HESI RN
HESI 799 RN Exit Exam Capstone
1. A male client admitted for schizophrenia is noted to be diaphoretic and pacing the hallway. What is the most important intervention?
- A. Take the client's temperature and blood pressure.
- B. Encourage the client to rest.
- C. Plan an activity involving physical exercise.
- D. Carefully observe the client throughout the shift.
Correct answer: D
Rationale: In this scenario, the most important intervention for a male client with schizophrenia who is diaphoretic and pacing the hallway is to carefully observe the client throughout the shift. Diaphoresis and pacing can be indicators of agitation or distress in clients with schizophrenia. Careful observation is crucial to monitor the client's safety, assess for any potential escalation of symptoms, and provide timely intervention if needed. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for safety and observation. Encouraging the client to rest (Choice B) may not be effective if the client is agitated. Planning an activity involving physical exercise (Choice C) could potentially exacerbate the situation rather than addressing the immediate need for observation and safety.
2. A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse’s initial action be?
- A. Increase the client's sedative dose
- B. Encourage the client to express her feelings and provide emotional support
- C. Initiate breathing techniques to manage anxiety
- D. Administer anxiolytic medication to calm the client
Correct answer: B
Rationale: The correct initial action for a client with anxiety disorder experiencing increased anxiety prior to vaginal delivery is to encourage the client to express her feelings and provide emotional support. Emotional support is crucial in reducing anxiety during childbirth. Initiating breathing techniques or administering medications should come after emotional support has been provided. Increasing sedative doses may not address the underlying emotional needs of the client and can have potential risks.
3. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?
- A. Flaccid paralysis
- B. Pupils fixed and dilated
- C. Diminished spinal reflexes
- D. Reduced sensory responses
Correct answer: B
Rationale: Fixed, dilated pupils are a sign of increased intracranial pressure or brain injury, indicating a potentially serious neurological condition. Flaccid paralysis, although concerning, may not always indicate immediate life-threatening issues. Diminished spinal reflexes and reduced sensory responses are important neurological assessments but are not as acutely concerning as fixed, dilated pupils in this context.
4. A client with Alzheimer's disease is exhibiting signs of agitation and aggression. What is the nurse's priority intervention?
- A. Reassure the client and provide emotional support.
- B. Redirect the client to a quiet activity.
- C. Administer a PRN dose of lorazepam.
- D. Apply soft restraints as needed to prevent harm.
Correct answer: B
Rationale: The correct answer is to redirect the client to a quiet activity. This intervention helps reduce agitation and aggression in clients with Alzheimer's disease by providing a distraction and promoting a calming environment. Reassuring the client and providing emotional support (Choice A) can be beneficial but is not the priority in this situation. Administering a PRN dose of lorazepam (Choice C) should not be the first intervention due to the risk of adverse effects and should only be considered if other non-pharmacological interventions are ineffective. Applying restraints (Choice D) should be avoided unless absolutely necessary for the client's safety as it can lead to further distress and is not the initial priority intervention.
5. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?
- A. Increased appetite
- B. Describes life without purpose
- C. Exhibits mood swings
- D. Complains of insomnia
Correct answer: B
Rationale: An adolescent expressing 'life without purpose' after taking duloxetine (Cymbalta) may be indicating suicidal ideation, which requires immediate attention. The initial period of antidepressant treatment can increase the risk of suicidal thoughts, especially in younger populations. Increased appetite (Choice A) is a common side effect of duloxetine and may not require immediate follow-up. Mood swings (Choice C) and insomnia (Choice D) are also possible side effects of the medication but are not as urgent as addressing suicidal ideation.
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