HESI MILESTONE 2 EXAMS BUNDLE 2026
EXAM STUDY GUIDE COMPLETE Q AND A
FULL SOLUTION VERIFIED
⩥ 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? Answer:
Ineffective denial related to situational anxiety
⩥ The nurse is interviewing a client with schizophrenia. Which client
behavior requires
immediate intervention? Answer: Muscle twitches in the back and neck
⩥ 32-year-old male client is admitted with paranoid schizophrenia
Answer: Reassure the client that he is safe and should rest.
⩥ What is schizophrenia? Answer: 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 Answer: 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? Answer: Encourage finger foods, distraction, speak
therapeutically
,⩥ 2 days after admission from alcohol withdrawal what should the nurse
do? Answer: Monitor HR and BP
⩥ which action should the nurse implement first for a client
experiencing alcohol
withdrawal? Answer: prepare the environment to prevent self injury: self
⩥ A patient won't take oral meds that is going through alcohol
withdrawal. The nurse
starts giving saline lock per alcohol protocol and thiamine. What do you
tell them that
it will help with recovery? Answer: Thiamine will replenish alcohol
effects on the body (something to do with iron)
⩥ A client comes in after being in a car accident and is experiencing
alcohol withdrawal,
magnesium level of 1.1, cardiac dysrhythmias. What would you give
first? Answer: Magnesium
⩥ Patient having to get treated for benzodiazepine and methadone
overdose. What do
you use? Answer: Narcan
, ⩥ When preparing to administer a domestic violence screening tool to a
female client,
which statement should the nurse provide? Answer: all clients are
screened for domestic abuse because it is common in our society
⩥ a mental health care worker caring for a client with escalating
aggressive behavior.
What action by the mental healthcare worker wards immediate
interventions? Answer: -attempting to physically restrain patient
⩥ Violence handling Answer: - Engage in dialogue to prevent escalation,
intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate need
for meds,
be consistent
⩥ a 30 year old sales manager tells the nurse "i am thinking about
a job change. i don't feel like i am living
up to my potential." which of maslows developmental stages is the
sales manager attempting to achieve Answer: self actualization:
⩥ A client is admitted to the mental health unit and reports taking extra
anti anxiety
EXAM STUDY GUIDE COMPLETE Q AND A
FULL SOLUTION VERIFIED
⩥ 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? Answer:
Ineffective denial related to situational anxiety
⩥ The nurse is interviewing a client with schizophrenia. Which client
behavior requires
immediate intervention? Answer: Muscle twitches in the back and neck
⩥ 32-year-old male client is admitted with paranoid schizophrenia
Answer: Reassure the client that he is safe and should rest.
⩥ What is schizophrenia? Answer: 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 Answer: 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? Answer: Encourage finger foods, distraction, speak
therapeutically
,⩥ 2 days after admission from alcohol withdrawal what should the nurse
do? Answer: Monitor HR and BP
⩥ which action should the nurse implement first for a client
experiencing alcohol
withdrawal? Answer: prepare the environment to prevent self injury: self
⩥ A patient won't take oral meds that is going through alcohol
withdrawal. The nurse
starts giving saline lock per alcohol protocol and thiamine. What do you
tell them that
it will help with recovery? Answer: Thiamine will replenish alcohol
effects on the body (something to do with iron)
⩥ A client comes in after being in a car accident and is experiencing
alcohol withdrawal,
magnesium level of 1.1, cardiac dysrhythmias. What would you give
first? Answer: Magnesium
⩥ Patient having to get treated for benzodiazepine and methadone
overdose. What do
you use? Answer: Narcan
, ⩥ When preparing to administer a domestic violence screening tool to a
female client,
which statement should the nurse provide? Answer: all clients are
screened for domestic abuse because it is common in our society
⩥ a mental health care worker caring for a client with escalating
aggressive behavior.
What action by the mental healthcare worker wards immediate
interventions? Answer: -attempting to physically restrain patient
⩥ Violence handling Answer: - Engage in dialogue to prevent escalation,
intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate need
for meds,
be consistent
⩥ a 30 year old sales manager tells the nurse "i am thinking about
a job change. i don't feel like i am living
up to my potential." which of maslows developmental stages is the
sales manager attempting to achieve Answer: self actualization:
⩥ A client is admitted to the mental health unit and reports taking extra
anti anxiety
