HESI MILESTONE 2 RETAKE EXAM QUESTIONS AND
ANSWERS (VERIFIED AND WELL DETAILED ANSWERS)
LATEST UPDATE 2025/2026
Schizophrenia care-
Establish trust and rapport, encourage the client to talk with you, be
consistent in setting expectations, explain the procedures and be certain
the client understands, give positive feedback for the client successes,
show empathy, do not be judgemental, never convey to the client that
you accept their delusions as reality.
Grief therapeutic response-
Allow the 5 steps of grieving: Denial, Anger, Bargaining, Depression,
and Acceptance (DABDA), active listening, and offering a supportive
presence.
Nursing Plans and Interventions:
A. If needed, refer to grief counseling or a support group.
B. Encourage activities that allow the individual to use past coping
strategies to promote a feeling of self-worth and increased self-esteem.
C. Encourage the individual to share his or her feelings.
D. Encourage socialization with family peers and reminisce about
significant life experiences.
Delirium care-
Know usual mental status and if changes noted are long-term, it
probably represents dementia; if they are sudden/acute in onset, it is
more likely to be delirium. Recognize and report symptoms
immediately. Treatment of underlying causes is important - if
untreated, it can lead to permanent, irreversible brain damage and
death.
,The primary goals of nursing care for clients with delirium
are: PROTECTION FROM INJURY, MANAGEMENT OF
CONFUSION, AND MEETING PHYSIOLOGICAL AND
PSYCHOLOGICAL NEEDS.
Ensure patient safety (fall risk) and manage behavioral problems.
Alert the prescriber of nonessential medications.
Nutritional and fluid intake must be monitored.
A quiet and calm environment.
Encourage visitors to touch and talk to patients.
Assess/manage pain.
Alzheimer's hallucination-
Occurs in the late-middle to later stages of the disease process and
is treated with antipsychotics such as Haldol
Alcohol withdrawal-
Symptoms of withdrawal usually begin 4 to 12 hours after cessation
or marked reduction of alcohol intake. Symptoms include coarse
hand tremors, sweating, elevated pulse, and blood pressure,
insomnia, anxiety, and nausea or vomiting. Severe or untreated
withdrawal may progress to transient hallucinations, seizures, or
delirium, called delirium tremors. Alcohol withdrawal usually peaks
on the second day and is over in about 5 days. This can vary, however,
and withdrawal may take 1 to 2 weeks. Safe withdrawal is usually
accomplished with the administration of benzodiazepines, such as
lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam
(Valium), to suppress the withdrawal symptoms.
Nursing Plans and Interventions
A. Maintain safety, nutrition, hygiene, and rest.
,B. Obtain a BAL on admission or when a client appears intoxicated after
admission.
C. Implement suicide precautions if assessment indicates risk.
D. In general
1. Monitor vital signs, input and output (I&O), and electrolytes.
2. Observe for impending DTs.
3. Prevent aspiration; implement seizure precautions.
4. Reduce environmental stimuli.
5. Medicate with antianxiety medication, usually chlordiazepoxide
(Librium) or lorazepam
(Ativan)
6. Provide high-protein diet and adequate fluid intake (limit caffeine).
7. Provide vitamin supplements, especially vitamins B1 and B complex.
8. Provide emotional support.
Methadone-
Detoxification and maintenance therapy for opioid use disorder.
Suppression of withdrawal symptoms during detox related to
opioids such as heroin.
It can cause respiratory depression.
Do not give it to patients with acute or severe bronchial asthma.
It is contraindicated for patients taking MAOIs.
Methadone Overdose:
A). Physical Assessment
-Constricted pupils
, - Respiratory depression leading to respiratory arrest
-Circulatory depression leading to cardiac arrest
-Unconsciousness leading to coma
-Death
B). General Appearance
-General physical and mental deterioration
-Rapid tolerance-overdose likely if not monitored.
-Impaired judgment
Aggression response-
The nurse must protect others from these clients' manipulative or
aggressive behaviors. At the beginning of treatment, he or she must
set limits on unacceptable behavior. The limit setting involves the
following three steps:
Inform clients of the rule or limits.
Explain the consequences if clients exceed the limit.
State expected behavior.
Nursing Plans and Interventions: Conduct and Defiant Disorders
A. Assess verbal and nonverbal cues for escalating behavior so as to
decrease outbursts.
