HESI Mental Health Questions And Answers
2022
A - ANS- While interviewing a client, the nurse takes notes to assist with accurate
documentation
... [Show More] later. Which statement is most accurate regarding note-taking during
an interview?
A. The nurse' ability to directly observe the client's nonverbal communication is
limited
with note taking.
B. Taking notes during an interview is a legal obligation of the examining nurse.
C. The client's comfort level is increased when the nurse breaks eye contact to take
note to take note.
D. The interview process is enhanced with note taking and allows the client speak at
normal pace.
B - ANS- An adolescent male receives a prescription for an antidepressant drug
because he is exhibiting a depressed affect. While the client is taking the
antidepressant, which comparison of the client's behavior before and after taking the
drug is most important for the nurse to obtain?
A. His appetite.
B. The emotional quality of his attitude
C. His level of activity.
D. The interactions he has with others.
B C D - ANS- A nurse is providing education about strategies for a safety plan for a
female client who is a victim of intimate partner violence. Which strategies should be
included in the safety plan? Select all that apply.
A. Purchase a gun to use for protection
B. Establish a code with family and friends to signify violence.
C. Plan an escape route to use if the abuser blocks the main exit.
D. Have a bag ready that has extra clothes for self and children
B - ANS- While sitting in the dayroom of the mental health unit, a male adolescent
avoids eye contact, looks at the floor, and talks softly when interacting verbally with
the nurse. The two trade places, and the nurse demonstrate the client's behavior.
What is the main goal of this therapeutic techniques?
A. Discuss the client's feeling when he responds.
B. Allow the client to identify the way he interacts.
C. Initiate a non-threatening conversation with the client.
D. Dialog about the ineffectiveness of his interactions.)
C - ANS- A client with depression remains in bed most of the day, and declines
activities. Which nursing problem has the greatest priority for this client?
A. Loss of interest in diversional activity.
B. Social isolation.
C. Refusal to address nutritional needs.
D. Low self-esteem.
B - ANS- The RN is preparing medications for a client with bipolar disorder and
notices that the client discontinued antipsychotic medication for several days. Which
medication should also be discontinued?
a. Lithium. (Lithotabs)
b. Benzotropine (Cogentin).
c. Alprazolam (Xanax).
d. Magnesium (Milk of Magnesia).
A - ANS- A female client requests that her husband be allowed to stay in the room
during the admission assessment. When interviewing the client, the RN notes a
discrepancy between the client's verbal and nonverbal communication. What action
does the RN take?
A. Pay close attention and document the nonverbal messages.
B. Ask the client's husband to interpret the discrepancy.
C. Ignore the nonverbal behavior and focus on the client's verbal messages.
D. Integrate the verbal and nonverbal messages and interpret them as one.
B - ANS- A male client approaches the RN with an angry expression on his face and
raises his voice, saying "My roommate is the most selfish, self-centered, angry
person I have ever met. If he loses his temper one more time with me, I am going to
punch him out!" The RN recognizes that the client is using which defense
mechanism?
A. Denial.
B. Projection.
C. Rationalization.
D. Splitting.
A - ANS- A male client with bipolar disorder who began taking lithium carbonate five
days ago is complaining of excessive thirst, and the RN finds him attempting to drink
water from the bathroom sink faucet. Which intervention should the RN implement?
A. Report the client's serum lithium level to the HCP.
B. Encourage the client to suck on hard candy to relieve the symptoms.
C. No action is needed since polydipsia is a common side effect.
D. Tell the client that drinking from the faucet is not allowed.
B - ANS- The RN is teaching a client about the initiation of the prescribed abstinence
therapy using disulfiram (Antabuse). What information should the client acknowledge
understanding?
A. Completely abstain from heroin or cocaine use.
B. Remain alcohol free for 12 hours prior to the first dose.
C. Attend monthly meetings of alcoholics anonymous.
D. Admit to others that he is a substance user.
D - ANS- A male client with schizophrenia is admitted to the mental health unit after
abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which
question is most important for the RN to ask the client?
A. Have you lost interest in the things that you used to enjoy?
B. Is your ability to think or concentrate decreased?
C. How many continuous hours do you sleep at night?
D. Do you hear sounds or voices that others do not hear?
D - ANS- During an annual physical by the occupational RN working in a corporate
clinic, a male employee tells the RN that is high-stress job is causing trouble in his
personal life. He further explains that he often gets so angry while driving to and from
work that he has considered "getting even" with other drivers. How should the RN
respond?
