HESI Mental Health RN Questions and Answers from V1-V3 Test Banks and Actual Exams (Latest Update 2020) Rated A+
1. During admission to the psychiatric
... [Show More] 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.
2. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem?
A. Acute confusion.
B. Ineffective community coping
C. Disturbed sensory perception.
D. Self-care deficit.
3. The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis?
A. Tell me what you think should happen.
B. How serious was the collision?
C. What do you think you should do?
D. Call for transportation to the hospital.
4. A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?
A. Ineffective sexual patterns.
B. Impaired environmental interpretation.
C. Disturbed sensory perception.
D. Compromised family coping.
5. The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client’s dressing?
A. Provide detailed thorough explanations when cleansing wound.
B. Perform the dressing change in a non-judgmental manner.
C. Ask in a non-threatening manner why the client cut own abdomen.
D. Request another staff member assist with the dressing change.
6. While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client’s behaviors. What is the main goal of this therapeutic technique?
A. Initiate a non-threatening conversation with the client.
B. Dialog about the ineffectiveness of his interactions.
C. Allow the client to identify the way he interacts.
D. Discuss the client’s feelings when he responds.
7. An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment?
A. Meet scheduled appointment with dietitian.
B. Sleep at least 6 hours a night.
C. Understands the purpose of the medication regimen.
D. Describes the reasons for hospitalization.
8. When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide?
A. If your partner is abusing you, I need to ask these questions.
B. State law mandates that I ask if you are a victim of domestic violence.
C. The HCP provider needs to know if you are experiencing any domestic abuse.
D. All clients are screened for domestic abuse because it is common in our society.
9. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?
A. Unless your sister has a medical education, ignore her comments.
B. I can hear that your sister comments are over-whelming you.
C. Do you think it’s possible that you might be a hypochondriac?
D. Besides your sister’s comments, what in your life is troubling you?
10. The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development?
A. Establishing a rapport with group members.
B. Clarifying the nurse’s role and clients’ responsibilities.
C. Discussing ways to use new coping skills learned.
D. Helping clients identify areas of problem in their lives.
11. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
A. Isolate the client from the other clients.
B. Administer PRN sedative.
C. Avoid recognizing the behavior.
D. Escort the client to his room.
12. A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription?
A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
B. Pulse rate of 68-78 BPM.
C. Temperature of 99.5-99.7 F.
D. Respiration rate of 24 breaths per minute.
13. The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT?
A. Hold all bedtime medications.
B. Keep the client NPO after mid-night.
C. Implement elopement precautions.
D. Give the client an enema at bedtime.
14. A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid?
A. Pan-seared catfish.
B. Peperoni pizza.
C. Deep fried shrimp.
D. Beef trips with gravy.
15. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
A. Is attempting the physically restrain the patient.
B. Remains at a distance of 4 feet from the client.
C. Tells the client to go to the quiet area of the unit.
D. Is using a load voice to talk to the client.
16. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
A. Not sleeping for several days.
B. Wishing to be with spouse.
C. Lack of interest in usual activities.
D. Eating very little.
17. A middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
A. Provide education on methods to enhance sleep.
B. Teach the client to develop a plan for daily structured activities.
C. Suggest that the client develop a list of pleasurable activities.
D. Encourage the client to exercise.
18. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
A. Impaired comfort.
B. Risk for injury.
C. Ineffective breathing pattern.
D. Ineffective coping.
19. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, “I am the boss here. I do what I want.” Which nursing problem best supports these observations?
A. Deficient diversional activity related to excess energy level.
B. Risk for other related violence related to disruptive behavior.
C. Risk for activity intolerance related to hyperactivity.
D. Disturbed personal identity related to grandiosity.
20. A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?
A. Dim the lights in the room to help the patient feel calm.
B. Sit within two feet of the client to enhance level of safety and security.
C. Reduce the noise level in the room by turning off the television and radio.
D. Position table between the client and the RN for extra personal space.
21. An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first?
A. Refer the client to the cardiology unit.
B. Obtain the client Blood pressure.
C. Assess the client for substance abuse.
D. Determine if Xanax was taken recently.
22. The mother of an 8-month-old infant with profound mental and physical disabilities tells he RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. How should the RN respond to the mother?
