Exam (elaborations) HESI PRACTICE TEST 75 PREGUNTAS 2020 HESI PRACTICE TEST 75 PREGUNTAS 2020

A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching? When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection. While I am on vacation and when I return, I will not eat or drink anything that contains alcohol. I will notify the healthcare provider if I have a sore throat or flu-like symptoms. I will continue to take my benztropine mesylate (Cogentin) every day. Rationale Photosensitivity is a side effect of Prolixin and a vacation in a tropical climate increases the client's chance of experiencing this side effect. The nurse should teach the client to avoid direct sun and wear sunscreen. The other client statements do not indicate the need for further teaching. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make? Did you really believe you were Jesus Christ? I think you're getting well. Others have had similar thoughts when under stress. Why did you think you were Jesus Christ? Rationale The nurse should offer support by assuring the client that others have suffered as he has. The other responses are not therapeutic and not indicated. A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response? Can your case manager take you to your appointments? Take your medication for anxiety before you ride the bus. Let's talk about what happens when you feel very anxious. What are some ways that you can cope with your anxiety? Rationale An open-ended question that assists the client in problem-solving ways to cope with the anxiety engages the client in self management. The other responses do not allow the client to explore ways to cope with anxiety. The nurse suspects child abuse when assessing a 3-year-old boy with several small, round burns on his legs and trunk that appear to be the result of cigarette burns. Which parental behavior provides the greatest validation for such interpretation? The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred. The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem. The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn. Rationale Disparity in the parental reports and objective findings of a child's injury provides the most validation. A child's explanation of an injury is often influenced by age, fear, or imagination. The other observations of the parents are not conclusive of child abuse. A young adult female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take? Encourage the client's self-motivation by asking her to pass trays for the rest of the week. Provide an additional challenge by asking the client to help feed the older clients. Suggest another way for this client to participate in the unit's activities. Tell the client that hospital guidelines allow only staff to pass the trays. Rationale Clients with anorexia should not be allowed to plan or prepare food for unit activities. The nurse should redirect the client's request and encourage the client to participate in another unit activity. The other responses are not indicated. The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the adolescent, what information is most important for the nurse to obtain from the parents? If he has seemed depressed recently. If a drug overdose has ever occurred before. If he might have taken any other drugs. If he has a desire to quit taking drugs. Rationale Knowledge of all substances taken guide further treatment, such as administration of antagonists. The nurse should ask the parents if the adolescent may have taken other drugs. The other assessments are not indicated at this time. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected therapeutic response has the highest priority during pharmacological managment for withdrawal? Client will not demonstrate cross-addiction. Codependent behaviors will be decreased. Excessive CNS stimulation will be reduced. Client's level of consciousness will increase. Rationale Substitution therapy with another CNS depressant is intended to decrease excessive CNS stimulation that can occur during benzodiazepine withdrawal. The other effects are not the expected therapeutic response. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is best for the nurse to make? I'll leave your tray here. I am available if you need anything else. You're not being poisoned. Why do you think someone is trying to poison you? No one on this unit has ever died from poisoning. You're safe here. I will talk to your healthcare provider about the possibility of changing your diet. Rationale The nurse should not argue with a client who is paranoid nor demand that the client eat, but should be supportive and convey the nurse's availability if needed. The other responses are not indicated. An adult client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal the client's clothing. Which action should the nurse to take? Encourage the client to actively participate in assigned activities on the unit. Place a lock on the client's closet. Ignore the client's paranoid ideation to extinguish these behaviors. Explain to the client that his suspicions are false. Rationale Diverting the client's attention from paranoid ideation and encouraging the client to complete unit assignments can be helpful in assisting develop a positive self-image. The other actions are not indicated. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse take? Call a staff member to escort the client to his room. Tell the client to talk to his healthcare provider about his privileges. Remind the client of the unit rules. Calmly address the client's inappropriate behavior. Rationale Calmly addressing inappropriate behavior minimizes escalation of the issue, specifically that the behavior is unacceptable. The other approaches are not indicated. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make? How can I help? Things probably aren't as bad as they seem right now. Let's talk about what is right with your life. I hear how miserable you are, but things will get better soon. Rationale Offering self shows empathy and caring and is the best response to provide. The other responses do not convey that the nurse is listening to the client's distress. An older female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide? Orient the client to the time, place, and person. Tell the client that the nurse is there and will help her. Remind the client that her mother is no longer living. Explain the seriousness of her injury and need for hospitalization. Rationale Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of "offering self" and "talking to the feelings" to provide reassurance. Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, and the other reponses are not likely to help the client's emotional distress. An adult female client has been increasingly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? No one is after you, you're safe here. You'll feel better after you have rested. I know you must feel lonely and frightened. Come with me to your room and I will sit with you. Rationale The best response offers support without judgment or demands. The other responses are not therapeutic communication for a client who is hallucinating or experiencing a delusion, which are perceive by this client as a crisis. At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things would one like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best response for the nurse to make? I am the leader today. Would you like to be the leader tomorrow?