HESI MILESTONE 2 EXAM UPDATED
QUESTIONS AND CORRECT ANSWERS.
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? - ANS 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? - ANS Ineffective denial related
to situational anxiety
The nurse is interviewing a client with schizophrenia. Which client behavior requires
immediate intervention? - ANS Muscle twitches in the back and neck
32-year-old male client is admitted with paranoid schizophrenia - ANS Reassure the client
that he is safe and should rest.
What is schizophrenia? - ANS it is a chemical imbalance in the brain that causes disorganized
thinking:
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,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 - ANS 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? - ANS Encourage finger foods, distraction, speak therapeutically
2 days after admission from alcohol withdrawal what should the nurse do? - ANS Monitor HR
and BP
which action should the nurse implement first for a client experiencing alcohol
withdrawal? - ANS prepare the environment to prevent self injury: self
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, 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? - ANS 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? - ANS Magnesium
Patient having to get treated for benzodiazepine and methadone overdose. What do
you use? - ANS Narcan
When preparing to administer a domestic violence screening tool to a female client,
which statement should the nurse provide? - ANS 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? - ANS -
attempting to physically restrain patient
Violence handling - ANS - 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
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
QUESTIONS AND CORRECT ANSWERS.
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? - ANS 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? - ANS Ineffective denial related
to situational anxiety
The nurse is interviewing a client with schizophrenia. Which client behavior requires
immediate intervention? - ANS Muscle twitches in the back and neck
32-year-old male client is admitted with paranoid schizophrenia - ANS Reassure the client
that he is safe and should rest.
What is schizophrenia? - ANS it is a chemical imbalance in the brain that causes disorganized
thinking:
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,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 - ANS 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? - ANS Encourage finger foods, distraction, speak therapeutically
2 days after admission from alcohol withdrawal what should the nurse do? - ANS Monitor HR
and BP
which action should the nurse implement first for a client experiencing alcohol
withdrawal? - ANS prepare the environment to prevent self injury: self
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, 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? - ANS 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? - ANS Magnesium
Patient having to get treated for benzodiazepine and methadone overdose. What do
you use? - ANS Narcan
When preparing to administer a domestic violence screening tool to a female client,
which statement should the nurse provide? - ANS 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? - ANS -
attempting to physically restrain patient
Violence handling - ANS - 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
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
