HESI Comprehensive Review for NCLEX-RN Exam

HESI Comprehensive Review for NCLEX-RN Exam Psychiatric 5.0 (1 review) Terms in this set (125) Science MedicineNursing Save A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful.Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of confusion related to ICU psychosis.Which nursing action is best for this client's behavior?

• Move all medical equipment away

from the client's bedside.

• Allay fears by teaching the client

about the causes of the disease.

• Cluster care to allow for brief rest

periods during the day.

• Encourage visitation by the client's

family members, including the client's young children.

• Cluster care to allow for brief rest periods

during the day.The best intervention is to organize care so that the client can experience rest periods. The critical care unit contains many lifesaving treatment modalities that offer clients an array of auditory, visual, and even painful stimuli. These stressors can result in isolation and confusion.

The nurse is reviewing techniques of therapeutic communication with a student nurse. Which of the student's statements will the nurse indicate as therapeutic? (Select all that apply.)

• "Am I correct in restating that you

are feeling less anxious today?"

• "In looking back at what you said,

you stated you are feeling better."

• "Why do you think you are feeling

better today?"

• "Surely you did not mean that you

are feeling better today."

• "Help me understand what you are

feeling today?"

• "Am I correct in restating that you are feeling

less anxious today?"

• "In looking back at what you said, you stated you

are feeling better."

• "Help me understand what you are feeling

today?" While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair.What action should the nurse take when the client with PTSD falls to the floor in a fetal position?

• Confront the client who tipped

over the chair about the inconsiderate behavior.

• Dismiss the other clients from the

group therapy session for a 10- minute break.

• Reinforce reality to the client on

the floor and remove him to a quiet space.

• Call a security code and medicate

both clients with an antianxiety drug.

• Reinforce reality to the client on the floor and

remove him to a quiet space.The client who is diagnosed with PTSD is re- experiencing the traumatic experience and needs reality reassurance (confirmation that there is no danger at this time) and reduced stimuli.

The parent and a 6-year-old present to the clinic for routine well-child care. The child weighs 35 pounds 15.9 kg; is wearing torn and dirty clothing; and, sits quietly with an apparent subtle rocking motion. What are the nurse's next actions? (Select all that apply.)

• Take the child's height, and vital

signs.

• Check the clothing closet at the

clinic for size appropriate clothing.

• Assess the child for any bruising,

or lacerations.

• Ask the accompanying parent to

leave the room.

• Ask the child about attendance at

school.

• Stay with the child during the

healthcare provider's assessment.

• Take the child's height, and vital signs.
• Assess the child for any bruising, or lacerations.
• Ask the accompanying parent to leave the room.
• Ask the child about attendance at school.
• Stay with the child during the healthcare

provider's assessment.Checking for appropriate clothing is a nice gesture, but that action does nothing to protect the child or assess for further signs of neglect. The remaining assessments will help validate for neglect. The normal height and weight for this child should be 45 pounds/20.4 kg and 45 inches/114 cm. This child is underweight for its age, but a height and comparison of stature to the parents will help confirm those findings. The subtle rocking motion may be an indication of emotional abuse. The goal of the nurse is to provide a safe and secure environment for the child. Nurses are mandatory reporters for suspected abuse.

A client states to the new nurse, "I can't tell you something important because you will tell the other nurses." What is a therapeutic response by the new nurse? (Select all that apply.)

• "I promise not to tell anyone what

is on your mind; your concerns are safe with me."

• "What you share with me is

confidential; I guarantee I will not say a word to anyone."

• "You can trust me not to tell your

concerns to the other nurses."

• "Since the information you have is

important to you; I encourage you to share."

• "I urge you to tell me what is on

your mind; you have something to disclose."

• "Since the information you have is important to

you; I encourage you to share."

• "I urge you to tell me what is on your mind; you

have something to disclose." The nurse cannot promise not to tell/share information. That is never appropriate in a therapeutic relationship. It is therapeutic to encourage the client to share important information.