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HESI MODULE 1-4 EXAM(A GRADED) LATEST QUESTIONS AND COMPLETE SOLUTIONS
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HESI module 1 exam Questions And Answers
A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson’s the... [Show More] ory of psychosocial development, the nurse tells the group that infants have which developmental need? Correct! Need to rely on the fact that their needs will be met Must have needs ignored for short periods to develop a healthy personality Need to tolerate a great deal of frustration and discomfort to develop a healthy personality Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs 7/19/2021 Module 1 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83912?module_item_id=1519717 2/105 Rationale: According to Erikson’s theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore the other options are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the option that contains the closed-ended word “must.” Eliminate the comparable or alike options and indicate that experiencing frustration is necessary. Review Erikson’s theory of psychosocial development as it relates to the infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Question 2 1 / 1 pts A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician’s office for a scheduled visit. The infant’s weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. The nurse should take which action? Tell the mother that the infant’s weight is increasing as expected. Correct! Tell the mother to decrease the daily number of feedings because the weight gain is excessive. Tell the mother that semisolid foods should not be introduced until the infant’s weight stabilizes. 7/19/2021 Module 1 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83912?module_item_id=1519717 3/105 Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate. Rationale: Infants usually double their birth weight by 6 months and triple it by 1 year of age. If the infant is 6 lb 8 oz, at birth, a weight of 13 lb at 6 months of age is to be expected. Semisolid foods are usually introduced between 4 and 6 months of age. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling that infants double their weight by 6 months of age will direct you to the correct option. Review the growth rate of an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Question 3 1 / 1 pts The nurse is assisting with data collection on a well-baby examination. The nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, the nurse should take which action? Report the presence of hydrocephalus to the health care provider. Suggest to the health care provider that a skull x-ray be performed. Tell the mother that the infant is growing faster than expected. 7/19/2021 Module 1 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83912?module_item_id=1519717 4/105 Document these measurements in the infant’s health care record. Correct! Rationale: The head circumference growth rate during the first year is approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the infant’s head and chest circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling the mother that the infant is growing faster than expected, and suggesting that a skull x-ray be performed are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the infant has a physiological problem. Review the expected growth rate of an infant if you had difficulty with this question. [Show Less]
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HESI Module 2 Exam
A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data?... [Show More] The client appears anxious. Blood pressure is 170/80 mm Hg. Correct! The client states that he has a rash. The client has diminished reflexes in the legs. Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that include data that the nurse would obtain during the physical examination. Review the difference between subjective and objective data if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam Question 2 1 / 1 pts A nurse is reviewing the findings of a physical examination that have been documented in a client’s record. Which piece of 7/19/2021 Module 2 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83895?module_item_id=1519718 2/106 information does the nurse recognize as objective data? The client is allergic to strawberries. The last menstrual period was 30 days ago. The client takes acetaminophen (Tylenol) for headaches. A 1 × 2-inch scar is present on the lower right portion of the abdomen. Correct! Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that include data that the nurse would obtain from the client during the health history. Review the difference between subjective and objective data if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam Ques 1 / 1 pts tion 3 A nurse is reading the report from the registered nurse for an initial home visit to a client with chronic obstructive pulmonary disease. The client was recently discharged from the hospital. Which type of database does the nurse read that contains this information from the client? 7/19/2021 Module 2 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83895?module_item_id=1519718 3/106 Episodic Follow-up Emergency Correct! Complete Rationale: A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting, such as a pediatric or family practice clinic; an independent or group private practice; a college health service; a women’s health care agency; a visiting nurse agency; or a community health agency. An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or one body system. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed. Test-Taking Strategy: Use the process of elimination. Noting the strategic words “initial home visit” in the question will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam [Show Less]
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HESI Module 3 Exam compass with Rationale
