MENTAL HEALTH HESI PRACTICE EXAM
A child is brought to the emergency room with a broken arm. Because of these injuries,
the nurse suspects the child may be a victim of abuse. When the nurse tries to give the
child an injection, the child 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
statement? 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 - Answers :C. Projecting her feelings onto the nurse
Rationale: Projection is attributing one's own thoughts, impulses, or behaviors onto
another -- it is the mother who is probably harming the child and she is attributing her
actions to the nurse.
A 72-year-old female is admitted to the psychiatric unit with a diagnosis of major
depression. Which statement by the client should be of greatest concern to the nurse
and require further assessment?
A. "I will die if my cat dies."
B. "I don't feel like eating this morning."
C. "I just went to my friend's funeral."
D. "Don't yo have more important things to do?" - Answers :A. "I will die if my cat dies."
Rationale: Sometimes a client will use an analogy to describe themselves, and (A)
would be an indication for conducting a suicide assessment.
A 19-year-old female client with diagnosis anorexia nervoua wants to help serve dinner
trays to other clients on a psychiatric unit. Which action should the nurse take?
A. Encourage the client self-motivation by asking her to pass trays for the rest of the
week.
B. Provide an additional challenge by asking the client to help feed the older clients.
C. Suggest another way or this client to participate in the unit's activities.
D. Tell the client that hospital guidelines allow only staff to pass the trays. - Answers :C.
Suggest another way or this client to participate in the unit's activities.
Rationale: Clients with anorexia should not be allowed to plan or prepare food for unit
activities and their desires to do so should be redirected.
Which diet selection by a client who is depressed and taking MAOI inhibitors
tranylcypromine (Parnate) indicated to the nurse that the client understands the dietary
restrictions imposed by this medication regimen?
A. Hamburger, French fries, and chocolate milkshake.
B. Liver and onion, broccoli, and decaffeinated coffee.
,C. Pepperoni and cheese pizza, tossed salad, and a soft drink.
D. Roast beef, baked potato with butter, and iced tea. - Answers :D. Roast beef, baked
potato with butter, and iced tea.
Rationale: Only (D) contains no tyramine. Tyramine in foods interacts with MAOI in the
body causing a hypertensive crisis which is life-threatening, and Parnate is classified as
an MAOI antidepressant.
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia.
When her tray is brought to her, she refuses to eat and tells the nurse. "i know you are
trying to poison me with food." Which response would be most important for the nurse to
make?
A. I'll leave your tray here. I am available if you need anything else
B. You are not being poisoned. Why do you think someone is trying to poison you
C. No one on this unit has ever died from poisoning. You are safe here.
D. I will talk to your healthcare provider about the possibility of changing your diet -
Answers :A. I'll leave your tray here. I am available if you need anything else
Rationale: (A) is the best choice cited. The nurse does not argue with the client nor
demand that she eat, but offers support by agreeing to "be there if needed," e.g. to
warm the food.
A 25-year-old female client has been particularly restless and the nurse finds her trying
to leave the psychiatric unit. She tells the nurse "Please let me go I must leave because
the secret police are after me." which is best for the nurse to make?
A. No one is after you. You are safe here
B. You will feel better after you have rested
C. I know you must feel lonely and frightened
D. Come with me to your room and I will sit with you - Answers :D. Come with me to
your room and I will sit with you
Rationale: (D) is the best response because it offers support without judgement or
demands.
A 45-year-old male client tells the nurse he used to believe he was Jesus Christ but now
he knows he is not. Which response is best for the nurse to make?
A. Did you really believe you were Jesus Christ?
B. I think you're getting well
C. Others have had similar thoughts when under stress
D. Why did you think you were Jesus Christ? - Answers :C. Others have had similar
thoughts when under stress
Rationale: (C) offers support by assuring the client that other have suffered as he has
(also the principle on with AA acts).
, A nurse working in the emergency room of a children hospital admits a child whose
injuries could have resulted from abuse. Which statement accurately describes the
nurse's responsibility in cases of suspected child abuse?
A. The nurse should obtain objective data such as x-rays before reporting suspicions to
authorities
B. The nurse should confirm any suspicions of child abuse with the health care provider
before reporting to the authorities.
C. The nurse should report any case of suspected child abuse to the charge nurse
D. The nurse should note in the client's record any suspicions of child abuse so that a
history of suspicions can be tracked. - Answers :C. The nurse should report any case of
suspected child abuse to the charge nurse
Rationale: It is the nurse's legal responsibility to report all suspected cases of child
abuse. Notifying the charge nurse starts the legal reporting.
