MENTAL HEALTH HESI EXAM VERSION 4
NEWEST 2024-2025 ACTUAL EXAM COMPLETE
84 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES
The nurse completes a physical assessment. When asked what brought her to the
hospital, the client replies that things just aren't right and begins to cry. After further
conversation, the client describes her mood as very sad now. She rarely goes out or
invites friends to visit. She admits that she feels like strangers are saying bad things
about her. Sometimes she hears a man's voice that is a little bit scary.
What is the priority focused nursing assessment? - CORRECT ANSWER - Determine
how long the client has been hearing the voice and what it is saying.
Rationale: Determining if voices are being heard and the type of voices are priority. The
nurse must assess the content of the auditory hallucinations for the presence of
command hallucinations. Command hallucinations may be telling the client to harm
herself or others.
The client is assessed by the nurse, a social worker, and the healthcare provider (HCP).
Based on their assessments, hospitalization is recommended for psychotic depression.
Which behavior is inconsistent with depression? - CORRECT ANSWER - Hearing a
man's voice.
,Rationale: Auditory hallucinations are inconsistent with depression and are more likely
to occur with psychoses. However, clients may experience a psychotic depression in
which there is evidence of psychosis.
The nurse asks the client to sign the consent for treatment.
If the client refuses treatment, which behaviors justify short-term involuntary treatment?
(Select all that apply. One, some, or all options may be correct.) - CORRECT ANSWER
- Unable to meet basic self-care needs.
Rationale: Involuntary treatment can be initiated if the client is unable to meet basic self-
care needs in such a way that he or she is a danger to self.
States she has a plan to harm herself.
Rationale: Short-term involuntary care may be initiated to protect the client if she has a
plan to harm herself. It can also be initiated if she presents an intentional danger to
others.
The client signs the treatment form and is admitted to the mental health unit. During the
first days of hospitalization, she begins antidepressant therapy with fluoxetine 10 mg.
In what classification of drugs is the antidepressant fluoxetine? - CORRECT ANSWER -
Selective serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
,What is the major action of SSRI antidepressants? - CORRECT ANSWER - Increase
availability of serotonin.
Rationale: The major action of SSRIs is to selectively inhibit the reuptake of serotonin
and increase the availability of serotonin.
The nurse understands that SSRIs are now more widely prescribed than tricyclics for
antidepressant therapy. What is the rationale? - CORRECT ANSWER - Tricyclics have
more dangerous side effects.
Rationale: SSRIs are more widely prescribed than tricyclics because they have fewer
side effects, and tricyclics can be lethal in an overdose because they are cardiotoxic.
When the client receives fluoxetine, the nurse must explain the purpose and when to
expect therapeutic effectiveness. What should the nurse tell the client regarding when
she will begin to feel less depressed? - CORRECT ANSWER - Generally within 1 to 4
weeks.
Rationale: In general, it takes 2 to 4 weeks for antidepressant effects to begin. However,
it depends on the individual, and some clients may feel effects start as soon as 1 week
or as late as 4 weeks. It is suggested that depression occurs when a depletion of
neurotransmitters in the synapse cause the transmitter receptors to increase. As the
antidepressants make more transmitters available, it takes the receptors several weeks
to return their numbers back to normal and allow normal synaptic activity.
, The nurse should be aware of common side effects of SSRI antidepressants such as
fluoxetine. Which side effect should be communicated to the client that commonly occur
in clients who are taking SSRI antidepressants? - CORRECT ANSWER -
Gastrointestinal disturbances.
Rationale: GI disturbances such as nausea and diarrhea, as well as genitourinary side
effects such as sexual dysfunction, are common with SSRIs. SSRIs do not have
significant anticholinergic, cardiovascular, or sedative side effects.
The client also begins an atypical antipsychotic, risperidone, because she reports
hearing a "scary voice" upon admission. Although the client remains very withdrawn and
noncommunicative, the nurse must explain the purpose of risperidone. Which
explanation is best? - CORRECT ANSWER - Risperidone will help the think more
clearly.
Rationale: Antipsychotic medications target symptoms related to disorders of thinking
such as psychosis and behaviors associated with agitation and disorganization or
speech and behavior.
The nurse is reviewing the client's admission lab work on the third day of hospitalization.
Admission labs include thyroid profile, urinalysis, chemistry panel, pregnancy test, urine
drug screen, and VDRL (RPR) which tests for venereal disease.
