Psych HESI Questions QUESTIONS AND ANSWERS
MOST TESTED AND PRACTICE QUESTIONS
A young adult male client is admitted to the emergency center following a suicide attempt. His records
reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond
to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the
client for gastric lavage?
1. he ingested the drug 3 hours prior to admission to the ED
2. the family reports that he took an entire bottle of acetaminophen
3. he is unresponsive to instructions and is unable to cooperate with emetic therapy
4. those with repeated suicide attempts desire punishment to relieve their guilt - ANSWER-3. he is
unresponsive to instructions and is unable to cooperate with emetic therapy
Rationale
Because the client is unable to follow instructions, emetic therapy would be very difficult to
implement, therefore gastric lavage is necessary. The other actions are not the basis for determining if
gastric lavage is indicated
Over a period of several weeks, a male participant of a socialization group at a community day care
center for the elderly monopolizes most of the group's time and interrupts others when they are talking.
What is the best action for the nurse to take in this situation?
1. talk to the client outside the group about his behavior during group meetings
2. remind the client to allow others in the group a chance to talk
3. allow the group to handle the problem
4. ask the client to join another group - ANSWER-3. allow the group to handle the problem
Rationale
The phase the group process is in--initial, working, or termination--this will help determine
communication styles between the group members. After several weeks, the group is in the working
phase and the group members should be allowed to determine the direction of the group. The nurse
should ignore the client's comments and allow the group to address the situation
A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday
because he has not had the opportunity to talk with the healthcare provider. Which response is best for
the nurse to provide this client?
1
,1. let me call and leave a message for your HCP
2. the HCP should be here on Monday morning
3. how can I help answer your questions?
4. what concerns do you have at this time? - ANSWER-1. let me call and leave a message for your
HCP
Rationale
Clients have the right to information about their treatment. The nurse should reassure the client that a
call to notify the healthcare provider will be readily placed. The other responses are not the highest
priority intervention.
The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very
depressed. What is the most important intervention to implement during the first 48 hours after the
client's admission to the unit?
1. monitor appetite and observe intake at meals
2. maintain safety in the client's milieu
3. provide ongoing, supportive contact
4. encourage participation in activities - ANSWER-2. maintain safety in the client's milieu
Rationale
A client who is depressed is at risk for suicide.The most important reason for close observation
immediately after admission is to maintain safety due to the client's potential risk for self injury. The
other interventions are not the priority
The nurse should include which interventions in the plan of care for a severely depressed client with
neurovegetative symptoms? (Select all that apply.)
1. permit rest periods as needed
2. speaking slowly and simply
3. place the client on suicide precautions
4. observe and encourage food and fluid intake
5. encourage vigorous exercise and long walks on the unit - ANSWER-1. permit rest periods as needed
2. speaking slowly and simply
3. place the client on suicide precautions
4. observe and encourage food and fluid intake
Rationale
Neurovegetative symptoms that accompany the mood disorder of depression include physiological
disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation. The client's
2
,plan of care should include measures that promote the client's comfort and well-being, such as rest,
nutrition, suicide precautions, and simple communications. Vigorous exercise and long walks are not
indicated for clients in a neurovegetative state.
An older female client reports to the nurse that recently she has been hearing voices. Which question
should the nurse ask this client first?
1. do you have problems with hallucinations?
2. are you ever alone when you hear the voices?
3. has anyone in your family had hearing problems?
4. do you see things that others cannot see? - ANSWER-2. are you ever alone when you hear the
voices?
Rationale
Determining if the client is alone when hearing voices will assist in differentiating between
hallucinations and hearing loss, which is common in the aging population. Other follow-up questions
should then be asked to further validate if the client is experiencing auditory hallucinations.
The nurse is taking a history for a female client who is requesting a routine female exam. Which
assessment finding requires follow-up?
1. menstruation onset at age 9
2. contraceptive method includes condoms only
3. menstrual cycle occurs every 35 days
4. 'black out' after one drink last night on a date - ANSWER-4. 'black out' after one drink last night on a
date
Rationale
A "black-out" typically occurs after ingestion of alcohol beverages that the client has no recall of
experiences or one's behavior and is indicative of high blood alcohol levels. The client's experience of a
"black-out" after one drink is suspicious of the client receiving a "date rape" drug, such as
flunitrazepam ("Rohypnol"), and needs additional follow-up. The other findings do not need follow-up
at this time
A male client with mental illness and substance dependency tells the mental health nurse that he has
started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which
person is best for the nurse to refer this client to first?
