HESI COMPASS MODULE EXAM 4 STUDY
GUIDE 2026 CRITICAL CARE AND RAPID
RESPONSE QUESTIONS AND ANSWERS
◉ An adolescent client has graduated high school and is preparing to
leave home to attend college. The adolescent is distressed about this
life change. The nurse plans to implement crisis interventions,
knowing that this situation is characteristic of:
Answer: A maturational crisis
Rationale: A maturational crisis involves the normal life transitions
that produce changes in individuals and how they perceive
themselves, their roles, and their status. A situational crisis occurs
when a specific external event disturbs an individual's psychological
equilibrium. An adventitious crisis is an unpredictable tragedy that
occurs without warning. An individual may experience crisis;
however, there is no formal type of crisis known as "individual
crisis."
◉ A heroin addict who overdoses on the drug is brought into the
emergency department. The client is having seizures, and the nurse
notes that his pupils are dilated. Which of the following
interventions does the nurse anticipate that the emergency
department physician will prescribe?
Answer: Naloxone (Narcan)
,Rationale: An opioid antagonist such as naloxone would be
prescribed to treat a heroin overdose to reverse central nervous
system depression. Gastric lavage is used for oral overdose of or oral
poisoning with certain substances. Intravenous fluid is a general
intervention in many situations. Ammonium chloride is used to
acidify the urine of a client who overdoses on amphetamines
◉ A client in a retirement center rings the night alarm and says to
the nurse, "Look at this old man! He keeps breaking into my
apartment! You've got to get him to stay out of here so I can sleep."
Which statement by the nurse would be most therapeutic?
Answer: "This must be very troubling to you, but I can't see the old
man. Perhaps I could stay with you for an hour or so while you try to
rest."
Rationale: The most therapeutic nursing response is the one that
expresses empathy and helps orient the client to reality. It also offers
self, builds trust, and provides support for the client's distress. In
asking, "Why not just throw him out yourself and lock up once and
for all?" the nurse reinforces the hallucination and delusional
thinking by responding as if the old man is really there. In stating,
"Now, you know that you're always seeing things and people at night
who aren't there," the nurse is patronizing and belittling in
responding to the client's concerns, a nontherapeutic
communication. In responding, "I'm sure that you're very frightened
right now. Do you recall my telling you that this is called sundowner
,syndrome? Go to sleep and he'll leave your apartment," the nurse is
lecturing the client and giving advice, which is not therapeutic.
◉ A schizophrenic client is seen seemingly talking to someone who
isn't there. Which nursing statement would be most therapeutic
initially?
Answer: "I've noticed your eyes darting back and forth, and I
wondered whether you might be hearing voices."
Rationale: The most therapeutic nursing statement is the one in
which the nurse addresses the client's behavior and asks whether
the client is hearing voices. With this statement, the nurse also
assesses the client's behavior. If the client is hearing voices, the
nurse prevents reinforcement of the hallucinatory thinking by telling
the client that he or she does not hear them. In asking, "Today is my
birthday. Would you like to go on an outing with my family?" the
nurse nontherapeutically changes the focus from the client. In
stating, "You need to wash up and get ready to go to supper in the
cafeteria with the other clients now," the nurse ignores the client's
obvious psychotic behavior and directs the client to socialize with
others. Such an intervention is not usually positive, because it floods
the client with stimuli that may contribute to an escalation of
psychotic behavior. In asking, "You were telling me yesterday that
your mother died last June of cancer. Can you tell me more about
that?" the nurse uses distraction, summarization, and refocusing.
, ◉ A nurse brings a meal tray to a psychotic client in his hospital
room. The client refuses the meal and says, "I'm not eating any more
poisoned food while I'm vacationing here. I'm starting on a fast to
stay healthy and alive." Which nursing intervention would be most
appropriate initially?
Answer: Having the client eat with other clients in the community
dining room
Rationale: Having the client eat with other clients in the community
room decreases the amount of time in which the client can stay
isolated and engage in suspicious thinking. Of the options provided,
this would be the initial intervention. It does not guarantee that the
client will eat but does reduce the client's isolation time. Taking the
tray away and canceling all meals until further notice and eating
some of the food off the client's tray to prove that it isn't poisoned
are both incorrect because they support the client's delusional
thinking. Telling the client that the psychiatrist will be called for a
prescription for a tube feeding is incorrect because it is a premature
action that would lead to a regressive struggle with the client and is
also a threat to the client.
◉ A nurse caring for a schizophrenic client is assessing the client's
ability to control distorted thought processes. Which of the following
findings indicates a positive outcome?
Answer: The client can identify the recurrence of hallucinations, can
refrain from responding to them, and reports a significant decrease
in the incidence of hallucinations.