B. Use a nonauthoritarian approach.
C. Avoid asking "why" questions.
D. Initiate a "show of force" with a child who is out of control.
E. Use a "quiet room" when external control is needed.
F. Clarify expressions or jargon if meanings are unclear.
ANSWERS (VERIFIED AND WELL DETAILED ANSWERS)
LATEST UPDATE 2025/2026
Schizophrenia care-
Establish trust and rapport, encourage the client to talk with you, be
consistent in setting expectations, explain the procedures and be certain
the client understands, give positive feedback for the client successes,
show empathy, do not be judgemental, never convey to the client that
you accept their delusions as reality.
Grief therapeutic response-
Allow the 5 steps of grieving: Denial, Anger, Bargaining, Depression,
and Acceptance (DABDA), active listening, and offering a supportive
presence.
Nursing Plans and Interventions:
A. If needed, refer to grief counseling or a support group.
B. Encourage activities that allow the individual to use past coping
strategies to promote a feeling of self-worth and increased self-esteem.
C. Encourage the individual to share his or her feelings.
D. Encourage socialization with family peers and reminisce about
significant life experiences.
Delirium care-
Know usual mental status and if changes noted are long-term, it
probably represents dementia; if they are sudden/acute in onset, it is
more likely to be delirium. Recognize and report symptoms
immediately. Treatment of underlying causes is important - if
untreated, it can lead to permanent, irreversible brain damage and
death.
,The primary goals of nursing care for clients with delirium
are: PROTECTION FROM INJURY, MANAGEMENT OF
CONFUSION, AND MEETING PHYSIOLOGICAL AND
PSYCHOLOGICAL NEEDS.
Ensure patient safety (fall risk) and manage behavioral problems.
Alert the prescriber of nonessential medications.
Nutritional and fluid intake must be monitored.
A quiet and calm environment.
Encourage visitors to touch and talk to patients.
Assess/manage pain.
Alzheimer's hallucination-
Occurs in the late-middle to later stages of the disease process and
is treated with antipsychotics such as Haldol
Alcohol withdrawal-
Symptoms of withdrawal usually begin 4 to 12 hours after cessation
or marked reduction of alcohol intake. Symptoms include coarse
hand tremors, sweating, elevated pulse, and blood pressure,
insomnia, anxiety, and nausea or vomiting. Severe or untreated
withdrawal may progress to transient hallucinations, seizures, or
delirium, called delirium tremors. Alcohol withdrawal usually peaks
on the second day and is over in about 5 days. This can vary, however,
and withdrawal may take 1 to 2 weeks. Safe withdrawal is usually
accomplished with the administration of benzodiazepines, such as
lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam
(Valium), to suppress the withdrawal symptoms.
Nursing Plans and Interventions
A. Maintain safety, nutrition, hygiene, and rest.
,B. Obtain a BAL on admission or when a client appears intoxicated after
admission.
C. Implement suicide precautions if assessment indicates risk.
D. In general
1. Monitor vital signs, input and output (I&O), and electrolytes.
2. Observe for impending DTs.
3. Prevent aspiration; implement seizure precautions.
4. Reduce environmental stimuli.
5. Medicate with antianxiety medication, usually chlordiazepoxide
(Librium) or lorazepam
(Ativan)
6. Provide high-protein diet and adequate fluid intake (limit caffeine).
7. Provide vitamin supplements, especially vitamins B1 and B complex.
8. Provide emotional support.
Methadone-
Detoxification and maintenance therapy for opioid use disorder.
Suppression of withdrawal symptoms during detox related to
opioids such as heroin.
It can cause respiratory depression.
Do not give it to patients with acute or severe bronchial asthma.
It is contraindicated for patients taking MAOIs.
Methadone Overdose:
A). Physical Assessment
-Constricted pupils
, - Respiratory depression leading to respiratory arrest
-Circulatory depression leading to cardiac arrest
-Unconsciousness leading to coma
-Death
B). General Appearance
-General physical and mental deterioration
-Rapid tolerance-overdose likely if not monitored.
-Impaired judgment
Aggression response-
The nurse must protect others from these clients' manipulative or
aggressive behaviors. At the beginning of treatment, he or she must
set limits on unacceptable behavior. The limit setting involves the
following three steps:
Inform clients of the rule or limits.
Explain the consequences if clients exceed the limit.
State expected behavior.
Nursing Plans and Interventions: Conduct and Defiant Disorders
A. Assess verbal and nonverbal cues for escalating behavior so as to
decrease outbursts.
B. Use a nonauthoritarian approach.
C. Avoid asking "why" questions.
D. Initiate a "show of force" with a child who is out of control.
E. Use a "quiet room" when external control is needed.
F. Clarify expressions or jargon if meanings are unclear.