A. "Anger is contagious and could result in major confrontation."
B. "Try not to let your anger cause you to act impulsively."
C. "Expressing your anger to a stranger could result in an unsafe situation."
D. "It sounds as if there are many situations that make you feel angry."
B - ANS- A client who has agoraphobia (a fear of crowds) is beginning
desensitization with the therapist, and the RN is reinforcing the process. Which
intervention has the highest priority for this client's plan of care?
A. Encourage substitution of positive thoughts and negative ones.
B. Establish trust by providing a calm, safe environment.
C. Progressively expose the client to larger crowds.
D. Encourage deep breathing when anxiety escalates in a crowd.
A D E - ANS- Which nursing actions are likely to help promote the self-esteem of a
male client with modern depression?
A. Ask the client what his long term goals are.
B. Discuss the challenges of his medical condition.
C. Include the client in determining treatment protocol.
D. Encourage the client to engage in recreational therapy.
E. Provide opportunities for the client to discuss his concerns.
D - ANS- A male client is admitted to the psychiatric unit for recurrent negative
symptoms of chronic schizophrenia and medication adjustment of Risperidone
(Risperdal). When the client walks to the nurse's station in a laterally contracted
position, he states that something has made his body contort into a monster. What
action should the RN take?
A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
C. Direct client to occupational therapy to distract him from somatic complaints.
D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
A - ANS- A mental health worker is caring for a client with escalating aggressive
behavior. Which action by the MHW warrant immediate intervention by the RN?
A. Is attempting to physically restrain the patient.
B. Tells the client to go to the quiet area of the unit.
C. Is using a loid voice to talk to the client.
D. Remains at a distance of 4 feet from the client.
C - ANS- A client on the mental health unit is becoming more agitated, shouting at
the staff, and pacing in the hallway. When the PRN medication is offered, the client
refuses the medication and defiantly sits on the floor in the middle of the unit hallway.
What nursing intervention should the RN implement first?
A. Transport of the client to the seclusion room.
B. Quietly approach the client with additional staff members.
C. Take other clients in the area to the client lounge.
D. Administer medication to chemically restrain the patient.
D - ANS- A client is admitted to the mental health unit and reports taking extra
antianxiety medication because, "I'm so stressed out. I just want to go to sleep." The
RN should plan one-on-one observation of the client based on which statement?
A. "What should I do? Nothing seems to help."
B. "I have been so tired lately and needed to sleep."
C. "I really think that I don't need to be here."
D. "I don't want to walk. Nothing matters anymore."
C - ANS- A male hospital employee is pushed out the way by a female employee
because of an oncoming gurney. The pushed employee becomes very angry and
swings at the female employee. Both employees are referred for counseling with the
staff psychiatric RN. Which factor in the pushed employee's history is most related to
the reaction that occurred?
A. Is worried about losing his job to a woman.
B. Tortured animals as a child.
C. Was physically abused by his mother.
D. Hates to be touched by anyone.
B - ANS- The RN documents the mental status of a female client who has been
hospitalized for several days by court order. The client states, "I don't need to be
here" and tells the RN that she believes the television talks to her. The RN should
document these assessment findings in which section of the mental status exam/
A. Level of concentration.
B. Insightandjudgement.
C. Remotememory. D. Mood and affect.
B - ANS- A client is admitted to the mental health unit reports shortness of breath
and dizziness. The client tells the RN, "I feel like I'm going to die". Which nursing
problem should the RN include in this client's plan of care?
A. Mood disturbance.
B. Moderate anxiety.
C. Alteredthoughts.
D. Social isolation.
A - ANS- A female client who is wearing dirty clothes and has foul body odor, comes
to the clinic reporting feeling scared because she is being stalked. What action is
most important for the RN to take?
A. Offer the client a safe place to relax before interviewing her.
B. Ask the client to describe why she is being stalked.
C. Recommend that the client talk with a social worker.
D. Assure the client that the HCP will see her today.
D - ANS- The RN leading a group session of adolescent clients gives the members a
handout about anger management. One of the male clients is fidgety, interrupts
peers when they try and talk, and talks about his pets at home. What nursing action
is best for the RN to take?