NEWEST 2024-2025 ACTUAL EXAM COMPLETE
84 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES
The nurse completes a physical assessment. When asked what brought her to the
hospital, the client replies that things just aren't right and begins to cry. After further
conversation, the client describes her mood as very sad now. She rarely goes out or
invites friends to visit. She admits that she feels like strangers are saying bad things
about her. Sometimes she hears a man's voice that is a little bit scary.
What is the priority focused nursing assessment? - CORRECT ANSWER - Determine
how long the client has been hearing the voice and what it is saying.
Rationale: Determining if voices are being heard and the type of voices are priority. The
nurse must assess the content of the auditory hallucinations for the presence of
command hallucinations. Command hallucinations may be telling the client to harm
herself or others.
The client is assessed by the nurse, a social worker, and the healthcare provider (HCP).
Based on their assessments, hospitalization is recommended for psychotic depression.
Which behavior is inconsistent with depression? - CORRECT ANSWER - Hearing a
man's voice.
,Rationale: Auditory hallucinations are inconsistent with depression and are more likely
to occur with psychoses. However, clients may experience a psychotic depression in
which there is evidence of psychosis.
The nurse asks the client to sign the consent for treatment.
If the client refuses treatment, which behaviors justify short-term involuntary treatment?
(Select all that apply. One, some, or all options may be correct.) - CORRECT ANSWER
- Unable to meet basic self-care needs.
Rationale: Involuntary treatment can be initiated if the client is unable to meet basic self-
care needs in such a way that he or she is a danger to self.
States she has a plan to harm herself.
Rationale: Short-term involuntary care may be initiated to protect the client if she has a
plan to harm herself. It can also be initiated if she presents an intentional danger to
others.
The client signs the treatment form and is admitted to the mental health unit. During the
first days of hospitalization, she begins antidepressant therapy with fluoxetine 10 mg.
In what classification of drugs is the antidepressant fluoxetine? - CORRECT ANSWER -
Selective serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
,What is the major action of SSRI antidepressants? - CORRECT ANSWER - Increase
availability of serotonin.
Rationale: The major action of SSRIs is to selectively inhibit the reuptake of serotonin
and increase the availability of serotonin.
The nurse understands that SSRIs are now more widely prescribed than tricyclics for
antidepressant therapy. What is the rationale? - CORRECT ANSWER - Tricyclics have
more dangerous side effects.
Rationale: SSRIs are more widely prescribed than tricyclics because they have fewer
side effects, and tricyclics can be lethal in an overdose because they are cardiotoxic.
When the client receives fluoxetine, the nurse must explain the purpose and when to
expect therapeutic effectiveness. What should the nurse tell the client regarding when
she will begin to feel less depressed? - CORRECT ANSWER - Generally within 1 to 4
weeks.
Rationale: In general, it takes 2 to 4 weeks for antidepressant effects to begin. However,
it depends on the individual, and some clients may feel effects start as soon as 1 week
or as late as 4 weeks. It is suggested that depression occurs when a depletion of
neurotransmitters in the synapse cause the transmitter receptors to increase. As the
antidepressants make more transmitters available, it takes the receptors several weeks
to return their numbers back to normal and allow normal synaptic activity.
, The nurse should be aware of common side effects of SSRI antidepressants such as
fluoxetine. Which side effect should be communicated to the client that commonly occur
in clients who are taking SSRI antidepressants? - CORRECT ANSWER -
Gastrointestinal disturbances.
Rationale: GI disturbances such as nausea and diarrhea, as well as genitourinary side
effects such as sexual dysfunction, are common with SSRIs. SSRIs do not have
significant anticholinergic, cardiovascular, or sedative side effects.
The client also begins an atypical antipsychotic, risperidone, because she reports
hearing a "scary voice" upon admission. Although the client remains very withdrawn and
noncommunicative, the nurse must explain the purpose of risperidone. Which
explanation is best? - CORRECT ANSWER - Risperidone will help the think more
clearly.
Rationale: Antipsychotic medications target symptoms related to disorders of thinking
such as psychosis and behaviors associated with agitation and disorganization or
speech and behavior.
The nurse is reviewing the client's admission lab work on the third day of hospitalization.
Admission labs include thyroid profile, urinalysis, chemistry panel, pregnancy test, urine
drug screen, and VDRL (RPR) which tests for venereal disease.
