HESI RN 31I Pharmacology Exam

Correct Answer A: Do you need a drink in the morning to get rid of a hangover?

Explanation:

This question addresses a physiological symptom of alcohol dependence — the presence of withdrawal symptoms and the need for alcohol to relieve them. Using alcohol first thing in the morning to avoid or relieve hangover symptoms is a strong indicator of physical dependence. It suggests the development of tolerance and withdrawal, both of which are hallmark features of alcohol use disorder. This behavior is not just about problematic drinking patterns but points directly to the body’s reliance on alcohol to function normally, making it the most clinically significant of the four CAGE questions.

Why Other Options Are Incorrect:

B: Have you ever felt guilty about drinking?

While this question reflects emotional and psychological awareness of a problem, guilt alone is a subjective emotion and does not confirm dependency. Many people may feel guilty after drinking excessively on a single occasion, without meeting criteria for alcoholism. It helps identify problematic behavior, but it’s not the strongest indicator of physiological addiction.

C: Have you ever felt you needed to cut down on your drinking?

This question is common in early recognition of problematic drinking. It shows insight into the behavior but may be present in social drinkers who don't have dependence. It signals concern but does not confirm the presence of addiction or physical need.

D: Have people annoyed you by criticizing your drinking?

This question reflects the impact of drinking on social relationships and defensiveness about alcohol use. While it supports the possibility of misuse, it is external and subjective, relying on the client’s perception of others’ opinions. It does not confirm dependence or compulsion to drink.

The correct answer is D: My name tag shows that I am a nurse here.

Explanation of the correct answer:

D. My name tag shows that I am a nurse here.

In the case of schizophrenia, clients may experience delusions, where they believe things that are not true. The most therapeutic response is to gently correct the delusion without directly confronting or arguing with the client about their beliefs. By calmly stating the truth (that the nurse is a nurse, not one of their children), the nurse provides a reality-based response that doesn't escalate the situation or challenge the client's beliefs in an aggressive or confrontational manner. The goal is to validate the client's feelings while reorienting them to the present reality.

Why the other options are incorrect:

A. I know that you don't have 20 children.

This response directly challenges the client's delusion, which can be seen as invalidating or dismissive. In patients with schizophrenia, directly confronting or disputing delusions often leads to increased anxiety or agitation, and the client may become defensive or upset.

B. Let's go ask another nurse if this is true.

While this response may seem to provide reassurance, it still indirectly engages with the delusion, encouraging the client to continue questioning reality in an unhelpful way. This approach doesn't provide a grounding or therapeutic correction to the client's false belief.

C. I cannot possibly be one of your children.

This response is too blunt and confrontational. It not only challenges the delusion but also does not provide an opportunity for the nurse to correct the reality in a calm and therapeutic way. It could escalate the situation, making the client feel misunderstood.

The correct answer is D: Social withdrawal.

Explanation of the correct answer:

D. Social withdrawal

Social withdrawal is a classic early warning sign of relapse in individuals with schizophrenia. It indicates that the client may be decompensating or experiencing an increase in negative symptoms (such as apathy, flat affect, or lack of interest in relationships), or it may even precede psychotic symptoms like hallucinations or delusions. Teaching the family to recognize this behavioral change allows for early intervention, which can help prevent a full relapse or hospitalization.

Why the other options are incorrect:

A. Decreased attention to detail

While changes in attention can occur in schizophrenia, mild cognitive changes are often chronic and not always indicative of a relapse. On their own, they are not as significant a red flag as social withdrawal.

B. Changes in appetite

Appetite changes may occur due to medication side effects or mood fluctuations, but they are non-specific and less directly related to a potential relapse compared to more behaviorally significant signs.

C. Fear of large dogs

A specific fear, unless part of a pattern of paranoid or delusional thinking, is not necessarily related to schizophrenia relapse. It may reflect a personal phobia or unrelated anxiety, not a psychotic symptom.

The correct answer is B: Speak calmly to the client stating assurance of safety.

Explanation of the correct answer:

B. Speak calmly to the client stating assurance of safety.

When a client is experiencing severe anxiety, particularly with physical symptoms like a racing heartbeat and dizziness, the priority is to calm the client and reassure them that they are safe. Speaking in a calm, soothing voice helps to de-escalate the anxiety response and promotes a sense of security. Reassuring the client about safety can help reduce feelings of impending doom and allow them to focus on more manageable thoughts. The nurse should focus on providing immediate comfort and stabilizing the client emotionally before moving on to further interventions.

