HESI Mental Health RN Practice Questions & Answers 2026
– Comprehensive Psychiatric Nursing Study Guide & Exam
Prep
1. The nurse is admitting an older patient from a nursing home. During the
assessment, the nurse notes a shallow open reddish, pink ulcer without slough on
the right heel of the patient. How will the nurse stage this pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: B
This would be a Stage II pressure ulcer because it presents as partial-thicknessskin
loss involving epidermis and dermis. The ulcer presents clinically as an abrasion,
blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a
bony prominence. With a Stage III pressure ulcer, subcutaneousfat may be visible,
but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness
tissue loss with exposed bone, tendon, or muscle.
2. The nurse is completing a skin assessment on a patient with darkly
pigmented skin. Which item should the nurse use first to assist in staging anulcer
on this patient?
a. Disposable measuring tape
b. Cotton-tipped applicator
c. Sterile gloves
d. Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to
accurately complete the first step in assessment—inspection—and the entire
assessment process. Natural light or a halogen light is recommended. Fluorescent
light sources can produce blue tones on darkly pigmented skin and can interfere
with an accurate assessment. Other items that could possibly be used during the
assessment include gloves for infection control, a disposable measuring device to
measure the size ofthe wound, and a cotton-tipped applicator to measure the depth
of the wound, but these items are not the first items used.
3. The nurse is caring for a patient with a Stage IV pressure ulcer.
– Comprehensive Psychiatric Nursing Study Guide & Exam
Prep
1. The nurse is admitting an older patient from a nursing home. During the
assessment, the nurse notes a shallow open reddish, pink ulcer without slough on
the right heel of the patient. How will the nurse stage this pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: B
This would be a Stage II pressure ulcer because it presents as partial-thicknessskin
loss involving epidermis and dermis. The ulcer presents clinically as an abrasion,
blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a
bony prominence. With a Stage III pressure ulcer, subcutaneousfat may be visible,
but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness
tissue loss with exposed bone, tendon, or muscle.
2. The nurse is completing a skin assessment on a patient with darkly
pigmented skin. Which item should the nurse use first to assist in staging anulcer
on this patient?
a. Disposable measuring tape
b. Cotton-tipped applicator
c. Sterile gloves
d. Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to
accurately complete the first step in assessment—inspection—and the entire
assessment process. Natural light or a halogen light is recommended. Fluorescent
light sources can produce blue tones on darkly pigmented skin and can interfere
with an accurate assessment. Other items that could possibly be used during the
assessment include gloves for infection control, a disposable measuring device to
measure the size ofthe wound, and a cotton-tipped applicator to measure the depth
of the wound, but these items are not the first items used.
3. The nurse is caring for a patient with a Stage IV pressure ulcer.
