HESI MENTAL HEALTH LATEST ACTUAL
EXAM QUESTIONS AND CORRECT
ANSWERS
A 35-year-old male client on the psychiatric ward of a general hospital
believes that someone is trying to poison him. The nurse understands that a
client's delusions are most likely related to his
A) early childhood experiences involving authority issues.
B) anger about being hospitalized.
C) low self-esteem.
D) phobic fear of food. - ----ANS:C
A 35-year-old male client who has been hospitalized for two weeks for chronic
paranoia continues to state that someone is trying to steal his clothing. Which
action should the nurse implement?
A) Encourage the client to actively participate in assigned activities on the unit.
B) Place a lock on the client's closet.
C) Ignore the client's paranoid ideation to extinguish these behaviors.
D) Explain to the client that his suspicions are false. - ----ANS:A
A 65-year-old female client complains to the nurse that recently she has been
hearing voices. What question should the nurse ask this client first?
A) Do you have problems with hallucinations?
B) Are you ever alone when you hear the voices?
C) Has anyone in your family had hearing problems?
D) Do you see things that others cannot see? - ----ANS:B
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? - ----ANS:Inform the
sister.
a bipolar patient has stopped taking an antipsychotic. What other medication
should the nurse expect to be D/C - ----ANS:benzotropine (Congentin)
A business man is stressed about his finances, has anxiety and
sleeplessness. - ----ANS:Limit intake of sugar and caffeine.
,A child is brought to the emergency room with a broken arm. Because of other
injuries, the nurse suspects the child may be a victim of abuse. When the
nurse tries to give the child an injection, the child's mother becomes very loud
and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!"
What is the best interpretation of the mother's statements? The mother is
A) regressing to an earlier behavior pattern. B) sublimating her anger.
C) projecting her feelings onto the nurse. D) suppressing her fear. - ----ANS:C
A child states "My dad used to drink a beer a day, now he drinks at least a
six-pack a day." What can the nurse determine from this statement? -
----ANS:The parent is exhibiting tolerance to alcohol
A chronic depressed older man refuses to leave his room. His family moved
away to a further location so they're not able to visit him as much. What
approach should the nurse take with this man? - ----ANS:May I lay with you for
a little?
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. - ----ANS:C
A client becomes agitated when the nurse is talking to his wife. He has not
eaten in 3 days. What should the nurse do? - ----ANS:Take to quiet room and
give PB crackers.
A client becomes upset when the nurse he requests is not assigned to him,
what is the nurse's best response? - ----ANS:Advise the client that nursing
assignments are not based on client requests.
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? - ----ANS:Magnesium
A client comes in and is 5'5, 75lbs.. what should the nurse do - ----ANS:Start
an IV for IV resuscitation
,A client comes into the ED with DTs. What should the nurse do first? -
----ANS:Administer Ativan.
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? - ----ANS:Move the client to a private room by the
nurse's station.
A client diagnosed with schizophrenia has been refusing prescribed oral
medication for several days. The client has broken chair and is coming after
another client with the broken chair leg, threatening to do physical harm. What
should the nurse do first? - ----ANS:Remove the other client from the room.
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? - ----ANS:Repression.
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? - ----ANS:Go and get more staff assistance.
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. - ----ANS:A
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." - ----ANS:D
, 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. - ----ANS:B
A client is admitted with a diagnosis of depression. The nurse knows that
which characteristic is most indicative of depression?
A) Grandiose ideation.
B) Self-destructive thoughts.
C) Suspiciousness of others.
D) A negative view of self and the future. - ----ANS:D
A client is confused in an acute care hospital setting. What would support the
dx of delirium instead of dementia?
. - ----ANS:Delirium: Started in hospital
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. - ----ANS:B
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. - ----ANS:C
A client is told to come in by friends, clients complaints include losing his job,
just got a divorce, single dad with two kids, what would be the best question
for nurse to ask? - ----ANS:What is troubling you the most?