A. Ask the mother if she has ever thought about harming herself or her child.
B. Reassure the mother that her child will achieve some growth and development milestones.
C. Determine if the mother has other children who do not have developmental disabilities.
D. Encourage the mother to write thoughts and feelings in journal.
23. Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?
A. Medication non-compliance.
B. Number of bathroom facilities.
C. Infection control.
D. Acting out behaviors.
24. A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement?
A. Assure the client that all food served in the hospital is safe to eat.
B. Tell the client that irrational thinking is a symptom of schizophrenia.
C. Obtain an order for a tube feeding for the client.
D. Provide the client with food in unopened containers.
25. The RN 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? (SOA)
A. Purchase a gun to use for protection.
B. Establish a code with family and friends to signify violence.
C. Take a self-defense course that retaliates the abuser with injury.
D. Have a bag ready that has extra clothes for self and children.
E. Plan an escape route to use if the abuser blocks the main exit.
26. The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?
A. Short term memory loss.
B. Five pound weight gain
C. Decreased affect.
D. Nausea and vomiting.
27. A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable?
A. Encourage oral fluids.
B. Monitor vital signs.
C. Keep the room dark.
D. Apply ice to his tongue.
28. A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?
A. Admit to others that he is a substance abuser.
B. Remain alcohol free for 12 hours prior to first dose.
C. Attend monthly meetings of alcoholics anonymous.
D. Completely sustain from heroin or cocaine use.
29. The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?
A. Don’t allow the client to go into the kitchen until the hallucination has subsided.
B. Report the behavior to the client’s case workers so that the family can be notified.
C. Assign the UAP to remain with the client at all times.
D. Document the behavior in the client’s record and notify the HCP.
30. A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated?
A. Allow the client to rest and sleep.
B. Ensure client attend groups addressing coping skills for dealing with depression.
C. Begin planning for the clients discharge.
D. Encourage verbalization of feelings.
20. Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
A. At least I hit the wall instead of hitting the psychiatric aide.
B. I am here because the police thought I was doing something wrong.
C. I want to be here because I know it is the best psychiatric facility.
D. Don’t believe everything my family tells you, I am not crazy.
13. A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client’s current feelings of depression?
A. Feelings of frustration.
B. A sense of loss
C. Poor self-esteem.
D. A lack of intimate relationships.
22. 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 that the t.v talks to her. The RN should document these assessment statements in which section of the mental status exam?
A. Insight and judgement.
B. Mood and affect.
C. Remote memory.
D. Level of concentration.
23. An older ale client with schizophrenia is found smearing feces n the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?
A. Explain that the feces belong in the toilet.
B. Show the client how to clean the walls.
C. Escort the client out of the bathroom.
D. Assist the client to clean the walls.
24. A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?
A. Weight gain of 75 lbs.
B. Thoughts of wanting to hurt himself.
C. Frequent days with diarrhea.
D. Alerted liver function test.
25. A college student who is a victim of a car-jacking presents to the community health center and report increased anxiety. During the interview, what nursing intervention should take the highest priority?
A. Identify support systems in the community that may be helpful.
B. Help the client feel safe to decrease anxiety.
C. Ask the client to describe coping strategies that were helpful in the past.
D. Encourage the client to verbalize anxiety related to event.
26. The RN completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the RN include in the documentation?
A. A summary of the client’s feelings.
B. Photographs.
C. A general description.
D. A client’s significant other’s statement.
19. Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client’s blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?
A. Prochlorperazine (Compazine) 5 mg IM.
B. Hydromorphone (Dialuadid) 2 mg IM.
C. Chlorpromazine (Thorazine) 50 mg IM.
D. Lorazepam (Ativan) 2 mg IM.
1. Part Three
2. A male adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first observe the client in the chair?
3. A female client engages in repeated checks of door and window locks. Behavior that prevents her from arriving on time and interferes with her ability to function e²ectively. What action should the nurse take plan a list of activities to be carried out daily.
