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HESI Mental Health NGN Exams 2025: Updated
Version A & B with Verified Answers and Rationale
(Grade A+!)
Client in abusive relationship and is assisting in the development of a safety plan.
First component of a safety plan? - (answers)Identify signs of escalation of
violence
It is important for the client to be able to identify signs of escalation of violence,
which are the greatest risk to the client. Therefore, this is the first component of
the safety plan because it increases awareness of when danger is imminent and it
is time to leave.
Child with conduct disorder and is behaving in a destructive manner, throwing
objects, and kicking others. Priority therapeutic nursing intervention? -
(answers)Reduce environmental stimuli
The greatest risk to the child and others is harm. Therefore, the nurse's priority
intervention is to reduce environmental stimuli in an attempt to de-escalate the
behavior and prevent injury.
Nurse is updating the plan of care for a client who has bulimia nervosa and is 5%
above their ideal body weight. Which intervention should the nurse include in the
plan? - (answers)Identify the client's trigger foods
The nurse should identify the trigger foods that initiate the client's binge and
assist the client to understand their thoughts and behavior that relate to the food.
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Nurse is assisting a client who has terminal illness adjust to progressive loss of
independence. Client statement indicates acceptance of illness? - (answers)"I am
going to order a wheelchair for when I am unable to walk"
The client is recognizing the reality of continued loss of independence and is
anticipating the need for assistive devices, which indicates the behavioral
response of acceptance.
Medication administration record for a client who is experiencing adverse effects
of chlorpromazine. Nurse should administer benztropine to relieve which of the
following adverse effects? - (answers)Acute dystonia
The nurse should administer benztropine, an anticholinergic agent, to relieve
acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine.
A nurse is carnig for an older adult client who is experiencing delirium. Which
intervention should the nurse include in the client's plan of care? -
(answers)Permit the client to perform daily rituals to decrease anxiety.
The nurse should provide a client who has delirium with a plan of care that
decreases agitation and anxiety by permitting the client to perform daily rituals.
Nurse is receiving change of shift report for four clients. Which client should the
nurse see first? - (answers)A client who is taking clozapine and reports a sore
throat and chills
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When using the urgent vs. nonurgent approach to client care, the nurse should
determine to first see the client who is taking clozapine and reports a sore throat
and chills. Clozapine can cause agranulocytosis, a serious adverse effect that
causes neutropenia. The nurse should withhold the medication and notify the
provider of these findings.
Nurse is planning care for client who has made repeated physical threats toward
others on the unit. Although the client does not want to leave the uhnit, the nurse
requests that provider to transfer the client to a unit that is equippted to manage
violent behavior. Which ethical principle? - (answers)Nonmaleficence
It is the responsibility of the nurse to do no harm to clients. The nurse is applying
the ethical principle of nonmaleficence by requesting to transfer this client to a
unit better able to manage their behavior and thereby prevent injury to others on
the unit.
Nurse is performing cognitive assessment to distinguish delirium from dementia
in a client whose family reports episodes fo confusion. Which assessment finding
supports delirium? - (answers)Easily distracted
Extreme distractibility is a hallmark manifestation of delirium.
Nurse is creating plan of care for a client who has been placed in seclusion after
threatening to harm others on the unit. Which intervention should the nurse
include in the plan? - (answers)Renew the prescription for the client every 4 hr.
HESI Mental Health NGN Exams 2025: Updated
Version A & B with Verified Answers and Rationale
(Grade A+!)
Client in abusive relationship and is assisting in the development of a safety plan.
First component of a safety plan? - (answers)Identify signs of escalation of
violence
It is important for the client to be able to identify signs of escalation of violence,
which are the greatest risk to the client. Therefore, this is the first component of
the safety plan because it increases awareness of when danger is imminent and it
is time to leave.
Child with conduct disorder and is behaving in a destructive manner, throwing
objects, and kicking others. Priority therapeutic nursing intervention? -
(answers)Reduce environmental stimuli
The greatest risk to the child and others is harm. Therefore, the nurse's priority
intervention is to reduce environmental stimuli in an attempt to de-escalate the
behavior and prevent injury.
Nurse is updating the plan of care for a client who has bulimia nervosa and is 5%
above their ideal body weight. Which intervention should the nurse include in the
plan? - (answers)Identify the client's trigger foods
The nurse should identify the trigger foods that initiate the client's binge and
assist the client to understand their thoughts and behavior that relate to the food.
,2|Page
Nurse is assisting a client who has terminal illness adjust to progressive loss of
independence. Client statement indicates acceptance of illness? - (answers)"I am
going to order a wheelchair for when I am unable to walk"
The client is recognizing the reality of continued loss of independence and is
anticipating the need for assistive devices, which indicates the behavioral
response of acceptance.
Medication administration record for a client who is experiencing adverse effects
of chlorpromazine. Nurse should administer benztropine to relieve which of the
following adverse effects? - (answers)Acute dystonia
The nurse should administer benztropine, an anticholinergic agent, to relieve
acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine.
A nurse is carnig for an older adult client who is experiencing delirium. Which
intervention should the nurse include in the client's plan of care? -
(answers)Permit the client to perform daily rituals to decrease anxiety.
The nurse should provide a client who has delirium with a plan of care that
decreases agitation and anxiety by permitting the client to perform daily rituals.
Nurse is receiving change of shift report for four clients. Which client should the
nurse see first? - (answers)A client who is taking clozapine and reports a sore
throat and chills
, 3|Page
When using the urgent vs. nonurgent approach to client care, the nurse should
determine to first see the client who is taking clozapine and reports a sore throat
and chills. Clozapine can cause agranulocytosis, a serious adverse effect that
causes neutropenia. The nurse should withhold the medication and notify the
provider of these findings.
Nurse is planning care for client who has made repeated physical threats toward
others on the unit. Although the client does not want to leave the uhnit, the nurse
requests that provider to transfer the client to a unit that is equippted to manage
violent behavior. Which ethical principle? - (answers)Nonmaleficence
It is the responsibility of the nurse to do no harm to clients. The nurse is applying
the ethical principle of nonmaleficence by requesting to transfer this client to a
unit better able to manage their behavior and thereby prevent injury to others on
the unit.
Nurse is performing cognitive assessment to distinguish delirium from dementia
in a client whose family reports episodes fo confusion. Which assessment finding
supports delirium? - (answers)Easily distracted
Extreme distractibility is a hallmark manifestation of delirium.
Nurse is creating plan of care for a client who has been placed in seclusion after
threatening to harm others on the unit. Which intervention should the nurse
include in the plan? - (answers)Renew the prescription for the client every 4 hr.