A. Explore the client's feelings about his pets and home life.
B. Encourage his peers to help involve him in the activity.
C. Give the client permission to leave and return in 10 minutes.
D. Redirect him by encouraging him to read from the handout.
B - ANS- A male adolescent was admitted to the unit two days ago for depression.
When the mental health RN tries to interview the client to establish rapport, he
becomes very irritated and sarcastic. Which action is best for the RN to take?
A. Report the behavior to the next shift.
B. Offer to play a game of cards with the client.
C. Document the behavior in the chart.
D. Plan to talk with the client the next day.
A - ANS- A male adult is admitted because of an acetaminophen (Tylenol) overdose.
After transfer to the mental health unit, the client is told he has liver damage. Which
information is most important for the nurse to include in the client's discharge plan?
A. Do not take any over the counter meds.
B. Eat a high carb, low fat, low protein diet.
C. Call the crisis hotline if feeling lonely.
D. Avoid exposure to large crowds.
B - ANS- After receiving treatment for anorexia, a student asks the school RN for
permission to work in the school cafeteria as part of the school's work study
program. What action should the RN take?
A. Refer the student to a psychiatrist for further discussion.
B. Recommend assignment to the receptionist's office.
C. Suggest that student work in the athletic department.
D. Determine the parent's opinion of the work assignment.
D - ANS- The Rn accepts a transfer to the metal health unit and understands that the
client is distractible and is exhibiting a decreased ability to concentrate. The RN only
has 15 minutes to talk to the client. To develop treatment plan for this client, which
assessment is most important for the RN to obtain?
A. Motivation of treatment.
B. History of substance use.
C. Medicationcompliance.
D. Mental status examination.
B - ANS- A male client who recently lost a loved one arrives at the mental health
center and tells the RN he is no longer interested is his usual activities and has not
slept for several days. Which priority nursing problem should the RN include in the
client's plan of care?
A. Risk for suicide.
B. Sleepdeprivation.
C. Situational low self-esteem.
D. Social isolation.
D - ANS- A male client with long history of alcohol dependency arrives in the
emergency department describing the feelings of bugs crawling on his body. His
blood pressure is 170/102, his pulse rate is 110 bpm, and is blood alcohol level is
0mg/dL. Which prescription should the RN administer?
A. Haloperidol (Haldol).
B. Thiamine (Vitamin B1).
C. Diphenhydramine(Benadryl).
D. Lorazepam (Ativan).
A - ANS- A client who refuses antipsychotic medications disrupts group activities,
talks with nonsensical words and wanders into client's rooms. The RN decides that
the client needs constant observation based on which of these assessment findings?
A. Wanders into the clients rooms.
B. Refuses antipsychotic medications.
C. Talks with nonsensical words.
D. Disrupts group activities.
B - ANS- A client with schizophrenia explains that she has 20 children and then very
seriously points to the RN and explains that she is one of them. What is the most
therapeutic response for the RN to provide/
A. "Let's go ask another RN is this is true."
B. "My name tag shows that I am a RN here."
C. "I can't possibly be one if your children."
D. "I know that you don't have 20 children."
B - ANS- A high school girl reveals to the high school RN that she has been
engaging in self- induced vomiting as weight-control measure. Which initial
assessment should the RN focus on with this adolescent?
A. National percentile of weight and height.
B. Frequency of bingeing and purging behaviors.
C. Perceptions of family and social relationships.
D. School grades and extracurricular activities.
C - ANS- Narcan was administered to an adult client following a suicide attempt with
an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert
and oriented. In planning nursing care, which intervention has the highest priority at
this time?
A. Encourage the client to increase fluid intake.
B. Obtain the client's serum Vicodin level.
C. Observe the client for further narcotic effects.
D. Determine the client's reason for attempting suicide.
B - ANS- Following surgery, a male client with antisocial personality disorder
frequently requests that a specific RN be assigned to is care and is belligerent when
another RN is assigned. What action should the charge RN implement?
A. Reassure the client that his request will be met whenever possible.
B. Advise the client that assignments are not based on the client's request.
C. Ask the client to explain why he constantly requests the RN.
D. Encourage the client to verbalize his feelings about the RN.
B - ANS- When preparing to administer a prescribed medication to a homeless male
at a community clinic, the client tells the RN that he usually takes a different dosage.