EXAM QUESTIONS AND CORRECT
ANSWERS
A 35-year-old male client on the psychiatric ward of a general hospital
believes that someone is trying to poison him. The nurse understands that a
client's delusions are most likely related to his
A) early childhood experiences involving authority issues.
B) anger about being hospitalized.
C) low self-esteem.
D) phobic fear of food. - ----ANS:C
A 35-year-old male client who has been hospitalized for two weeks for chronic
paranoia continues to state that someone is trying to steal his clothing. Which
action should the nurse implement?
A) Encourage the client to actively participate in assigned activities on the unit.
B) Place a lock on the client's closet.
C) Ignore the client's paranoid ideation to extinguish these behaviors.
D) Explain to the client that his suspicions are false. - ----ANS:A
A 65-year-old female client complains to the nurse that recently she has been
hearing voices. What question should the nurse ask this client first?
A) Do you have problems with hallucinations?
B) Are you ever alone when you hear the voices?
C) Has anyone in your family had hearing problems?
D) Do you see things that others cannot see? - ----ANS:B
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? - ----ANS:Inform the
sister.
a bipolar patient has stopped taking an antipsychotic. What other medication
should the nurse expect to be D/C - ----ANS:benzotropine (Congentin)
A business man is stressed about his finances, has anxiety and
sleeplessness. - ----ANS:Limit intake of sugar and caffeine.
,A child is brought to the emergency room with a broken arm. Because of other
injuries, the nurse suspects the child may be a victim of abuse. When the
nurse tries to give the child an injection, the child's mother becomes very loud
and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!"
What is the best interpretation of the mother's statements? The mother is
A) regressing to an earlier behavior pattern. B) sublimating her anger.
C) projecting her feelings onto the nurse. D) suppressing her fear. - ----ANS:C
A child states "My dad used to drink a beer a day, now he drinks at least a
six-pack a day." What can the nurse determine from this statement? -
----ANS:The parent is exhibiting tolerance to alcohol
A chronic depressed older man refuses to leave his room. His family moved
away to a further location so they're not able to visit him as much. What
approach should the nurse take with this man? - ----ANS:May I lay with you for
a little?
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. - ----ANS:C
A client becomes agitated when the nurse is talking to his wife. He has not
eaten in 3 days. What should the nurse do? - ----ANS:Take to quiet room and
give PB crackers.
A client becomes upset when the nurse he requests is not assigned to him,
what is the nurse's best response? - ----ANS:Advise the client that nursing
assignments are not based on client requests.
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? - ----ANS:Magnesium
A client comes in and is 5'5, 75lbs.. what should the nurse do - ----ANS:Start
an IV for IV resuscitation
,A client comes into the ED with DTs. What should the nurse do first? -
----ANS:Administer Ativan.
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? - ----ANS:Move the client to a private room by the
nurse's station.
A client diagnosed with schizophrenia has been refusing prescribed oral
medication for several days. The client has broken chair and is coming after
another client with the broken chair leg, threatening to do physical harm. What
should the nurse do first? - ----ANS:Remove the other client from the room.
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? - ----ANS:Repression.
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? - ----ANS:Go and get more staff assistance.
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. - ----ANS:A
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." - ----ANS:D
, 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. - ----ANS:B
A client is admitted with a diagnosis of depression. The nurse knows that
which characteristic is most indicative of depression?
A) Grandiose ideation.
B) Self-destructive thoughts.
C) Suspiciousness of others.
D) A negative view of self and the future. - ----ANS:D
A client is confused in an acute care hospital setting. What would support the
dx of delirium instead of dementia?
. - ----ANS:Delirium: Started in hospital
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. - ----ANS:B
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. - ----ANS:C
A client is told to come in by friends, clients complaints include losing his job,
just got a divorce, single dad with two kids, what would be the best question
for nurse to ask? - ----ANS:What is troubling you the most?