4. 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 nurse to ask the client Do you hear voices.
5. A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home.
6. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take Ask client about alcohol quantity, frequency, and time of last drink
7. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit I am here because the police thought I was doing something wrong
8. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations Risk for other related violence related to disruptive
9. What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks not attempt to commit suicide
10. Alcohol-Pancreatitis health assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN pancreatitis
11. Anorexia Nervosa-syncope Syncope is a clinical feature Abuse-BAL-
12. Admission A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take Blood alcohol level- ask the client about alcohol quantity, frequency, and time of the last drink.
13. IPV- difficulty leaving victim of intimate partner violence what 3 things should you do 1. establish a code with family and friends to signify violence, 2. plan an escape route to use if the abuser blocks main exit, 3.have a bag ready that has extra clothes for self and children
14. Anger Management Give the client permission to be angry
15. Antisocial- interrupting A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the nurse implement? C. Escort the client to a quieter place.
16. borderline personality disorder self-inflicted lacerations on abdomen perform the dressing change in a non-judgemental manner *ask to summarize-others need time also Borderline-interaction The nurse is assessing a client who is believed to have a borderline personality disorder. Which question is most important to include in this assessment? C. Do you frequently have temper tantrums? Self-critical demanding, whiney, manipulative, argumentative and can be verbally abusive suicidal gestures. borderline personality disorder self-inflicted lacerations on abdomen perform the dressing change in a non -judge mental manner.
17. Conversion disorder patient complains of blindness Conversion disorder Disorder characterized by transferring a mental conflict into a physical symptom for which there is no organic cause. Ex: blindness, paralysis, seizures, deafness, and pseudocyesis(false pregnancy).
18. Countertransference occurs when a mental health care professional redirects his or her feelings toward a client or becomes emotionally entangled with a client counter transference.
19. Part five
20. After returning to work after a weekend off the nurse gets report that a depressed client has been in bed all weekend. What should the nurse to first?
21. Assist the client out of bed and involve in activity.
22. A client with dementia uses the defense mechanism of confabulation. What is the reasoning?
23. To decrease anxiety.
24. A husband states to the nurse that his wife is not sleeping, buying impulsively, taking last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx?
HESI MENTAL HEALTH V3 2017 55 QUESTIONS
25. Disturbed thought process.
26. A nurse is explaining a fire drill routine to a group of clients. A client becomes disruptive and continually interrupts the group. What is the nurse's best response?
27. When you interrupt, I cannot explain what to do to the group.
28. When performing a MSE on a client which assessment intervention would best assist the nurse?
29. Ask the client to interpret the proverb a stitch in time saves nine.
30. A client comes in after being in a car accident and is experiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysthrythmias. What would you give first?
31. Magnesium.
32. A woman is just told of her husband's dx of terminal cancer. What would the nurse offer for the spouse (wife)?
33. How would you like to be involved with your husband's care?
34. A nurse is to remove staples from an abdominal incision, the client is very anxious. What is the most important intervention?
35. Attempt to distract the client with general conversation.
36. A man who was stranded on the roof of his house for two days after a natural disaster, months later ...
37. Implement anxiety control strategies
38. A man dx with bipolar disorder states, "I don't understand, I believe in God and have not done anything to deserve this". What is the nurse's best response?
39. You didn't do anything wrong. You have a chemical imbalance in your brain.
40. A client becomes upset when the nurse he requests is not assigned to him, what is the nurse's best response?
41. Advise the client that nursing assignments are not based on client requests.
42. A client needs to wash her hands for two hours before able to go on with her morning. She doesn't want to sit on the chairs in the dayroom for fear of getting dirty. What is this mechanism?
43. Compulsion.
44. A client in group is talking about her prostitution, the nurse asks her if she was abused by her parents. She states "my mother ran my father out when I was young". What defense mechanism was used?
45. Repression.
46. A woman calls the crisis hotline and says she has a loaded gun and is going to kill herself. To maintain patient confidentiality what would the nurse do?
47. Contact the person the client chooses to go to the home and remove the weapon.
48. A client with anger management issues uses belt making and bangs the leather heavily. What defense mechanisms is being used?
