Hesi Milestone 2 (100% correct answers)

A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the RN to ask the client? correct answers Do you hear sounds or voices that others do not hear? 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? correct answers Ineffective denial related to situational anxiety The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? correct answers Muscle twitches in the back and neck 32-year-old male client is admitted with paranoid schizophrenia correct answers Reassure the client that he is safe and should rest. What is schizophrenia? correct answers 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 correct answers 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? correct answers Encourage finger foods, distraction, speak therapeutically 2 days after admission from alcohol withdrawal what should the nurse do? correct answers Monitor HR and BP which action should the nurse implement first for a client experiencing alcohol