BSN 346 PRACTICE HESI Exam Questions with Correct Answers

The nurse completes an emergency admission of a male client with schizophrenia who has not been taking his antipsychotic medications. The client is pacing, is extremely irritable, and has a blood pressure of 146/96. What is the priority nursing action? - Answer-Reevaluate the client's blood pressure in an hour. A young adult female client with panic disorder arrives in the Emergency Center with a 4-day history of chest pain that began when her boyfriend left her. Initial assessment reveals normal cardiopulmonary findings. Which information is most important for the nurse to obtain? - Answer-Drugs taken in last 7 days. A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, "There wasn't anything I could do to stop her drinking this morning." What intervention should the nurse take at this time? - Answer-Tell the client that therapy cannot take place while she is intoxicated. The nurse is planning care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan of care? - Answer-Search the client's personal belongings. A male client is brought to the emergency department by a police officer, who reports the client was "disturbing the peace" by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment? (Choose all that apply.) - Answer-Threats to kill his friend, hears voices telling him to kill himself, reports he has not needed a bath in 4 months and says he has not eaten in 3 days. The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing problem? - Answer-High risk for fluid and electrolyte imbalance. At the end of a group therapy session, a client who is hospitalized for psychosis falls to the floor when attempting to stand. What intervention should the nurse implement first? - Answer-Ask a group member to seek help