49. Sublimation.
50. A bipolar client comes into the clinic and tells the nurse that the next time she sees her sister I'm going to kill her. What should the nurse do?
51. Inform the sister.
52. What would be the nurse's highest priority for a newly admitted depressed client upon admission?
53. The nurse should go through the client's belongings.
54. Who is most prone to being abused (elder abuse)?
55. Females over 75 living with their families.
56. A client in the dayroom had tipped over a table and is escalating and has picked up a chair which he is threatening to throw at another client. What should the nurse do first?
57. Go and get more staff assistance.
58. A woman who is psychotic is carrying all of her belongings around with her because she is afraid that someone will steal it. What is the best way to establish trust?
59. Make brief contact with the client throughout the day.
60. In adolescent group discussing a handout on anger management, a client is becoming increasingly interruptive and talking about his home and pets. What is the nurse's most appropriate response?
61. Redirect the client to read the handout.
62. What is the most important intervention for a client with bulimia?
63. Plan scheduled meals.
64. A client comes into the ED with DTs. What should the nurse do first?
65. Administer Ativan.
66. What are the side effects of Resperdal?
67. Fever, tachycardia, and sweating.
68. A client who is refusing to take his medication is wandering on the unit and going in and out of resident's rooms. What is the priority?
69. Wandering in and out of other client's rooms.
70. A nurse observes a client in the dayroom talking to himself. What should the nurse do first?
71. Ask the client if he’s currently hearing voices?
72. A client comes to the nurses' station and told the nurse that her roommate had cut her wrists in the bathroom. After assessing and dressing the wounds, what should the nurse do next?
73. Move the client to a private room by the nurse's station.
74. A man comes into the ER after being in a car accident with an alcohol level greater than 2, what should the nurse prepare to administer?
75. Give Ativan (I DONT THINK THIS ONE IS CORRECT)
76. What would be proper teaching for a client who is to start taking Antabuse?
77. Has not had anything alcoholic to drink for the last 48 hours.
78. Alzheimer's patient-nurse goes to do dressing change and the client refuses. What should the nurse do?
79. Leave and come back 30 minutes later.
80. A client is confused in an acute care hospital setting. What would support the dx of delirium instead of dementia?
81. Delirium: Started in hospital.
82. An elderly woman is brought to the ER with multiple stages of healing bruises. What should the nurse do?
83. Take the woman aside and ask her about abuse.
84. A business man is stressed about his finances, has anxiety and sleeplessness.
85. Limit intake of sugar and caffeine.
86. A mother comes into the clinic with her son who is being accused of a crime. She is worried her son will go to jail. What should the nurse say to the mother?
87. Consequences of enabling behaviors.
88. What is a common side effect of cocaine use.
89. Heart attack.
90. A client on LSD comes into the ER. How do you approach the client?
91. Talk calmly and soothing to the client.
92. A client taking Meth and Benzo's, what would the nurse prepare to do for overdose?
93. Give Narcan.
94. An alcoholic father tells his wife and children to stay away from him. What is the most important nursing dx?
95. Risk for injury.
96. onWhat should you advise a patient a MAOI not to eat?
97. Cheese, beer, and avocado.
98. The parents of a teenager who has overdosed what is the first question to ask?
99. What drug did the client ingest?
100. A client becomes agitated when the nurse is talking to his wife. He has not eaten in 3 days. What should the nurse do?
101. Take to quiet room and give PB crackers.
102. When opening a mental health clinic...
103. American Nursing Association.
104. A client with a hx of depression and abusing alcohol with their depression getting worse. What is the most important nursing dx?
105. Ineffective coping.
106. A woman is being abused by her husband, the abuse is escalating. What would the nurse ask first?
107. Do you have a plan in place when you are not safe? (SAFETY!!!)
108. A patient has stopped taking Depakote six months ago, what would the nurse assess?
109. Mood.
110. A nurse visits a community half way house with one bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper towels.
111. Infection control.
112. A client with Alzheimer's keeps asking for his mother. What is the nurses appropriate response? [Show Less]