GUIDE 2026 CRITICAL CARE AND RAPID
RESPONSE QUESTIONS AND ANSWERS
◉ An adolescent client has graduated high school and is preparing to
leave home to attend college. The adolescent is distressed about this
life change. The nurse plans to implement crisis interventions,
knowing that this situation is characteristic of:
Answer: A maturational crisis
Rationale: A maturational crisis involves the normal life transitions
that produce changes in individuals and how they perceive
themselves, their roles, and their status. A situational crisis occurs
when a specific external event disturbs an individual's psychological
equilibrium. An adventitious crisis is an unpredictable tragedy that
occurs without warning. An individual may experience crisis;
however, there is no formal type of crisis known as "individual
crisis."
◉ A heroin addict who overdoses on the drug is brought into the
emergency department. The client is having seizures, and the nurse
notes that his pupils are dilated. Which of the following
interventions does the nurse anticipate that the emergency
department physician will prescribe?
Answer: Naloxone (Narcan)
,Rationale: An opioid antagonist such as naloxone would be
prescribed to treat a heroin overdose to reverse central nervous
system depression. Gastric lavage is used for oral overdose of or oral
poisoning with certain substances. Intravenous fluid is a general
intervention in many situations. Ammonium chloride is used to
acidify the urine of a client who overdoses on amphetamines
◉ A client in a retirement center rings the night alarm and says to
the nurse, "Look at this old man! He keeps breaking into my
apartment! You've got to get him to stay out of here so I can sleep."
Which statement by the nurse would be most therapeutic?
Answer: "This must be very troubling to you, but I can't see the old
man. Perhaps I could stay with you for an hour or so while you try to
rest."
Rationale: The most therapeutic nursing response is the one that
expresses empathy and helps orient the client to reality. It also offers
self, builds trust, and provides support for the client's distress. In
asking, "Why not just throw him out yourself and lock up once and
for all?" the nurse reinforces the hallucination and delusional
thinking by responding as if the old man is really there. In stating,
"Now, you know that you're always seeing things and people at night
who aren't there," the nurse is patronizing and belittling in
responding to the client's concerns, a nontherapeutic
communication. In responding, "I'm sure that you're very frightened
right now. Do you recall my telling you that this is called sundowner
,syndrome? Go to sleep and he'll leave your apartment," the nurse is
lecturing the client and giving advice, which is not therapeutic.
◉ A schizophrenic client is seen seemingly talking to someone who
isn't there. Which nursing statement would be most therapeutic
initially?
Answer: "I've noticed your eyes darting back and forth, and I
wondered whether you might be hearing voices."
Rationale: The most therapeutic nursing statement is the one in
which the nurse addresses the client's behavior and asks whether
the client is hearing voices. With this statement, the nurse also
assesses the client's behavior. If the client is hearing voices, the
nurse prevents reinforcement of the hallucinatory thinking by telling
the client that he or she does not hear them. In asking, "Today is my
birthday. Would you like to go on an outing with my family?" the
nurse nontherapeutically changes the focus from the client. In
stating, "You need to wash up and get ready to go to supper in the
cafeteria with the other clients now," the nurse ignores the client's
obvious psychotic behavior and directs the client to socialize with
others. Such an intervention is not usually positive, because it floods
the client with stimuli that may contribute to an escalation of
psychotic behavior. In asking, "You were telling me yesterday that
your mother died last June of cancer. Can you tell me more about
that?" the nurse uses distraction, summarization, and refocusing.
, ◉ A nurse brings a meal tray to a psychotic client in his hospital
room. The client refuses the meal and says, "I'm not eating any more
poisoned food while I'm vacationing here. I'm starting on a fast to
stay healthy and alive." Which nursing intervention would be most
appropriate initially?
Answer: Having the client eat with other clients in the community
dining room
Rationale: Having the client eat with other clients in the community
room decreases the amount of time in which the client can stay
isolated and engage in suspicious thinking. Of the options provided,
this would be the initial intervention. It does not guarantee that the
client will eat but does reduce the client's isolation time. Taking the
tray away and canceling all meals until further notice and eating
some of the food off the client's tray to prove that it isn't poisoned
are both incorrect because they support the client's delusional
thinking. Telling the client that the psychiatrist will be called for a
prescription for a tube feeding is incorrect because it is a premature
action that would lead to a regressive struggle with the client and is
also a threat to the client.
◉ A nurse caring for a schizophrenic client is assessing the client's
ability to control distorted thought processes. Which of the following
findings indicates a positive outcome?
Answer: The client can identify the recurrence of hallucinations, can
refrain from responding to them, and reports a significant decrease
in the incidence of hallucinations.