What action should the RN take?
A. Tell him to take the medication then verify the dosage at the next healthcare team
meeting.
B. Withhold the medication until the dosage can be confirmed.
C. Inform him that he may refuse the medication and document whether or not he
takes it.
D. Explain to the client that the dosage has been changed.
C - ANS- The nurse orients a female client with depression to the new room on the
mental health unit. The client states "It seems strange that I don't have a T.V in my
room." Which statement would be best for the RN to provide?
A. "You can watch T.V as much as you want outside of your room."
B. "Sometimes clients feel like the T.V is sending them messages."
C. "It's important to be out of you room and talking to others."
D. "Watching T.V is a passive activity and we want you to be active."
C - ANS- A client admitted with a closed head injury after a fall has a blood alcohol
level of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6
hours following admission should the RN identify as the priority?
A. Give lorazepam (Ativan) PRN for signs of withdrawal.
B. Administer disulfiram (Antabuse) immediately.
C. Place in a side lying position with head of bed elevated.
D. Provide thiamine and folate supplements as prescribed.
A - ANS- The RN is completing the admission assessment of an underweight
adolescent who is admitted to a psychiatric unit with a diagnosis of depression.
Which finding requires notification to the HCP?
A. Potassium level of 2.9 mEq/dl.
B. Blood pressure of 110/70 mmHg.
C. WBCof10,000mm^3.
D. Body mass index of 21.
D - ANS- The Rn is planning client teaching for a 35-year-old client with alcoholic
cirrhosis. Which self-care measure should the RN emphasize for the client's
recovery?
A. Support group meetings.
B. VitaminBandmultivitaminsupplements.
C. Diet with adequate calories and protein.
D. Alcohol abstinence.
B - ANS- A teenager has lost 20 pounds in the last three months is admitted to the
hospital with hypotension and tachycardia. The client reports irregular menses and
hair loss. Which intervention is most important for the RN to include in the clients
plan of care?
A. Implement behavioral modification therapy.
B. Initiate caloric and nutritional therapy.
C. Evaluate the client for low self-esteem.
D. Record daily weights and graft trend.
D - ANS- While interviewing a client, the nurse takes notes to assist with accurate
documentation later. Which statement is most accurate regarding note-taking during
an interview?
A. The client's comfort level is increased when the RN breaks eye contact to take
notes.
B. The interview process is enhanced with note taking and allows the client to speak
at a normal pace.
C. Taking notes during an interview is a legal obligation of examining RN.
D. The RN's ability to directly observe the client's non-verbal communication is
limited
with note taking.
C - ANS- A client is receiving substitution therapy during withdrawal from
benzodiazepines. Which expected outcome statement has the highest priority when
planning nursing care?
a. Client will not demonstrate cross addiction.
b. Co-dependent behaviors will be decreased.
c. CNS stimulation will be reduced.
d. Client's level of consciousness will increase.
B - ANS- A client who is being treated with lithium carbonate for manic depression
begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse
take?
a. Notify the physician immediately and force fluids.
b. Prior to giving the next dose, notify the physician of the symptoms.
c. Record the symptoms and continue medication as prescribed.
d. Hold the medication and refuse to administer additional amounts of the
drug.
D - ANS- While caring for an older client, the RN observes multiple bruises in Over
the client's legs, arms, back, and gluteal areas. When the client Contact, the RN
suspects elder abuse. What action should the RN take?
A. Report family conversations and anger towards the client when visiting.
B. Ask the client specific questions about someone causing the bruising.
C. Question the family members and caregiver how the bruising occurred.
D. Measure and document size, shape and color of the bruised areas.
C - ANS- The RN is performing intake interviews at a psychiatric clinic. A female
client with a known history of drug abuse reports that she had a heart attack four
years ago. Use of which substance places the client at highest risk for myocardial
infarction?
A. Benzodiazepine
B. Alcohol
C. Methamphetamine
D. Marijuana
D - ANS- After receiving treatment for anorexia, a student asks the school RN for
permission to work in the school cafeteria as part of the school's work study
program. What action should the RN take?
A. Suggest that the student work in the athletic department.
B. Determine the parent's opinion of the work assignments.
C. Referthestudenttoapsychiatristforfurtherdiscussion.
D. Recommend assignment to the receptionist's office.
B - ANS- A client who is homeless is diagnosed with schizophrenia and admitted on
an involuntary basis to a mental health hospital 4 days ago. The client stopped
taking prescribed antipsychotic drugs approximately one month ago. Since
hospitalization the client continues to have poor judgment and refuses all
medications. What action should the RN take?
