Hesi Milestone 2 Revision Exam
Questions With Solved Solutions.
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? - 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? - Answer Ineffective denial related to
situational anxiety
The nurse is interviewing a client with schizophrenia. Which client behavior requires
immediate intervention? - Answer Muscle twitches in the back and neck
32-year-old male client is admitted with paranoid schizophrenia - Answer Reassure the client that he is
safe and should rest.
What is schizophrenia? - 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 - 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
utensils on the floor and then refuses to eat. What action should the nurse
implement? - Answer Encourage finger foods, distraction, speak therapeutically
2 days after admission from alcohol withdrawal what should the nurse do? - Answer Monitor HR and
BP
which action should the nurse implement first for a client experiencing alcohol
withdrawal? - 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? - 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? - Answer Magnesium
Patient having to get treated for benzodiazepine and methadone overdose. What do
you use? - Answer Narcan
, When preparing to administer a domestic violence screening tool to a female client,
which statement should the nurse provide? - 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? - Answer -attempting to
physically restrain patient
Violence handling - 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 - Answer self actualization:
A client is admitted to the mental health unit and reports taking extra anti anxiety
medication because, "I'm so stressed out. I just want to go to sleep." The RN should
plan one-on-one observation of the client based on which statement? - Answer "I don't want to walk.
Nothing matters anymore."
What is the most important goal for a client diagnosed with major depression who has
been receiving an antidepressant medication for two weeks? - Answer not attempt to commit suicide
The nurse is obtaining the medical histories of new clients at a community-based
primary care clinic. Which individual has the highest risk for experiencing elder
abuse? - Answer A 78 year old female on a fixed income who lives with her relatives
Questions With Solved Solutions.
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? - 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? - Answer Ineffective denial related to
situational anxiety
The nurse is interviewing a client with schizophrenia. Which client behavior requires
immediate intervention? - Answer Muscle twitches in the back and neck
32-year-old male client is admitted with paranoid schizophrenia - Answer Reassure the client that he is
safe and should rest.
What is schizophrenia? - 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 - 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
utensils on the floor and then refuses to eat. What action should the nurse
implement? - Answer Encourage finger foods, distraction, speak therapeutically
2 days after admission from alcohol withdrawal what should the nurse do? - Answer Monitor HR and
BP
which action should the nurse implement first for a client experiencing alcohol
withdrawal? - 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? - 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? - Answer Magnesium
Patient having to get treated for benzodiazepine and methadone overdose. What do
you use? - Answer Narcan
, When preparing to administer a domestic violence screening tool to a female client,
which statement should the nurse provide? - 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? - Answer -attempting to
physically restrain patient
Violence handling - 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 - Answer self actualization:
A client is admitted to the mental health unit and reports taking extra anti anxiety
medication because, "I'm so stressed out. I just want to go to sleep." The RN should
plan one-on-one observation of the client based on which statement? - Answer "I don't want to walk.
Nothing matters anymore."
What is the most important goal for a client diagnosed with major depression who has
been receiving an antidepressant medication for two weeks? - Answer not attempt to commit suicide
The nurse is obtaining the medical histories of new clients at a community-based
primary care clinic. Which individual has the highest risk for experiencing elder
abuse? - Answer A 78 year old female on a fixed income who lives with her relatives
