BSN366 Exam 2 Actual Exam Style V2 |
BSN 366 HESI RN Exit | Nightingale
1. A nurse is caring for a client who has a history of alcohol use disorder and is experiencing
withdrawal. Which of the following findings should the nurse identify as a manifestation of
alcohol withdrawal delirium?
A. Hypervigilance
B. Disorientation to time and place
C. Bradycardia
D. Somnolence
Answer: B
Rationale: Alcohol withdrawal delirium is a medical emergency that typically occurs 2 to 3
days after cessation of alcohol. It is characterized by severe disorientation, psychotic
manifestations, and cardiac dysrhythmias. Monitoring vital signs and safety is the priority
nursing intervention during this period.
2. A nurse is assessing a client who has anorexia nervosa. Which of the following findings
should the nurse expect?
A. Warm, flushed skin
B. Tachycardia
C. Hypertension
,D. Amenorrhea
Answer: D
Rationale: Amenorrhea is a common physiological consequence of anorexia nervosa due
to low body weight and hormonal imbalances. Clients also typically exhibit bradycardia and
hypotension rather than tachycardia and hypertension. Peripheral edema and lanugo are
other common physical findings in these patients.
3. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which of the
following laboratory values should the nurse monitor to prevent lithium toxicity?
A. Serum calcium
B. Serum creatinine
C. Serum glucose
D. Serum potassium
Answer: B
Rationale: Lithium is excreted primarily by the kidneys, so renal function must be
monitored closely to prevent toxicity. An increase in serum creatinine indicates impaired
kidney function, which can lead to dangerously high lithium levels. Nurses should also
encourage consistent sodium intake to maintain stable drug levels.
4. A nurse is evaluating a client who has schizophrenia and is taking haloperidol. The nurse
should identify that which of the following findings is an extrapyramidal symptom (EPS)?
A. Extreme thirst
, B. Akathisia
C. Weight gain
D. Hypotension
Answer: B
Rationale: Akathisia is an extrapyramidal symptom characterized by physical restlessness
and an urgent need to move. It is a common side effect of first-generation antipsychotics
like haloperidol. Other EPS include acute dystonia, pseudoparkinsonism, and tardive
dyskinesia.
5. A nurse is caring for a client who was just admitted with a diagnosis of major depressive
disorder. Which of the following actions is the nurse’s priority?
A. Encourage the client to attend group therapy.
B. Help the client identify negative thought patterns.
C. Assess the client’s risk for suicide.
D. Assist the client with activities of daily living.
Answer: C
Rationale: Safety is the highest priority when caring for a client with major depressive
disorder. The nurse must conduct a thorough suicide risk assessment to identify any
immediate danger to the client. Once safety is established, the nurse can proceed with
psychosocial interventions and ADL support.
BSN 366 HESI RN Exit | Nightingale
1. A nurse is caring for a client who has a history of alcohol use disorder and is experiencing
withdrawal. Which of the following findings should the nurse identify as a manifestation of
alcohol withdrawal delirium?
A. Hypervigilance
B. Disorientation to time and place
C. Bradycardia
D. Somnolence
Answer: B
Rationale: Alcohol withdrawal delirium is a medical emergency that typically occurs 2 to 3
days after cessation of alcohol. It is characterized by severe disorientation, psychotic
manifestations, and cardiac dysrhythmias. Monitoring vital signs and safety is the priority
nursing intervention during this period.
2. A nurse is assessing a client who has anorexia nervosa. Which of the following findings
should the nurse expect?
A. Warm, flushed skin
B. Tachycardia
C. Hypertension
,D. Amenorrhea
Answer: D
Rationale: Amenorrhea is a common physiological consequence of anorexia nervosa due
to low body weight and hormonal imbalances. Clients also typically exhibit bradycardia and
hypotension rather than tachycardia and hypertension. Peripheral edema and lanugo are
other common physical findings in these patients.
3. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which of the
following laboratory values should the nurse monitor to prevent lithium toxicity?
A. Serum calcium
B. Serum creatinine
C. Serum glucose
D. Serum potassium
Answer: B
Rationale: Lithium is excreted primarily by the kidneys, so renal function must be
monitored closely to prevent toxicity. An increase in serum creatinine indicates impaired
kidney function, which can lead to dangerously high lithium levels. Nurses should also
encourage consistent sodium intake to maintain stable drug levels.
4. A nurse is evaluating a client who has schizophrenia and is taking haloperidol. The nurse
should identify that which of the following findings is an extrapyramidal symptom (EPS)?
A. Extreme thirst
, B. Akathisia
C. Weight gain
D. Hypotension
Answer: B
Rationale: Akathisia is an extrapyramidal symptom characterized by physical restlessness
and an urgent need to move. It is a common side effect of first-generation antipsychotics
like haloperidol. Other EPS include acute dystonia, pseudoparkinsonism, and tardive
dyskinesia.
5. A nurse is caring for a client who was just admitted with a diagnosis of major depressive
disorder. Which of the following actions is the nurse’s priority?
A. Encourage the client to attend group therapy.
B. Help the client identify negative thought patterns.
C. Assess the client’s risk for suicide.
D. Assist the client with activities of daily living.
Answer: C
Rationale: Safety is the highest priority when caring for a client with major depressive
disorder. The nurse must conduct a thorough suicide risk assessment to identify any
immediate danger to the client. Once safety is established, the nurse can proceed with
psychosocial interventions and ADL support.
