and
assess the client for symptoms such as vomiting, diarrhea, or tremors. Maintaining stable
sodium and fluid intake is critical during lithium therapy to prevent toxicity levels from
rising further.
2. A nurse is assessing a client with Schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is most therapeutic?
A. I don’t hear the voices, but I understand they are real to you.
B. The voices are just part of your illness and not actually real.
,C. Try to ignore the voices and focus on our conversation.
D. What are the voices telling you to do right now?
Answer: D
Rationale: Safety is the priority when a client is experiencing hallucinations, especially
command hallucinations. Asking what the voices are saying allows the nurse to assess for
potential harm to self or others. This approach acknowledges the client’s experience while
focusing on immediate safety risks.
3. A client taking Phenelzine, an MAOI, is being educated on dietary restrictions. Which food
choice indicates the client understands the teaching?
A. Pepperoni pizza with extra aged cheese.
B. A grilled chicken sandwich with lettuce and tomato.
C. A sourdough bagel with smoked salmon and cream cheese.
D. Guacamole with tortilla chips and a glass of red wine.
Answer: B
Rationale: Clients taking MAOIs must follow a low-tyramine diet to avoid a hypertensive
crisis. Fresh meats like grilled chicken are safe, whereas aged cheeses, smoked meats, and
red wine are high in tyramine. Educating the client on recognizing the symptoms of
hypertensive crisis, such as a severe headache, is also essential for safety.
, 4. Which physical assessment finding is most characteristic of a client suffering from Anorexia
Nervosa?
A. Presence of fine, downy hair on the back and arms
B. Hypertension and tachycardia
C. Increased core body temperature
D. Dental enamel erosion on the lingual surfaces
Answer: A
Rationale: Lanugo, which is fine, downy hair, grows as a compensatory mechanism to keep
the body warm when body fat is severely depleted. Clients with anorexia often exhibit
bradycardia and hypotension rather than hypertension. Dental erosion is more commonly
associated with the purging behaviors found in Bulimia Nervosa.
5. A nurse is caring for a client with Borderline Personality Disorder who is ‘splitting’ staff
members. What is the most appropriate nursing intervention?
A. Allow the client to choose which nurse they prefer to work with.
B. Confront the client about their manipulative behavior immediately.
C. Hold a staff meeting to ensure a consistent approach by all team members.
D. Assign the same nurse to the client for the entire week.
Answer: C
BSN 366 HESI RN Exit | Nightingale
1. A client is prescribed Lithium carbonate for the treatment of Bipolar I Disorder. Which
serum laboratory value indicates the nurse should withhold the medication and notify the
provider?
A. Lithium level of 1.0 mEq/L
B. Lithium level of 1.2 mEq/L
C. Lithium level of 0.6 mEq/L
D. Lithium level of 1.6 mEq/L
Answer: D
Rationale: A lithium level of 1.6 mEq/L is above the therapeutic range of 0.6 to 1.2 mEq/L
and indicates early toxicity. The nurse should immediately withhold the next dose and
assess the client for symptoms such as vomiting, diarrhea, or tremors. Maintaining stable
sodium and fluid intake is critical during lithium therapy to prevent toxicity levels from
rising further.
2. A nurse is assessing a client with Schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is most therapeutic?
A. I don’t hear the voices, but I understand they are real to you.
B. The voices are just part of your illness and not actually real.
,C. Try to ignore the voices and focus on our conversation.
D. What are the voices telling you to do right now?
Answer: D
Rationale: Safety is the priority when a client is experiencing hallucinations, especially
command hallucinations. Asking what the voices are saying allows the nurse to assess for
potential harm to self or others. This approach acknowledges the client’s experience while
focusing on immediate safety risks.
3. A client taking Phenelzine, an MAOI, is being educated on dietary restrictions. Which food
choice indicates the client understands the teaching?
A. Pepperoni pizza with extra aged cheese.
B. A grilled chicken sandwich with lettuce and tomato.
C. A sourdough bagel with smoked salmon and cream cheese.
D. Guacamole with tortilla chips and a glass of red wine.
Answer: B
Rationale: Clients taking MAOIs must follow a low-tyramine diet to avoid a hypertensive
crisis. Fresh meats like grilled chicken are safe, whereas aged cheeses, smoked meats, and
red wine are high in tyramine. Educating the client on recognizing the symptoms of
hypertensive crisis, such as a severe headache, is also essential for safety.
, 4. Which physical assessment finding is most characteristic of a client suffering from Anorexia
Nervosa?
A. Presence of fine, downy hair on the back and arms
B. Hypertension and tachycardia
C. Increased core body temperature
D. Dental enamel erosion on the lingual surfaces
Answer: A
Rationale: Lanugo, which is fine, downy hair, grows as a compensatory mechanism to keep
the body warm when body fat is severely depleted. Clients with anorexia often exhibit
bradycardia and hypotension rather than hypertension. Dental erosion is more commonly
associated with the purging behaviors found in Bulimia Nervosa.
5. A nurse is caring for a client with Borderline Personality Disorder who is ‘splitting’ staff
members. What is the most appropriate nursing intervention?
A. Allow the client to choose which nurse they prefer to work with.
B. Confront the client about their manipulative behavior immediately.
C. Hold a staff meeting to ensure a consistent approach by all team members.
D. Assign the same nurse to the client for the entire week.
Answer: C