1. the ED nurse
2. his case manager
3. the clinic HCP
4. his support group sponsor - ANSWER-2. his case manager
3
, Rationale
The case manager is responsible for coordinating community services. Since this client has a dual
diagnosis, the nurse should refer the client to the case manager to explore available treatment options.
The other referrals are not indicated.
A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying to
poison him. What intervention should the nurse include in this client's plan of care?
1. remind the client that his suspicions are not true
2. ask one nurse to spend time with the client daily
3. encourage the client to participate in group activities
4. assign the client to a room closest to the activity room - ANSWER-2. ask one nurse to spend time
with the client daily
Rationale
A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationships,
the plan of care should include providing one nurse to spend time with the client daily, which is likely
to be therapeutic for this client. The other actions are too stressful for the client and not indicated.
The nurse is leading a "current events group" with client who have chronic psychiatric illnesses. One
group member states, "Clara Barton was my nurse during my last hospitalization. She was a very mean
nurse and wasn't nice to me." Which response is best for the nurse to make?
1. Clara Barton was not your nurse
2. what did she do to you that was so mean?
3. I didn't know that Clara Barton was a nurse
4. Clara Barton started the American Red Cross - ANSWER-4. Clara Barton started the American Red
Cross
Rationale
The historical fact that Clara Barton was a nurse during the Civil War is referencing the concept of
universality in this group therapy discussion. Stating the original role of Clara Barton in nursing should
be presented, which is the reality in nursing and the American culture. The other responses are not
indicated
A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting,
and drowsiness. What action should the nurse take?
1. notify the HCP immediately and prepare for administration of an antidote
2. notify the HCP of the symptoms prior to the next administration of the drug
3. record the symptoms as normal side effects and continue administration of the prescribed dosage
4
MOST TESTED AND PRACTICE QUESTIONS
A young adult male client is admitted to the emergency center following a suicide attempt. His records
reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond
to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the
client for gastric lavage?
1. he ingested the drug 3 hours prior to admission to the ED
2. the family reports that he took an entire bottle of acetaminophen
3. he is unresponsive to instructions and is unable to cooperate with emetic therapy
4. those with repeated suicide attempts desire punishment to relieve their guilt - ANSWER-3. he is
unresponsive to instructions and is unable to cooperate with emetic therapy
Rationale
Because the client is unable to follow instructions, emetic therapy would be very difficult to
implement, therefore gastric lavage is necessary. The other actions are not the basis for determining if
gastric lavage is indicated
Over a period of several weeks, a male participant of a socialization group at a community day care
center for the elderly monopolizes most of the group's time and interrupts others when they are talking.
What is the best action for the nurse to take in this situation?
1. talk to the client outside the group about his behavior during group meetings
2. remind the client to allow others in the group a chance to talk
3. allow the group to handle the problem
4. ask the client to join another group - ANSWER-3. allow the group to handle the problem
Rationale
The phase the group process is in--initial, working, or termination--this will help determine
communication styles between the group members. After several weeks, the group is in the working
phase and the group members should be allowed to determine the direction of the group. The nurse
should ignore the client's comments and allow the group to address the situation
A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday
because he has not had the opportunity to talk with the healthcare provider. Which response is best for
the nurse to provide this client?
1
,1. let me call and leave a message for your HCP
2. the HCP should be here on Monday morning
3. how can I help answer your questions?
4. what concerns do you have at this time? - ANSWER-1. let me call and leave a message for your
HCP
Rationale
Clients have the right to information about their treatment. The nurse should reassure the client that a
call to notify the healthcare provider will be readily placed. The other responses are not the highest
priority intervention.
The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very
depressed. What is the most important intervention to implement during the first 48 hours after the
client's admission to the unit?