1.ID: 21580640372 The husband of a terminally ill client says to the nurse, “My company went bankrupt, my son is a drug addict, my daughter is an alcoh... [Show More] olic, and now this! My doctor wants me to try some stress reduction because my blood pressure is up. Whose wouldn’t be? I’ve tried music and relaxation, but they don’t work.” Which statement by the nurse would be therapeutic? A. “You have a lot of problems. How long does your wife have to live, and what is her relationship with your children?” B. “Before we talk about stress management, let’s discuss your children.” C. “Let’s talk more about what has been helpful to you in the past.” Correct D. “Can you afford to pay for therapy sessions? I see that your benefits are pretty much maxed out, and I’d hate to ask you to take on any additional burden.” 2.ID: 21580640345 A client who recently lost his hand in a workplace accident says to the nurse, “I don’t know how I’m going to support my family with a plastic hand. I might as well be dead.” Which nursing response would be therapeutic? A. “Perhaps you need to focus on being happy that you survived.” B. “You’ll never need to worry about work again, because your employer will cover all of your expenses and make a settlement that will support you for life.” C. “You’re saying that you feel useless without your hand?” Correct D. “Don’t worry about all of that at this point. You’re going to be fine.” 3.ID: 21580640309 A 35-year-old recently divorced parent of twins comes to the intake office of the psychiatric clinic for the first time with a possible diagnosis of generalized anxiety disorder. The client says to the nurse, “My mother always called me a worrywart like my nana, so I guess I come by my problems naturally. I keep worrying about things I can’t change, like my divorce, and blaming myself when I know I’m not the only one responsible for the divorce.” Which nursing statement would be therapeutic? A. “Yet you seem to be dwelling on the thought that the divorce is all your fault.” B. “I wonder whether you think you’re responsible for making everything turn out right.” C. “Can you tell me more about the worrying and blaming you are experiencing?” Correct D. “So you’re a natural worrywart, divorced with twins. I guess you can be forgiven for a little worrying, but tell me about the blaming you’ve been doing.” 4.ID: 21580640357 A client’s son and daughter were killed during a fellow student’s murderous rampage at their high school 9 months ago. The client says to the nurse, “My wife and I just feel empty and exhausted. I can’t believe that I had a vasectomy after our son and daughter were born because we wanted to give them both whatever they needed. We have college funds for both of them that they’ll never use now.” The nurse should make which appropriate statement to the client? A. “My parents would be devastated if they lost me and my sister, too. How can I be of service to you?” B. “Your loss touches me so. How truly devastated you both must be. Can you share what things you have been doing to grieve?” Correct C. “Your loss is incalculable. Perhaps you could consider some ways in which to commemorate their lives for you and in your community.” D. “Your feelings are appropriate for the extent of your loss and how your children’s deaths happened.” 5.ID: 21580640642 The wife of a dying man is ignoring his rapid physiological decline and imminent death. She continues with her usual activities, exhibits inability to remember what others have just told her, and misses important appointments. Which therapeutic statement should the nurse make to the wife? A. “I cannot emphasize how much your husband needs you to be there for him right now. He is in the stage of denial.” B. “You will need to concentrate on getting to these appointments on time and write down what everyone says so you will remember.” C. “Can you talk about what’s happening to you right now? Your behavior is not appropriate at this stage of your husband’s illness. You seem to be having sympathy pains for him, like men during their wives’ pregnancies.” D. “It isn’t unusual for family to suffer from anticipatory grief when a loved one is dying.” Correct 6.ID: 21580638582 A client in group therapy says to the two nurses conducting the group, “You two are great at psychoanalyzing us, but what about you two? Do you have trouble being assertive with your bosses or the doctors like we do?” Which statement by one of the nurses would be most therapeutic? A. “Why do I feel attacked by someone whom I’m trying to help? Could it be that you don’t want to work in this group anymore?” B. “You’re interested in talking with us about our assertiveness, but this group is for all of you here to help you to deal with problems more effectively.” Correct C. “Maybe some others in this group want to talk about the assignment that we all agreed would be completed today.” D. “Your deflection from your own problems here in this group is inappropriate. Let us remind you that you signed up for this group and agreed to participate in it.” 7.ID: 21580641015 The nurse is evaluating the coping skills of a client with a diagnosis of depression. Which statement indicates to the nurse the need to help the client learn and appropriately use these skills? A. “I have learned ways to deal with stress.” B. “I know that I can’t do everything.” C. “I won’t ever be depressed again.” Correct D. “I need to take my medications.” 8.ID: 21580641027 A client says to the nurse, “I’ve started a journal because my health care provider suggested it, and I’m writing about the things that bother me each day. Sometimes I dictate my feelings and what happened during the day into a recorder and write them up before I go to bed — and, do you know, they seem silly to me then. Is this helping me?” Which response by the nurse would be appropriate? A. “Well, it will take some time, but let’s see how you’re doing over a month. In the meantime, keep writing.” B. “I’m not certain that using a tape recorder will help you with the journalkeeping.” C. “It seems that people who write in their journals and can share traumatic events improve their self-awareness.” Correct D. “Well, I wonder about the dictation, because the writing is what helps reduce stress.” . 9.ID: 21580640688 A single mother whose son was suspended from school for carrying a gun into the school, says to the nurse, “I know he has no dad, but I’ve brought him up to know better, and anyway, where did he get the stupid gun? What should I do? He just won’t listen to me.” Which nursing response would be helpful at this time? A. “Many young people die of gunshots every day in this country, so your son’s behavior is unacceptable.” B. “Do you know all of your son’s friends, or is he left alone after school because you work?” C. “There is quite a bit that you can do. Let’s talk about what you’re already doing first.” Correct D. “Boys who are cared for only by their moms are at highest risk for violent behavior.” 