MILESTONE 2 HESI RELIABLE EXAM 2 2025/2026
QUESTIONS WITH ANSWERS GRADED A+
✔✔Therapeutic communication abuse victim - ✔✔1. Physical manifestations of abuse
2. Client safety
3. Legal responsibilities of the nurse
4. For children, the nurse is legally responsible for reporting all suspected cases of
abuse. In intimate-partner abuse, it is the adult's decision; the nurse should be
supportive of the decision. Remember to document objective factual assessment data
and the client's exact words in cases of sexual abuse and rape
✔✔Therapeutic Relationship Stages- TERMINATION - ✔✔Unresolved feelings related
to loss most likely may be recognized during this stage.
✔✔A nurse is preparing a client for the termination phase of the nurse-client
relationship. The nurse prepares to implement which nursing task appropriate for this
phase? - ✔✔Making appropriate referrals
✔✔Which features are prominent in anorexia nervosa? - ✔✔-Amenorrhea for three
cycles
-Perfectionism
-Powerlessness
-Rigid food rituals
✔✔Describe the clinical symptoms of anorexia nervosa: - ✔✔Weight loss of at least
15% of ideal or original body weight; hair loss; dry skin; irregular heart rate; decreased
pulse; decreased BP; amenorrhea; dehydration; electrolyte imbalance
✔✔A client with anorexia has her friend bring her several cookbooks so she can plan a
party when she is discharged. What nursing intervention is appropriate in addressing
this behavior? - ✔✔Discuss activities that don't involve food that can take place after
discharge. Discuss the cookbooks with the treatment team, and if the treatment plan so
indicates, take the books from the client.
✔✔Bizarre social behavior - ✔✔- assess physical needs, suicide risk, ensure safety at
all time
- sit w/ client, silence, tell when leaving
- limit stimuli / 1-1 interaction
✔✔Complication Hypertension Risk - ✔✔Elevated BUN = kidney dysfunction =
associated with hypertension
, ✔✔The nurse is reviewing blood pressure readings for a group of client's on a medical
unit. Which client is at the highest risk for complications related to hypertension? - ✔✔B.
Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL
✔✔Hypothyroidism - Sleep/ Depression - ✔✔- Depression can result from untreated
hypo
- falling/staying asleep difficult = avoid sedation
- frequent rest but stay action
✔✔Diverticulosis S/S - ✔✔LLQ abdominal pain (descending/sigmoid colon)
Bloating
Fever
Nausea/Vomiting
Constipation alt. w/ diarrhea
Anorexia
✔✔Gout Medication- Allopurinol - ✔✔- bone marrow depression, vomiting, abd. pain
- avoid starting/increasing med during active flare up
- AFTER MEALS!
✔✔Gout Medication- Allopurinol teaching - ✔✔- avoid alcohol
- purine-rich foods (red meat/shellfish/fructose drinks)
- increase fluids
- reduce stress
✔✔Diabetes Mellitus- Poor compliance - ✔✔- The patient may use a urine dipstick
(Ketostix or Chemstrip uK) to detect ketonuria. The reagent pad on the strip turns purple
when ketones are present. → unmanaged diabetes or control over DM is deteriorating
DKA: complication of type 1 diabetes, serum glucose >250, ketonuria in large amounts
✔✔Left-Sided Heart Failure - ✔✔(Left is LUNG)
congestion, dyspnea, crackles, fatigue, pink/frothy sputum
✔✔Right-Sided Heart Failure - ✔✔(Systemic)
congestion, peripheral edema, ascities, jugular vein distention, hepatomegaly
✔✔Osteoarthritis Exercise - ✔✔- Use correct posture/body mechanics, use of assistive
devices, walking, physical therapy, strength training, yoga, tai chi.
✔✔Small Bowel Obstruction Actions: - ✔✔- Auscultate bowels
QUESTIONS WITH ANSWERS GRADED A+
✔✔Therapeutic communication abuse victim - ✔✔1. Physical manifestations of abuse
2. Client safety
3. Legal responsibilities of the nurse
4. For children, the nurse is legally responsible for reporting all suspected cases of
abuse. In intimate-partner abuse, it is the adult's decision; the nurse should be
supportive of the decision. Remember to document objective factual assessment data
and the client's exact words in cases of sexual abuse and rape
✔✔Therapeutic Relationship Stages- TERMINATION - ✔✔Unresolved feelings related
to loss most likely may be recognized during this stage.
✔✔A nurse is preparing a client for the termination phase of the nurse-client
relationship. The nurse prepares to implement which nursing task appropriate for this
phase? - ✔✔Making appropriate referrals
✔✔Which features are prominent in anorexia nervosa? - ✔✔-Amenorrhea for three
cycles
-Perfectionism
-Powerlessness
-Rigid food rituals
✔✔Describe the clinical symptoms of anorexia nervosa: - ✔✔Weight loss of at least
15% of ideal or original body weight; hair loss; dry skin; irregular heart rate; decreased
pulse; decreased BP; amenorrhea; dehydration; electrolyte imbalance
✔✔A client with anorexia has her friend bring her several cookbooks so she can plan a
party when she is discharged. What nursing intervention is appropriate in addressing
this behavior? - ✔✔Discuss activities that don't involve food that can take place after
discharge. Discuss the cookbooks with the treatment team, and if the treatment plan so
indicates, take the books from the client.
✔✔Bizarre social behavior - ✔✔- assess physical needs, suicide risk, ensure safety at
all time
- sit w/ client, silence, tell when leaving
- limit stimuli / 1-1 interaction
✔✔Complication Hypertension Risk - ✔✔Elevated BUN = kidney dysfunction =
associated with hypertension
, ✔✔The nurse is reviewing blood pressure readings for a group of client's on a medical
unit. Which client is at the highest risk for complications related to hypertension? - ✔✔B.
Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL
✔✔Hypothyroidism - Sleep/ Depression - ✔✔- Depression can result from untreated
hypo
- falling/staying asleep difficult = avoid sedation
- frequent rest but stay action
✔✔Diverticulosis S/S - ✔✔LLQ abdominal pain (descending/sigmoid colon)
Bloating
Fever
Nausea/Vomiting
Constipation alt. w/ diarrhea
Anorexia
✔✔Gout Medication- Allopurinol - ✔✔- bone marrow depression, vomiting, abd. pain
- avoid starting/increasing med during active flare up
- AFTER MEALS!
✔✔Gout Medication- Allopurinol teaching - ✔✔- avoid alcohol
- purine-rich foods (red meat/shellfish/fructose drinks)
- increase fluids
- reduce stress
✔✔Diabetes Mellitus- Poor compliance - ✔✔- The patient may use a urine dipstick
(Ketostix or Chemstrip uK) to detect ketonuria. The reagent pad on the strip turns purple
when ketones are present. → unmanaged diabetes or control over DM is deteriorating
DKA: complication of type 1 diabetes, serum glucose >250, ketonuria in large amounts
✔✔Left-Sided Heart Failure - ✔✔(Left is LUNG)
congestion, dyspnea, crackles, fatigue, pink/frothy sputum
✔✔Right-Sided Heart Failure - ✔✔(Systemic)
congestion, peripheral edema, ascities, jugular vein distention, hepatomegaly
✔✔Osteoarthritis Exercise - ✔✔- Use correct posture/body mechanics, use of assistive
devices, walking, physical therapy, strength training, yoga, tai chi.
✔✔Small Bowel Obstruction Actions: - ✔✔- Auscultate bowels