1. monitor appetite and observe intake at meals
2. maintain safety in the client's milieu
3. provide ongoing, supportive contact
4. encourage participation in activities - ANSWER-2. maintain safety in the client's milieu
Rationale
A client who is depressed is at risk for suicide.The most important reason for close observation
immediately after admission is to maintain safety due to the client's potential risk for self injury. The
other interventions are not the priority
The nurse should include which interventions in the plan of care for a severely depressed client with
neurovegetative symptoms? (Select all that apply.)
1. permit rest periods as needed
2. speaking slowly and simply
3. place the client on suicide precautions
4. observe and encourage food and fluid intake
5. encourage vigorous exercise and long walks on the unit - ANSWER-1. permit rest periods as needed
2. speaking slowly and simply
3. place the client on suicide precautions
4. observe and encourage food and fluid intake
Rationale
Neurovegetative symptoms that accompany the mood disorder of depression include physiological
disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation. The client's
2
,plan of care should include measures that promote the client's comfort and well-being, such as rest,
nutrition, suicide precautions, and simple communications. Vigorous exercise and long walks are not
indicated for clients in a neurovegetative state.
An older female client reports to the nurse that recently she has been hearing voices. Which question
should the nurse ask this client first?
1. do you have problems with hallucinations?
2. are you ever alone when you hear the voices?
3. has anyone in your family had hearing problems?
4. do you see things that others cannot see? - ANSWER-2. are you ever alone when you hear the
voices?
Rationale
Determining if the client is alone when hearing voices will assist in differentiating between
hallucinations and hearing loss, which is common in the aging population. Other follow-up questions
should then be asked to further validate if the client is experiencing auditory hallucinations.
The nurse is taking a history for a female client who is requesting a routine female exam. Which
assessment finding requires follow-up?
1. menstruation onset at age 9
2. contraceptive method includes condoms only
3. menstrual cycle occurs every 35 days
4. 'black out' after one drink last night on a date - ANSWER-4. 'black out' after one drink last night on a
date
Rationale
A "black-out" typically occurs after ingestion of alcohol beverages that the client has no recall of
experiences or one's behavior and is indicative of high blood alcohol levels. The client's experience of a
"black-out" after one drink is suspicious of the client receiving a "date rape" drug, such as
flunitrazepam ("Rohypnol"), and needs additional follow-up. The other findings do not need follow-up
at this time
A male client with mental illness and substance dependency tells the mental health nurse that he has
started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which
person is best for the nurse to refer this client to first?
1. the ED nurse
2. his case manager
3. the clinic HCP
4. his support group sponsor - ANSWER-2. his case manager
3
, Rationale
The case manager is responsible for coordinating community services. Since this client has a dual
diagnosis, the nurse should refer the client to the case manager to explore available treatment options.
The other referrals are not indicated.
A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying to
poison him. What intervention should the nurse include in this client's plan of care?
1. remind the client that his suspicions are not true
2. ask one nurse to spend time with the client daily
3. encourage the client to participate in group activities
4. assign the client to a room closest to the activity room - ANSWER-2. ask one nurse to spend time
with the client daily
Rationale
A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationships,
the plan of care should include providing one nurse to spend time with the client daily, which is likely
to be therapeutic for this client. The other actions are too stressful for the client and not indicated.
The nurse is leading a "current events group" with client who have chronic psychiatric illnesses. One
group member states, "Clara Barton was my nurse during my last hospitalization. She was a very mean
nurse and wasn't nice to me." Which response is best for the nurse to make?
1. Clara Barton was not your nurse
2. what did she do to you that was so mean?
3. I didn't know that Clara Barton was a nurse
4. Clara Barton started the American Red Cross - ANSWER-4. Clara Barton started the American Red
Cross
Rationale
The historical fact that Clara Barton was a nurse during the Civil War is referencing the concept of
universality in this group therapy discussion. Stating the original role of Clara Barton in nursing should
be presented, which is the reality in nursing and the American culture. The other responses are not
indicated
A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting,
and drowsiness. What action should the nurse take?
1. notify the HCP immediately and prepare for administration of an antidote
2. notify the HCP of the symptoms prior to the next administration of the drug
3. record the symptoms as normal side effects and continue administration of the prescribed dosage
4