10.ID: 21580640385 During a one-to-one nurse-client session, the client plays with her pack of cigarettes and says, “I just get a couple of DVDs and watch movies so I won’t have to look at my husband or talk to him.” Which coping mechanism does the nurse recognize in the client’s behaviors? A. Wishful thinking B. Self-blame C. Avoidance Correct D. Reframing 11.ID: 21580640312 The home care nurse makes a new-baby visit to a young husband and wife. The visit takes two-and-a-half hours because the parents are so detailed in giving information and asking questions of the nurse. Which intervention by the nurse would be therapeutic? A. Having the home care office secretary call the nurse’s cell phone 20 minutes after starting the visit to expedite the nurse’s departure B. Ordering a follow-up visit to the family pediatrician and mental health clinical specialist C. Blocking out more time for the next visit and scheduling a follow-up visit as soon as possible to assess how they are coping and gauge their level of anxiety Correct D. Informing all home care nurses to schedule their visits to the couple as their last visit of the day [Show Less]
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ESI MODULE 5 Exam Latest Update
A client with leukemia is being considered for a bone marrow transplant. The health care team is discussing the risks and benefits of this treatment and ... [Show More] other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of health care ethics is the team practicing? Justice Fidelity Autonomy Correct! Nonmaleficence Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in health care ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Health care professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other health care professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action. Test-Taking Strategy: Use knowledge of the subject to help you with the process of elimination. Think about the definition of each item in the options. Note the relationship of the words “least possible harm” in the question and the definition of nonmaleficence. Review the principles of health care ethics if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 2/117 Question 2 1 / 1 pts Which action by the nurse represents the ethical principle of beneficence? The nurse upholds a client’s decision to refuse chemotherapy for lung cancer. The nurse follows a plan of care designed to relieve pain in a client with cancer. The nurse administers an immunization to a child even though it may cause discomfort. Correct! The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 3/117 Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Fidelity is keeping promises made to clients, families, and other health care professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that you are agreeing to respect that person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients. Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action to help others will direct you to the correct option. Review the principles of health care ethics if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 3 1 / 1 pts The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right? Performing a procedure without consent Correct! Telling the client that he or she may not leave the hospital Threatening to give a client a medication against his or her will Observing the provision of care to the client without the client’s permission 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 4/117 Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy. Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of the subject and the words in the correct option. If you had difficulty with this question, review the concept of false imprisonment. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Question 4 1 / 1 pts A nurse and a nursing assistant enter a client’s room to provide care and find the client lying on the floor. Which action should the nurse take first? Ask the nursing assistant to complete an incident report Correct! Check the client s level of consciousness and vital signs Ask the nursing assistant to assist in getting the client back to bed Contact the unit secretary on the intercom and ask that the client’s health care provider be called 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 5/117 Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client’s level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to move the client, the nurse should ask the nursing assistant to assist in getting the client into bed. The nurse should then contact the health care provider and file an incident report. Test-Taking Strategy: Note the strategic word “first.” Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Remember to always assess the client first if a client sustains a fall. Review client injuries and procedures for filing incident reports if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 5 1 / 1 pts Which action exemplifies the use of evidence-based practice in the delivery of client care? Donning sterile gloves to change an abdominal wound dressing Correct! Encouraging a client to take an herbal substance to treat his insomnia Advising a client to agree to the treatment recommended by her health care provider 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 6/117 Taking a rectal temperature from a client for whom bleeding precautions have been instituted Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing reflects evidencebased practice because it prevents the entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based practice. Taking an herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to advise a client to agree to a treatment. Because of the risk of injury to the rectal mucosa, rectal temperature-taking is avoided in the client for whom bleeding precautions have been instituted. Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall the definition of evidence-based practice and note the words “sterile gloves” in the correct option. Review the situations that reflect evidence-based practice if you had difficulty with this question. [Show Less]
