Exam (elaborations)
NSG-322 PRACTICE HESI 2024/2025
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NSG-322 PRACTICE HESI NSG-322 PRACTICE HESI NSG-322 PRACTICE HESI
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NSG-322 PRACTICE HESIThe nurse completes an emergency admission of a male client with schizophrenia who has not been
taking his antipsychotic medications. The client is pacing, is extremely irritable, and has a blood
pressure of 146/96. What is the priority nursing action? - ANS Reevaluate the client's blood pressure
in an hour.
A young adult female client with panic disorder arrives in the Emergency Center with a 4-day history
of chest pain that began when her boyfriend left her. Initial assessment reveals normal
cardiopulmonary findings. Which information is most important for the nurse to obtain? - ANS Drugs
taken in last 7 days.
A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse,
"There wasn't anything I could do to stop her drinking this morning." What intervention should the
nurse take at this time? - ANS Tell the client that therapy cannot take place while she is intoxicated.
The nurse is planning care for a client with major depression who is admitted to the unit after a
recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan
of care? - ANS Search the client's personal belongings.
A male client is brought to the emergency department by a police officer, who reports the client was
"disturbing the peace" by running naked in the street, striking out at others, and smashing car
windows. Which behaviors should the client demonstrate to determine if he should be evaluated for
involuntary commitment? (Choose all that apply.) - ANS Threats to kill his friend, hears voices telling
him to kill himself, reports he has not needed a bath in 4 months and says he has not eaten in 3
days.
The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless.
What is the priority nursing problem? - ANS High risk for fluid and electrolyte imbalance.
At the end of a group therapy session, a client who is hospitalized for psychosis falls to the floor
when attempting to stand. What intervention should the nurse implement first? - ANS Ask a group
member to seek help.
Which nursing intervention should the nurse implement with parents who experience a fetal demise
and express the wish not to see the baby? - ANS Keep the body available for a few hours in case they
change their minds.
, An adult female who is married and works full-time in a factory has been absent from work for three
days at a time on several occasions. Each time she returns to work, she wears dark glasses to cover
facial bruising. Her supervisor refers her to the occupational health nurse. What assessment
question should the nurse use? - ANS How did this happen to you?
A client on the mental health unit reports concerns about weight gain as a result of taking divalproex
(Depakote) and requests assistance to fill out a menu. The nurse should initiate a referral to which
healthcare team member? - ANS Dietician.
The nurse is planning the care for a client based on the psychoanalytical model. Which intervention
should the nurse include in the plan of care? - ANS Focus on the client's positive or negative feelings
toward the nurse.
A woman admitted to the Emergency Department is bleeding profusely from a patch where hair was
lost from her scalp. She is accompanied by her husband who tells the nurse that his wife caught her
hair on the railing and pulled it out when she fell down the stairs. The husband is solicitous of his
wife and quickly answers questions on her behalf. He attempts to comfort his wife by saying to her,
"I am right here with you, dear. Nothing can keep us apart." What is the priority nursing
intervention? - ANS Require the husband to leave the cubicle while the client is being treated.
A female client with severe depression is given information about the risks, benefits, alternatives,
and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for
treatment. After the client's family leaves, the client tells the nurse, "I signed the papers because my
husband told me I will be deported if my depression is not cured." What information should the
nurse report to the healthcare provider? - ANS The client's consent may have been coerced.
A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry,
and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams,
"Don't touch me! You're so stupid that you'll make it worse!" Which intervention is best for the
nurse to implement? - ANS Provide information about infection prevention.
The nurse is assessing a client with a history of borderline personality disorder. Which question
should the nurse include in the assessment? - ANS Do you frequently have temper tantrums?
During the admission of a male client to the mental health unit, the client tells the nurse that he had
a panic attack today and ran out of the physician's office. Which question is most important for the
nurse to ask this client? - ANS Have you had any thoughts of hurting yourself?
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