HESI practice questions
A woman tells the PN that for the past 6 months she has been terrified of leaving home. Whenever she thinks about going outdoors her heart pounds, she shakes and cries, and feels dizzy. Based on these findings, which nursing diagnoses should the PN consider when caring for this client?
Social isolation related to avoidance behavior as evidence by inability to go out of doors
the pn is answering questions that the mother and her teenage daughter who is admitted with anorexia nervosa are asking about hospitalization. which statement by the clients mother indicates to the pn that she understands this disease?
she sees herself as being very fat even though she is severely underweight.
A male client with depression is unresponsive and preoccupied with guilt and hopelessness. Which statement should the PN use that provides therapeutic feedback to the client?
"the group appreciated your comments today"
A client with delusions of persecution has been refusing all hospital meals for the last three days and tells the PN that the food contains poison. What action should the PN implement?
Provide foods in the original closed containers
an older adult who has pneumnia and is admitted becomes disoriented and confused 2 days after admission. which factor should the PN identify to differentiate that the client is experiencing delirium, not dementia?
acute onset of symptoms
a male client with dementia who lives in an extended care facility is placed in a wheelchair each day and is positioned in the hall where he kicks people who walk past him. what interventions should the PN implement?
call him by name until he focuses his attention
a female client tells the PN that she wants to lead a healthier, more balanced lifestyle. She asks the PN how should she begin the process of self-exploration. Which message should the PN convey?
each adult is responsible for one's own behaviors, including unhealthy behaviors
a male client is admitted to the hospital with distorted sensory perceptions, disordered thoughts, and an increase in non-goal directed motor activity. The client does not respond to the PN's calming efforts. What is the next intervention the PN should initiate?
ensure the environment is safe
A 19-year-old calls the clinic and tells the PN that since bringing her newborn infant home, she has felt apathetic, fatigued, and helpless. She states "I don't know what's expected of me." What action is the most important for the PN to take?
tell the charge nurse to come to the phone and talk with the client
A male client is admitted with major depression and tells the PN that he feels like a greak since he is being admitted to a psych unit in the hospital. He feels like he is the only one with this problem. Which info should the PN provide the client?
About 50% of the population between the ages of 15 and 55 have had a psychiatric disorder
An older client who is hospitalized with pneumonia becomes disoriented and confused 2 days after admission. Which factor should the PN identify to differentiate that the client is experiencing delirium, not dementia?
Acute onset of symptoms
Which nursing intervention is best to help a female client with progressive memory deficit?
Assist the client to perform simple tasks by giving step-by-step instructions
A PN is reinforcing the steps for a dressing change for a male client who has a leg ulcer. When the client tries to change the dressing, he says he is inadequate, incompetent, and feels helpless. Which problem should the PN recognize that the client is exhibiting?
Self-esteem disturbance
During a prenatal visit, a client who is in the second trimester of pregnancy tells the PN that she is using the cocaine. What info about cocaine is most important for the PN to provide the client?
Cocaine can cause miscarriage or premature onset of labor
The PN is caring for a client with bulimia who continues to deny purging. Which finding should the PN report to the RN?
Dental erosion
A client with schizophrenia approaches the PN and says "the voices are bothering me. They're yelling and telling me I'm bad. Can't you hear them?" Which response should the PN provide?
I can't hear the voices, but I can see that you are upset
The PN is assessing a newly admitted client with paranoid schizophrenia who is hypervigilant and and who constantly scans the environment. The client tells the PN "I saw those two doctors in the hall talking about me." What descriptive terminology should the PN document to describe the client's thought process?
Ideas of reference
A man who has been admitted several times for alcohol detoxification is found wandering in the street and is unable to identify himself or his home address. He is manifesting ataxia, nystagmus, and confusion and has a blood alcohol level (BAL) of 0.29%. Which prescribed medication should the PN administer to prevent Korsakoff's psychosis?
Thiamine
A client diagnosed with Stage 3 Alzheimer's disease is experiencing difficulty toileting appropriately. What instruction is best for the PN to provide the family?
Label the client's bathroom door
a male client who is hospitalized for depression ruminates over poor financial decisions that he made in the past and calls himself "stupid". which strategy should the PN implement to limit the amount of time client spends on negative self-evaluation?
schedule occupational therapy and unit activities for the client.
The nurse who is leading a group therapy session is called to manage a unit emergency and assigns the PN as the leader of the group. During the therapeutic session, a client challenges the PN as the leader. Which response should the PN communicate?
You are saying that I should not be the leader?
the pn is inquiring about coping strategies with a male client who is admitted for alcohol abuse. the client tells the PN that his job skills and communication skills are his best asset and support. What additional info should the pn obtain about maladaptive mechanisms?
self indulgence
A 20-year-old male client who is admitted to the mental health unit for an adjustment disorder is telling the PN that he wants to find an apartment, but he is afraid he does not make enough money. Using Erikson's theory of phychosocial development, which developmental stage should the PN explore with this client?
sense of freedom in the community