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HESI Module 4 EXAM(A Graded) Latest Questions and Complete Solutions
A client with schizophrenia says, “I’m away for the day ... but don’t think we should play … or do we have feet of clay?” Which alteration in t... [Show More] he client’s speech does the nurse document? Neologism Word salad Correct! Clang association Associative looseness Rationale: Clang association is the meaningless rhyming of words in which the rhyming is more important than the context of the words. A neologism is a made-up word that has meaning only to the client. Word salad is the term for a mixture of meaningless phrases, either to the client or to the listener. Associative looseness is a term used to describe schizophrenic speech in which connections and threads are interrupted or missing. Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client with schizophrenia is needed to answer this question. Focus on the data in the question and note the meaningless rhyming of words. Review these speech patterns with schizophrenia if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 2 1 / 1 pts 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 2/116 A client with schizophrenia and his parents are meeting with the nurse. One of the young man’s parents says to the nurse, “We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he’s had another relapse, and we can’t understand why he stopped his medication.” Which response by the nurse is appropriate? Telling the parents, “Medication noncompliance is the most frequent reason that people with this diagnosis relapse.” Telling the parents, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” Asking the client, “How can we help you to take your medicine or to tell us when you’re having problems so that your medication can be adjusted?” Correct! Saying to the parents, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 3/116 Rationale: The therapeutic response is the one in which the nurse models speaking directly to the client. This facilitates further assessment of the situation and helps elicit the causes of and motivations for the client’s behavior for both the nurse and the family. In the correct option, the nurse also seeks clarification of the degree of openness and mutuality felt by the client and his family toward each other. The nurse provides information to the family when stating that noncompliance is the most frequent reason for relapse in people with this diagnosis. However, the statement is nontherapeutic at this time because it does not facilitate the expression of feelings. The nurse uses a superego style of communication when stating, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” The content of this statement may be true, but it is nontherapeutic in that it carries a threatening message and may prevent the family from trusting the nurse. By stating “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication,” the nurse gives approval and prematurely analyzes the client’s motivation without sufficient assessment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. Also note that the correct option is the only option in which the nurse directly addresses the client. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 3 1 / 1 pts An acutely ill client with schizophrenia says to the nurse, “He keeps saying that he likes you, and I keep telling him you’re married, but he won’t listen, and I think he’s going to get fresh with you.” Once the nurse has determined that the client is 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 4/116 hallucinating, which response to the client would be most appropriate statement? “Try not to listen to the voices right now so that I can talk with you.” Correct! “I think that you can help him stop his behavior if you concentrate.” “Tell him I said to mind his p’s and q’s or I’ll call the police on him.” “I think that you’re trying to share your own feelings toward me, but you’re shy.” Rationale: The appropriate statement by the nurse is the one that does not acknowledge the client’s hallucinations. By responding “I think that you can help him stop his behavior if you concentrate” or “Tell him I said to mind his p’s and q’s or I’ll call the police on him,” the nurse acknowledges the hallucinations. The nurse attempts to interpret the client’s thinking with a statement such as “I think that you’re trying to share your own feelings toward me, but you’re shy.” Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember that the nurse should not acknowledge the client’s hallucinations. Also note that the correct option is the only one that encourages realistic verbalization from the client. Review therapeutic communication techniques with a client who is hallucinating if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 5/116 Question 4 0 / 1 pts A client says to the nurse, “It’s over for me—the whole thing is over.” Which response by the nurse would be therapeutic? You Answered “What do you mean, ‘The whole thing is over’?” “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence.” “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential.” “Let’s talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members.” Correct Answer 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 6/116 Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs the client that the nurse needs to share any information that requires crisis intervention with other staff members. Asking “What do you mean, ‘The whole thing is over’?” employs paraphrasing, but the message is blunt and closed-ended. In stating “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence,” the nurse uses hysterical exaggeration (at an inappropriate time) and gives incorrect information regarding confidentiality. In stating “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential,” the nurse uses the therapeutic technique of seeking clarification but does not clarify with the client that the information might need to be shared. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that shared information will be maintained as confidential. To select from the remaining options, focus on the statement that addresses the client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. [Show Less]
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