A. Encourage the client to stay in the hospital so the client does not have to be
homeless.
B. Provide the client with medication if the client presents an imminent risk to self
and
others.
C. Administer a long acting antipsychotic medication so that the client can be
discharged to a shelter.
D. Describe to the client treatment options provided at the community mental health
clinics.
B - ANS- A male client comes to the emergency center because he has an erection
that will not resolve. The client reports that he is taking trazodone (Desyrel) for
insomnia. Which information is most important for the nurse ask the client?
A. When was the last time you drank alcoholic beverage?
B. Have you taken any medications for erectile dysfunction?
C. Are you having any other sexual dysfunctions or problems?
D. Do you have a history of angina or high blood pressure?
D - ANS- On admission to the mental health unit, a client diagnosed with
schizophrenia tells the RN that he is the son of god. Based on this statement, which
intervention should the RN include in this client's plan of care?
A. Lead the client by his arm to the seclusion room.
B. Ensure the client's environment is safe.
C. Schedule activity therapy twice a week.
D. Confront his delusion as not consistent with reality.
C - ANS- The RN on the day shift receive report about a client with depression who
was in bed most of the weekend. The RN walks into the client's room in the morning
and finds the client in bed. What intervention is best for the RN to implement?
A. Monitor the client's appetite and pattern of sleep.
B. Assess the client's feelings about the hospital stay.
C. Assist the client to get out of bed and involved in an activity.
D. Explain that staff will check on the client every 30 minutes.
B - ANS- Which client information indicates the need for the RN to use CAGE
questionnaire during the admission interview?
A. Client's medication history includes the frequent use of antidepressants.
B. Describe self as a social drinker who drinks alcoholic beverages daily.
C. Reports difficulties with short term memory since traumatic brain injury.
D. Medical history includes that the client was recently sexually assaulted.
A - ANS- A female client admitted to the mental health unit starts to shout and
scream at the RN. What is the best approach for the RN to take?
A. Stay quietly with the patient
B. Tell her that she is out of control.
C. Distractherbyofferingherfingerfoods.
D. Ignore the client's acting out behavior.
D - ANS- A woman is brought to the psychiatric clinic by her husband. He reports
that his wife is reluctant to leave home because of what she describes as a fear of
open places and crowds. Which nursing problem applies to this client's behavior?
A. Ineffective protection to guard self from internal or external threats.
B. Risk for injury related to inability to communicate.
C. Risk prone health behavior related to self-esteem assault.
D. Anxiety related to real or perceived threat to physical integrity.
B - ANS- A client is receiving benztropine mesylate (Cogentin) for drug-induced
extrapyramidal syndrome (EPS). Which finding indicates that the RN should further
evaluate the client?
A. Decreased bowel movements.
B. Presence of a dry mouth.
C. Decreasinghandtremors.
D. Increased mouth movements.
D - ANS- A male client in the mental health unit is guarded and vaguely answers the
nurse's questions. He isolates in his room and sometimes opens the door to peek
into the hall. Which problem can the RN anticipate?
A. Visual hallucinations.
B. Auditory hallucinations.
C. Excessive motor activity.
D. Delusions of persecution.
D - ANS- A female client with obsessive compulsive personality disorder is admitted
to the hospital for a cardiac catheterization. The afternoon before the procedure, the
client begins to keep detailed notes of the nursing care she is receiving, and reports
her findings to the RN at bedtime. What action should the nurse implement?
A. Explain to the client that her behavior invades the rights of the nursing staff.
B. Ask the client to explain why she is keeping a detailed record of her nursing care.
C. Teach the client strategies to control her obsessive compulsive behavior.
D. Encourage the client to express her feelings regarding the upcoming procedure.
A - ANS- During admission to the psychiatric unit, a female client is extremely
anxious and states that she is worried about the sun coming up the next day. What
intervention is most important for the RN to implement during the admission
process?
A. Assist the client in developing alternative coping skills.
B. Remain calm and use a matter of fact approach.
C. Ask the client why she is so anxious
D. Administer a PRN sedative to help relieve her anxiety.
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