HESI Exit Exam Practice 5 Questions and Answers
A male client with bipolar disorder has not slept or eaten in four days. He paces and becomes increasingly agitated and loud wile the nurse talks to his spouse. What inter
...
HESI Exit Exam Practice 5 Questions and Answers
A male client with bipolar disorder has not slept or eaten in four days. He paces and becomes increasingly agitated and loud wile the nurse talks to his spouse. What intervention is best for the nurse to implement at this time?
A. Walk with the client to the cafeteria and stay as he eats lunch.
B. Encourage the spouse to eat lunch with the client.
C. Request a full tray from the dietary department.
D. Move to a quiet area and provide peanut butter with crackers.
Answer
D. Move to a quiet area and provide peanut butter with crackers.
Rationale
Both inadequate nutrition and inadequate sleep patterns plague clients with bipolar disorder and contribute to agitation, hostility, and aggressiveness. Using a calm, confident manner, the client should be moved to a quiet area (D) to decrease environmental stimuli and limit involvement with the spouse while nutritional needs, such as "finger foods", should be provided. (A, B, and C) are less effective when the client is unable to sit long enough to eat.
To assess for the presence of egophony, what instruction should the nurse give the client who has a lung abscess?
A. Repeat vocalizing the letter E while the thorax is auscultated.
B. Breathe in and out while all lobes of both lungs are auscultated.
C. Repeat the number 99 during a systematic auscultation of the thorax.
D. Whisper "one, two, three" in a sequence during auscultation of the thorax.
Answer
A. Repeat vocalizing the letter E while the thorax is auscultated.
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