Page 1 of 92
HESI MILESTONE 2 ACTUAL EXAM 3 LATEST VERSIONS
(V1, V2 AND V3) EACH VERSION CONTAINS 100
QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY 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? .....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
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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)
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-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.
, Page 4 of 92
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
HESI MILESTONE 2 ACTUAL EXAM 3 LATEST VERSIONS
(V1, V2 AND V3) EACH VERSION CONTAINS 100
QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY 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? .....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
,Page 2 of 92
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)
,Page 3 of 92
-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.
, Page 4 of 92
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
