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Hesi Milestone 2 Revision Exam Questions With Solved Solutions.
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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? - Answer Do you hear sounds or voices that others do not hear? The schizophr...

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  • February 19, 2025
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  • 2024/2025
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Hesi Milestone 2 Revision Exam
Questions With Solved Solutions.
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? - Answer Do you hear sounds or voices that others do not
hear?



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? - Answer Ineffective denial related to
situational anxiety



The nurse is interviewing a client with schizophrenia. Which client behavior requires

immediate intervention? - Answer Muscle twitches in the back and neck



32-year-old male client is admitted with paranoid schizophrenia - Answer Reassure the client that he is
safe and should rest.



What is schizophrenia? - Answer 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



grief process/ therapeutic response - Answer 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 out

misrepresentations.

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.



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? - Answer Encourage finger foods, distraction, speak therapeutically



2 days after admission from alcohol withdrawal what should the nurse do? - Answer Monitor HR and
BP



which action should the nurse implement first for a client experiencing alcohol

withdrawal? - Answer prepare the environment to prevent self injury: self



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? - Answer Thiamine will replenish alcohol effects on the body (something to
do with iron)



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? - Answer Magnesium



Patient having to get treated for benzodiazepine and methadone overdose. What do

you use? - Answer Narcan

, When preparing to administer a domestic violence screening tool to a female client,

which statement should the nurse provide? - Answer all clients are screened for domestic abuse
because it is common in our society



a mental health care worker caring for a client with escalating aggressive behavior.

What action by the mental healthcare worker wards immediate interventions? - Answer -attempting to
physically restrain patient



Violence handling - Answer - 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



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 - Answer self actualization:



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

plan one-on-one observation of the client based on which statement? - Answer "I don't want to walk.
Nothing matters anymore."



What is the most important goal for a client diagnosed with major depression who has

been receiving an antidepressant medication for two weeks? - Answer not attempt to commit suicide



The nurse is obtaining the medical histories of new clients at a community-based

primary care clinic. Which individual has the highest risk for experiencing elder

abuse? - Answer A 78 year old female on a fixed income who lives with her relatives

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