HESI MILESTONE 2 QUESTIONS
AND ANSWERS 2024 VERIFIED
1. 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?: Do you hear sounds or
voices that others do not hear?
2. 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?: Ineffective denial
related to situational anxiety
3. The nurse is interviewing a client with schizophrenia. Which client
behavior requires
immediate intervention?: Muscle twitches in the back and neck
4. 32-year-old male client is admitted with paranoid schizophrenia: Reassure
the client that he is safe and should rest.
5. What is schizophrenia?: 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
,6. grief process/ therapeutic response: 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
outmisrepresentations.
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.
7. 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?: Encourage finger foods, distraction, speak therapeutically
8. 2 days after admission from alcohol withdrawal what should the nurse do?:
Monitor HR and BP
9. which action should the nurse implement first for a client experiencing
alcohol
withdrawal?: prepare the environment to prevent self injury: self
10. 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?: Thiamine will replenish alcohol effects on the body
(something to do with iron)
11. 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?:
Magnesium
12. Patient having to get treated for benzodiazepine and methadone overdose.
What do
you use?: Narcan
13. When preparing to administer a domestic violence screening tool to a
female client,
which statement should the nurse provide?: all clients are screened for domestic
abuse because it is common in our society
14. a mental health care worker caring for a client with escalating aggressive
behavior.
What action by the mental healthcare worker wards immediate interventions?-
: -attempting to physically restrain patient
15. Violence handling: - 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
16. 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:
self actualization:
17. 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
AND ANSWERS 2024 VERIFIED
1. 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?: Do you hear sounds or
voices that others do not hear?
2. 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?: Ineffective denial
related to situational anxiety
3. The nurse is interviewing a client with schizophrenia. Which client
behavior requires
immediate intervention?: Muscle twitches in the back and neck
4. 32-year-old male client is admitted with paranoid schizophrenia: Reassure
the client that he is safe and should rest.
5. What is schizophrenia?: 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
,6. grief process/ therapeutic response: 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
outmisrepresentations.
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.
7. 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?: Encourage finger foods, distraction, speak therapeutically
8. 2 days after admission from alcohol withdrawal what should the nurse do?:
Monitor HR and BP
9. which action should the nurse implement first for a client experiencing
alcohol
withdrawal?: prepare the environment to prevent self injury: self
10. 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?: Thiamine will replenish alcohol effects on the body
(something to do with iron)
11. 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?:
Magnesium
12. Patient having to get treated for benzodiazepine and methadone overdose.
What do
you use?: Narcan
13. When preparing to administer a domestic violence screening tool to a
female client,
which statement should the nurse provide?: all clients are screened for domestic
abuse because it is common in our society
14. a mental health care worker caring for a client with escalating aggressive
behavior.
What action by the mental healthcare worker wards immediate interventions?-
: -attempting to physically restrain patient
15. Violence handling: - 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
16. 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:
self actualization:
17. 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