Why the other options are incorrect:

A. Help the client to identify thoughts that may be triggers.

While cognitive interventions can be effective in managing anxiety in the long term, during a severe anxiety episode, the immediate priority is not to engage in cognitive exploration but to address the physiological and emotional distress. Asking the client to identify triggers may cause additional stress and be overwhelming in the moment.

C. Attempt to distract to another focus or activity.

Although distraction can be a helpful strategy to reduce anxiety in some situations, when a client is severely anxious, focusing on their emotions and providing reassurance about safety is more effective. Distraction may seem dismissive or fail to provide the necessary support in such an intense moment.

D. Explore past behaviors that have provided relief.

This is a helpful long-term strategy for managing anxiety. However, in the acute phase of anxiety, exploring past coping mechanisms could be overwhelming or not immediately effective. The priority should be to calm the client and ensure their safety before moving on to exploring coping strategies.

Correct Answer C: Advise to sit up slowly from a reclining position.

Explanation:

Clonidine and Orthostatic Hypotension:

Clonidine is an alpha-2 adrenergic agonist that works by decreasing sympathetic outflow, which reduces withdrawal symptoms such as anxiety, agitation, muscle aches, and sweating. However, one of its most significant side effects is orthostatic hypotension (a drop in blood pressure when changing positions). To minimize the risk of dizziness, fainting, or falls, it is essential to educate the client to rise slowly from sitting or reclining positions. This helps their body adjust to postural changes more gradually, maintaining safety during the withdrawal process.

Why Other Options Are Incorrect:

A: Compare daily electrolyte levels prior to each morning dose

Clonidine does not typically affect electrolyte balance, and daily electrolyte monitoring is not indicated for this medication. This intervention would be more relevant for medications like diuretics or certain chemotherapies that directly affect sodium, potassium, or magnesium.

B: Administer the medication on an empty stomach

Clonidine can be taken with or without food, and there is no requirement for it to be administered on an empty stomach. In fact, taking it with food may help reduce gastrointestinal discomfort in some clients.

D: Monitor for signs of bleeding or hemorrhage

Clonidine is not an anticoagulant or antiplatelet agent and is not associated with bleeding risks. This would be an appropriate precaution for medications like heparin or warfarin but not for clonidine.

Correct Answer A: Measure and document size, shape, and color of the bruised areas.

Explanation:

Objective Documentation as the First Priority:

When elder abuse is suspected, the nurse's first step is to collect and document objective data. Accurately measuring and describing the bruises — including size, shape, color, and location — provides essential evidence. This documentation establishes a clear, unbiased clinical record that may later support legal or protective interventions. Objective findings carry more weight than subjective interpretations and help differentiate between accidental injuries and potential abuse.

Legality and Professional Responsibility:

Nurses are mandated reporters, meaning they are legally required to report suspected abuse. But before a formal report can be made, detailed, factual evidence must be collected. Describing the bruises clearly and precisely in the medical record ensures that any further evaluation, whether medical or legal, starts from a credible foundation. Jumping to conclusions or asking leading questions without proper assessment could compromise the investigation or violate the client’s rights.

Why Other Options Are Incorrect:

B: Report family conversations and anger towards the client when visiting

While it's important to be aware of and document concerning behavior from visitors, this option is subjective and secondary to physical evidence. The nurse should focus on what's directly observable before interpreting behavior or intent. Documentation of conversations may follow, but it is not the first or most critical action.

C: Ask the client specific questions about someone causing the bruising

Although it's important to eventually speak with the client, this should come after an initial objective assessment. Also, the client may be fearful or unable to speak openly in certain situations. Asking too directly or too soon may cause withdrawal or anxiety without gathering essential physical evidence.

D: Question the family members and caregiver how the bruising occurred

This may become necessary, but should not be the nurse’s first response. Family members or caregivers might not provide truthful answers, especially if abuse is occurring. Confrontation before collecting physical evidence could alert them and jeopardize the client's safety or the integrity of any investigation.

The correct answer is C: Lorazepam 2 mg PO bedtime.

Explanation of the correct answer:

C. Lorazepam 2 mg PO bedtime

Lorazepam is a benzodiazepine that is commonly used for its anxiolytic (anxiety-reducing) and sedative properties. The client is reporting being "so upset" that she cannot sleep, which suggests anxiety or stress as the primary issue. Lorazepam would help address both her anxiety and her difficulty with sleep, making it the most appropriate choice in this scenario. Additionally, it is commonly prescribed for short-term management of anxiety symptoms, especially during periods of significant stress like starting chemotherapy.

