Grand Canyon University NSG-322 PRACTICE HESI || 100%
Detailed 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? correct answers 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? correct
answers 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? correct answers 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? correct answers 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.) correct answers 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? correct answers 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? correct answers
Ask a group member to seek help.
Which nursing intervention should the nurse implement with parents who experience a fetal
demise and express the wish not to see the baby? correct answers Keep the body available for a
few hours in case they change their minds.
An adult female who is married and works full-time in a factory has been absent from work for
three days at a time on several occasions. Each time she returns to work, she wears dark glasses
to cover facial bruising. Her supervisor refers her to the occupational health nurse. What
assessment question should the nurse use? correct answers How did this happen to you?
A client on the mental health unit reports concerns about weight gain as a result of taking
divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a
referral to which healthcare team member? correct answers Dietician.
The nurse is planning the care for a client based on the psychoanalytical model. Which
intervention should the nurse include in the plan of care? correct answers Focus on the client's
positive or negative feelings toward the nurse.
A woman admitted to the Emergency Department is bleeding profusely from a patch where hair
was lost from her scalp. She is accompanied by her husband who tells the nurse that his wife
caught her hair on the railing and pulled it out when she fell down the stairs. The husband is
solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his
wife by saying to her, "I am right here with you, dear. Nothing can keep us apart." What is the
priority nursing intervention? correct answers Require the husband to leave the cubicle while the
client is being treated.
A female client with severe depression is given information about the risks, benefits, alternatives,
and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for
treatment. After the client's family leaves, the client tells the nurse, "I signed the papers because
my husband told me I will be deported if my depression is not cured." What information should
Detailed 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? correct answers 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? correct
answers 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? correct answers 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? correct answers 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.) correct answers 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? correct answers 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? correct answers
Ask a group member to seek help.
Which nursing intervention should the nurse implement with parents who experience a fetal
demise and express the wish not to see the baby? correct answers Keep the body available for a
few hours in case they change their minds.
An adult female who is married and works full-time in a factory has been absent from work for
three days at a time on several occasions. Each time she returns to work, she wears dark glasses
to cover facial bruising. Her supervisor refers her to the occupational health nurse. What
assessment question should the nurse use? correct answers How did this happen to you?
A client on the mental health unit reports concerns about weight gain as a result of taking
divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a
referral to which healthcare team member? correct answers Dietician.
The nurse is planning the care for a client based on the psychoanalytical model. Which
intervention should the nurse include in the plan of care? correct answers Focus on the client's
positive or negative feelings toward the nurse.
A woman admitted to the Emergency Department is bleeding profusely from a patch where hair
was lost from her scalp. She is accompanied by her husband who tells the nurse that his wife
caught her hair on the railing and pulled it out when she fell down the stairs. The husband is
solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his
wife by saying to her, "I am right here with you, dear. Nothing can keep us apart." What is the
priority nursing intervention? correct answers Require the husband to leave the cubicle while the
client is being treated.
A female client with severe depression is given information about the risks, benefits, alternatives,
and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for
treatment. After the client's family leaves, the client tells the nurse, "I signed the papers because
my husband told me I will be deported if my depression is not cured." What information should
