HESI MILESTONE 2 PRACTICE EXAM |
QUESTION AND VERIFIED ANSWERS |
RATED A+ | 2024/2025 GUIDE
A mental health worker is caring for a client with escalating aggressive
behavior. Which action by the MHW warrant immediate intervention by the
RN?
A. Is attempting to physically restrain the patient.
B. Tells the client to go to the quiet area of the unit.
C. Is using a loud voice to talk to the client.
D. Remains at a distance of 4 feet from the client.
A. Is attempting to physically restrain the patient.
A female client admitted to the mental health unit starts to shout and
scream at the RN. What is the best approach for the RN to take?
A. Stay quietly with the patient
B. Tell her that she is out of control.
C. Distract her by offering her finger foods.
D. Ignore the client's acting out behavior.
A. Stay quietly with the patient
A female client with obsessive-compulsive disorder complains that she
feels "driven" to check the locks on her front door. Which response is best
,for the nurse to provide?
A. Have you had a bad experience related to unlocked doors?
B. What are your thoughts when you are checking the locks?
C. Feelings of being driven to do something are related to anxiety.
D. Repeating the same behavior helps you diminish your anxiety.
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic.
Which action should the nurse implement first?·
A. Administer morphine sulfate ·
B. Start IV fluids
C. Place the infant in a knee-chest position.
D. Provide 100% oxygen by face mask
C. Place the infant in a knee-chest position
A newborn yellow abdomen and chest
Assess bilirubin level
A client delivers a viable infant, but begins to have excessive uncontrolled
vaginal bleeding after the IV Pitocin is infused. When notifying the
healthcare provider of the condition, what information is most important for
the nurse to provide?
Maternal blood pressure
,A 36-week primigravida is admitted to labor and delivery with severe
abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and
tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the
maternal heart rate is 120 beats/minute. What action should the nurse
implement first?
obtain written consent for an emergency cesarean section
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul
respiration. The nurse determines that the increased respiratory rate is a
compensatory mechanism for wich acid base alteration?
Metabolic acidosis
The nurse is interacting with a female client who is diagnosed with
postpartum depression. Which finding should the nurse document as an
objective signs of depression? (Select all that apply.)
A. Avoids eye contact.
B. Interacts with a flat affect.
C. Reports feeling sad.
D. Expresses suicidal thoughts.
E. Has a disheveled appearance.
A. Avoids eye contact.
B. Interacts with a flat affect.
, C. Reports feeling sad.
D. Expresses suicidal thoughts.
Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after
spontaneous rupture of the membranes, the nurse notes several sudden
decreases in the fetal heart rate with quick return to baseline, with and
without contractions. Based on this fetal heart rate pattern, which
intervention is best for the nurse to implement?
Place the client in a slight Trendelenburg position.
Rationale: The goal is to relieve pressure on the umbilical cord, and placing
the client in a slight Trendelenburg position is most likely to relieve that
pressure. The FHR pattern is indicative of a variable fetal heart rate
deceleration, which is typically caused by cord compression and can occur
with or without contractions.
The nurse calls a client who is 4 days postpartum to follow up about her
transition with her newborn son at home. The woman tells the nurse, "I
don't know what is wrong. I love my son, but I feel so let down. I seem to
cry for no reason!" Which adjustment phase should the nurse determine the
client is experiencing?
Postpartum blues
Rationale: During the postpartum period, when serum hormone levels fall,
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