Why the other options are incorrect:

A. Ondansetron 8 mg PO three times a day PRN

Ondansetron is an antiemetic used to prevent and treat nausea and vomiting, commonly prescribed for clients undergoing chemotherapy. However, the client's primary complaint is related to anxiety and insomnia, not nausea or vomiting. Therefore, ondansetron would not address the current symptoms of anxiety and difficulty sleeping.

B. Oxycodone, acetylsalicylic acid one tablet PO every 4 hours PRN

Oxycodone is an opioid pain medication, and acetylsalicylic acid (aspirin) is a nonsteroidal anti-inflammatory drug (NSAID). While these medications may help manage pain, the client is not reporting pain as her primary issue. In fact, opioids should be used cautiously in non-pain situations due to their sedating effects and potential for dependence. This medication combination would not address the anxiety and insomnia described in the situation.

D. Acetaminophen, diphenhydramine 2 capsules bedtime

Acetaminophen is a pain reliever and diphenhydramine is an antihistamine with sedative properties that can help with sleep. However, the client's primary complaint is anxiety rather than pain. Diphenhydramine might help with sleep, but it does not address the underlying anxiety, and its sedative effects might not be as effective as a benzodiazepine like lorazepam in managing the level of distress the client is experiencing.

The correct answer is

A. Intrusive thought

B. Avoidance of places associated with the assault

C. Exaggerated startle response

F. Social withdrawal

Explanation of the correct answers:

A. Intrusive thoughts

Intrusive thoughts are a common symptom of rape-trauma syndrome and other trauma-related disorders. These can include disturbing memories or flashbacks of the assault that resurface unexpectedly, leading to emotional distress and difficulty functioning in daily life.

B. Avoidance of places associated with the assault

Avoidance behaviors are often seen in individuals who have experienced trauma. Survivors may intentionally avoid places, people, or activities that remind them of the assault. This is a way of coping with the emotional pain and anxiety associated with the trauma.

C. Exaggerated startle response

An exaggerated startle response is common in individuals with post-traumatic stress disorder (PTSD), which can be a component of rape-trauma syndrome. Survivors of assault often experience hypervigilance and are easily startled by sudden noises or events, as they remain on high alert for perceived threats.

F. Social withdrawal

Social withdrawal is another common symptom of long-term rape-trauma syndrome. Individuals may avoid social interactions due to feelings of shame, guilt, or fear of being judged. This withdrawal can lead to isolation and difficulty forming or maintaining relationships.

Why the other options are incorrect:

D. Hallucinations

Hallucinations are not typical symptoms of rape-trauma syndrome. While trauma can cause significant emotional distress, hallucinations are more commonly associated with severe mental health conditions, such as schizophrenia or substance abuse, rather than trauma alone.

E. Overeating

Overeating is not a core symptom of rape-trauma syndrome, though some individuals might cope with trauma by engaging in unhealthy eating habits. However, it is not considered a defining characteristic of long-term trauma responses like avoidance, intrusive thoughts, or hyperarousal.

Correct Answer D: What is troubling you most?

Explanation:

Focus on Client-Centered Exploration:

The best response is open-ended and client-centered, encouraging the client to identify and express the most pressing concern from their perspective. The statement, "What is troubling you most?" helps the nurse prioritize what the client sees as the primary issue and establishes a therapeutic rapport. It avoids judgment, assumes nothing, and invites the client to share more detail in their own words, which is crucial during an initial psychiatric evaluation.

Assessment with Sensitivity:

The client has already revealed several emotionally charged topics—betrayal by a spouse, a past history of substance use, and a connection to spiritual beliefs and children. These suggest inner conflict and potential distress. Asking “what is troubling you most” helps the nurse narrow the focus without overwhelming the client or making assumptions about which of those issues is most significant right now.

Why Other Options Are Incorrect:

A: What does this have to do with the reason for your visit?

This response sounds dismissive and invalidating. It implies that the client’s concerns are irrelevant and can create resistance in communication. It lacks empathy and therapeutic tone.

B: Why are you here?

While this question might seem straightforward, it can come off as abrupt or even accusatory. It lacks warmth and therapeutic engagement, which can make a client defensive, especially during an initial visit.

C: What would you like us to do to help you?

This assumes that the client already knows what kind of help they need. In many psychiatric settings, especially early on, clients may be confused, ambivalent, or unsure of what help they’re seeking. It’s premature to ask this before clarifying the central issue.