HESI Milestone 2 Exam Questions & Answers – Latest Update Study Guide, Practice Review & Nursing Exam Preparation

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HESI MILESTONE 2 EXAM | QUESTIONS
& ANSWERS (VERIFIED) | LATEST
UPDATE | GRADED A+



A male client with schizophrenia is admitted to the mental health unit after abruptly

stopping his prescription for ziprasidone (Geodon) one month ago. Which question is

most important for the RN to ask the client?

Correct Answer: Do you hear sounds or voices that others do not hear?



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?

Correct Answer: Ineffective denial related to situational anxiety



The nurse is interviewing a client with schizophrenia. Which client behavior requires

immediate intervention?

Correct Answer: Muscle twitches in the back and neck



32-year-old male client is admitted with paranoid schizophrenia

Correct Answer: Reassure the client that he is safe and should rest.




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What is schizophrenia?

Correct 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

Correct 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




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utensils on the floor and then refuses to eat. What action should the nurse

implement?

Correct Answer: Encourage finger foods, distraction, speak therapeutically



2 days after admission from alcohol withdrawal what should the nurse do?

Correct Answer: Monitor HR and BP



which action should the nurse implement first for a client experiencing alcohol

withdrawal?

Correct 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?

Correct 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?

Correct Answer: Magnesium



Patient having to get treated for benzodiazepine and methadone overdose. What do

you use?




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Correct Answer: Narcan



When preparing to administer a domestic violence screening tool to a female client,

which statement should the nurse provide?

Correct 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?

Correct Answer: -attempting to physically restrain patient



Violence handling

Correct 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

Correct Answer: self actualization:




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