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.
1
,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
2
,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?
3
, 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:
4
& 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.
1
,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
2
,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?
3
, 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:
4
