1
the purpose of therapeutic interaction
ANSWER : to allow the client to autonomy to make choices when appropriate. keep statements value-
free, advice free, and reassurance-free
what action should the nurse take in a psychiatric situation when the client describes a physical
problem?
ANSWER : assess. example: if a client has schizophrenia complains of chest pain take their blood
pressure
basic communication principles
ANSWER : establish trust, nonjudgemental attitude,active listening, offer self, accept client's feelings,
validate client's statements, matter of fact approach
nausea is a common complaint after ECT
ANSWER : vomiting by an unconscious can lead to aspiration. maintain a paten airway
common physiological responses to anxiety
ANSWER : increased heart rate, and blood pressure, rapid shallow respirations, dry mouth, tight feeling
in throat, tremors, muscle twitching, anorexia, urinary frequency, palmar sweating
nurse-client anxiety
ANSWER : anxiety is contagious, nurse needs to asses on anxiety level and remain calm. it helps gain
control, decrease anxiety, and increase feelings of security
desensitization
ANSWER : is the nursing intervention for phobia disorders. --assess client to recognize the factors
associated with feared stimuli.
-teach and practice with client alternative coping strategies
-expose client to feared stimuli
-provide positive reinforcement
the nurse should place an anxious client where there are reduced environmental stimuli
HESI Fundamentals UPDATED VERSION
2023 GRADED A+

2
ANSWER : quiet area of the unit away from the nurse's station
the best time for interaction with a client is at the completion of the performed ritual
ANSWER : the client's anxiety is lowest at this time and its an optimal time for learning
compulsive acts are used in response to anxiety, which may or may not be related to the obsession. its
the nurse's responsibility help alleviate anxiety
ANSWER : its the nurse's responsibility help alleviate anxiety, interfering will increase the anxiety
as long as the client's acts are free of violence: nurse should....
ANSWER : -actively listen to the clients obsessive themes
-acknowledge the effects that ritualistic acts have on the client
-demonstrate empathy
-avoid being judgmental
ford clients with PTSD, the nurse should....
ANSWER : -actively listen to client's stories of experiences surrounding the traumatic event
-assess suicide risk
-assist client to develop objectivity about the event and problem solve regarding possible means of
controlling anxiety related to the event
-encourage group therapy with other clients who have experienced the same traumatic event
be aware of your own feelings when dealing with this somatoform clients.
ANSWER : the pain is real to the person experiencing it
theses disorders cannot be explained medically, it results from internal conflict. the nurse should...

3
ANSWER : -acknowledge the symptom or complaint
-reaffirm that diagnostic test results reveal no organic pathology
-determine the secondary gains acquired by the client
avoid giving clients with dissociative disorders too much information about past events at one time
ANSWER : the various types of amnestic that accompany dissociative disorders provide protection from
pain and too much to soon can cause decompensation
personality disorders are long standing behavioral traits that are maladaptive responses to anxiety and
that cause difficulty in relating to and working with other individuals
ANSWER : persons with personality disorders are usually comfortable with their disorders and believe
that they are right and the world is wrong and have little motivation
people with anorexia gain pleasure from providing others with food and watching them eat
ANSWER : these behaviors reinforce their perception of self-control. don not allow these clients to plan
or prepare food for unit-based activities
individuals with Bulimia often use syrup of ipecac to induce vomiting. if ipecac is not vomited and is
absorbed, cardiotoxicity may occur and cause conduction disturbances, cardiac dysrhythmias, fatal
myocarditis, and circulatory failure
ANSWER : because heart failure is not usually seen in this age group, it is often overlooked. assess for
edema and listen to breath sounds
physical assessment and nutritional support are a priority, the physiological implication are great. nursing
interventions should increase self-esteem and develop a positive body image.
ANSWER : family therapy is most effective because issues of control are common in these (eating
disorders.) therapy is usually long term
the most important s/s of depression are a depressed mood with a loss of interest in the pleasures in life

4
ANSWER : the client has a sustained loss
s/s of depression
ANSWER : -significant change in appetite
-insomnia
-fatigue or lack of energy
-feelings of hopelessness
-loss of ability to concentrate
-preoccupation with death or suicide
depressed clients have difficulty hearing and accepting compliments because of their lowered self-
concept
ANSWER : comment on signs of improvement by noting behavior
the nurse knows depressed clients are improving when they
ANSWER : begin to take an interest in their appearance or begin to perform self-care activities
the nurse should suspect an imminent suicide attempt if a depressed client becomes "better"
ANSWER : be aware a happy affect may signify the the client feels relieved that a plan has been made
and is prepared for the suicide attempt
when dealing with a depressed client the nurse should assist with personal hygiene tasks and encourage
the client to initiate grooming activities even when they dont feel like doing so
ANSWER : this helps to promote self-esteem and a sense of control
nursing intervention for depressed client

5
ANSWER : sit quietly with the client, offering your support with your presence
side effects of antianxiety drugs
ANSWER : sedation, drowsiness
s/e of antidepressants drugs
ANSWER : anticholinergic effects, postural hypotension
s/e MAO inhibitors
ANSWER : hypertensive crisis
lithium requires renal function assessment and monitoring
ANSWER : phenothiazines cause EPS (tardic dyskinesia can be permanent)
phenothiazines cause photosensitivity so client must wear protective clothing and sunglasses
ANSWER : MAO inhibitors require dietary restrictions to prevent hypertensive crisis
atypical antipsychotics drugs are also indication for mania
ANSWER :

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6
where should a manic client be place on the unit?
ANSWER : make every attempt to reduce stimuli in the environment, place client in quiet part of the unit
what intervention should the nurse use if the client becomes abusive
ANSWER : -redirect negative behavior
-suggest a walk
-set limits on intrusive behavior
-seclude or administer medication
Bleuler's 4 A's for schizophrenia
ANSWER : autism (preoccupied with self)
affect (flat)
associations (loose)
ambivalence (difficulty making decisions)
observe for increased motor activity and erratic response to staff and other clients

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11
d. GI suctioning
e. Decrease in fluid intake
f. Increase in fluid output such as sweating
g. Massive edema
h. Ascites
Common causes of fluid volume overload:
ANSWER : a. Heart failure
b. Renal failure
c. Cirrhosis
d. Excess ingestion of table salt
e. Overhydration with sodium containing fluids
Identify two examples of isotonic IV fluids.
ANSWER : a. Ringers lactate
b. Normal saline
List three systems that maintain acid base balance.
ANSWER : a. Lungs
b. Kidneys
c. Chemical buffers
normal ABGs
ANSWER : a. pH: 7.35-7.45
b. PaCO2: 35-45

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13
ANSWER : a. Teaching client to splint incision when coughing
b. Encouraging coughing and deep breathing in early postoperative period when sutures are strong.
c. Monitoring for signs of infection
d. Malnutrition
e. Dehydration
f. Encouraging high-protein diet
Identify three nursing interventions that prevent postoperative urinary tract infections.
ANSWER : a. Avoiding postoperative catheterization
b. Increasing oral fluid intake
c. Emptying bladder every 4 to 6 hours
d. Early ambulation
Identify

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2023 HESI Fundamental of Nursing Practice Exam With Answers (319 Solved Questions)

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