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 atrial fibrillation is prescribed warfarin. What is the most important instruction the nurse should give?
- A. Take the medication with aspirin to improve effectiveness.
- B. Increase intake of green leafy vegetables to support the medication.
- C. Avoid foods high in potassium to reduce bleeding risk.
- D. Avoid alcohol and over-the-counter medications without consulting the provider.
Correct answer: D
Rationale: The correct answer is D. Clients taking warfarin should avoid alcohol and over-the-counter medications without consulting their healthcare provider, as these can interact with warfarin and increase the risk of bleeding. Aspirin, in particular, can exacerbate this risk. Choice A is incorrect because taking warfarin with aspirin can increase the risk of bleeding. Choice B is incorrect as while green leafy vegetables contain vitamin K which can interact with warfarin, it is more important to maintain a consistent intake rather than increase it. Choice C is incorrect because foods high in potassium do not directly impact the bleeding risk associated with warfarin.
3. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
- A. Muscle tension decreases with fine motor skill projects, so these activities should be encouraged.
- B. The chorea or movements are temporary and will eventually disappear.
- C. Permanent lifestyle changes are not needed to promote safety in the home.
- D. Consistent discipline is not directly related to controlling the movements.
Correct answer: B
Rationale: Chorea, or sudden aimless movements associated with rheumatic fever, is temporary in nature and will eventually disappear on its own. It is important for the nurse to reassure the parents that these movements are part of the condition and typically resolve over time without the need for permanent lifestyle changes or strict discipline. Providing accurate information and reassurance to the parents can help alleviate concerns and promote understanding of the condition's course. Choices A, C, and D are incorrect because muscle tension, permanent lifestyle changes, and consistent discipline are not directly related to the resolution of chorea in rheumatic fever.
4. A female client’s significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?
- A. Obtain a prescription from the healthcare provider regarding visitation privileges
- B. Request a consultation with the ethics committee for resolution of the situation
- C. Encourage the client to speak with her husband regarding his disruptive behavior
- D. Communicate the client’s wishes to all members of the multidisciplinary team
Correct answer: B
Rationale: In a situation where a client's estranged husband demands to restrict the visitation of the significant other, it is essential to prioritize the client's wishes while addressing the conflict. Requesting a consultation with the ethics committee is appropriate as it allows for a comprehensive and impartial resolution, ensuring the client's autonomy and well-being are upheld. Option A is incorrect because visitation privileges are not solely determined by a healthcare provider's prescription in this scenario. Option C may not be appropriate as it puts the client in a potentially uncomfortable or unsafe position. Option D, while important, does not directly address the conflict between the estranged husband and the significant other.
5. A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?
- A. Monitor for signs of alcohol withdrawal.
- B. Administer thiamine as prescribed.
- C. Provide a quiet environment to reduce confusion.
- D. Initiate fall precautions.
Correct answer: B
Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.