A client who is being treated with lithium carbonate for bipolar disorder develops
diarrhea, vomiting, and drowsiness. What action should the nurse take?
A. Notify the healthcare provider. Immediately and prepare for administration of an
antidote
B. Notify the healthcare provider of the symptoms prior to the next administration of the
drug
C Record the symptoms as normal side effects and continue administration of
prescribed dosage.
D. Hold the medication and refuse to administer additional amount of the drug -
Answers :B. Notify the healthcare provider of the symptoms prior to the next
administration of the drug
Rationale: Early side effects of lithium carbonate (occurring with serum lithium levels
below 2.0 mEq per liter) generally follow a progressive pattern beginning with diarrhea,
vomiting, drowsiness, and muscular weakness. At higher levels, ataxia, tinnitus, blurred
vision, and large dilute urine output may occur. (B) is the best choice. Although these
are expected symptoms, the HCP should be notified prior to the next administration of
the drug.
A client on the psychiatric unit appears to imitate a certain nurse on the unit.. the client
seeks out this particular nurse and imitates her mannerisms.. the nurse knows that the
client is using which defense mechanism
A. Sublimation
B. Identification
C. Introjection
D. Repression - Answers :B. Identification
Rationale: Identification (B) is an attempt to be like someone or emulate the personality
traits of another.
A child is brought to the emergency room with a broken arm. Because of these injuries,
the nurse suspects the child may be a victim of abuse. When the nurse tries to give the
child an injection, the child 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
statement? 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 - Answers :C. Projecting her feelings onto the nurse
Rationale: Projection is attributing one's own thoughts, impulses, or behaviors onto
another -- it is the mother who is probably harming the child and she is attributing her
actions to the nurse.
A 72-year-old female is admitted to the psychiatric unit with a diagnosis of major
depression. Which statement by the client should be of greatest concern to the nurse
and require further assessment?
A. "I will die if my cat dies."
B. "I don't feel like eating this morning."
C. "I just went to my friend's funeral."
D. "Don't yo have more important things to do?" - Answers :A. "I will die if my cat dies."
Rationale: Sometimes a client will use an analogy to describe themselves, and (A)
would be an indication for conducting a suicide assessment.
A 19-year-old female client with diagnosis anorexia nervoua wants to help serve dinner
trays to other clients on a psychiatric unit. Which action should the nurse take?
A. Encourage the client self-motivation by asking her to pass trays for the rest of the
week.
B. Provide an additional challenge by asking the client to help feed the older clients.
C. Suggest another way or this client to participate in the unit's activities.
D. Tell the client that hospital guidelines allow only staff to pass the trays. - Answers :C.
Suggest another way or this client to participate in the unit's activities.
Rationale: Clients with anorexia should not be allowed to plan or prepare food for unit
activities and their desires to do so should be redirected.
Which diet selection by a client who is depressed and taking MAOI inhibitors
tranylcypromine (Parnate) indicated to the nurse that the client understands the dietary
restrictions imposed by this medication regimen?
A. Hamburger, French fries, and chocolate milkshake.
B. Liver and onion, broccoli, and decaffeinated coffee.
,C. Pepperoni and cheese pizza, tossed salad, and a soft drink.
D. Roast beef, baked potato with butter, and iced tea. - Answers :D. Roast beef, baked
potato with butter, and iced tea.
Rationale: Only (D) contains no tyramine. Tyramine in foods interacts with MAOI in the
body causing a hypertensive crisis which is life-threatening, and Parnate is classified as
an MAOI antidepressant.
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia.
When her tray is brought to her, she refuses to eat and tells the nurse. "i know you are
trying to poison me with food." Which response would be most important for the nurse to
make?
A. I'll leave your tray here. I am available if you need anything else
B. You are not being poisoned. Why do you think someone is trying to poison you
C. No one on this unit has ever died from poisoning. You are safe here.
D. I will talk to your healthcare provider about the possibility of changing your diet -
Answers :A. I'll leave your tray here. I am available if you need anything else
Rationale: (A) is the best choice cited. The nurse does not argue with the client nor
demand that she eat, but offers support by agreeing to "be there if needed," e.g. to
warm the food.
A 25-year-old female client has been particularly restless and the nurse finds her trying
to leave the psychiatric unit. She tells the nurse "Please let me go I must leave because
the secret police are after me." which is best for the nurse to make?
A. No one is after you. You are safe here
B. You will feel better after you have rested
C. I know you must feel lonely and frightened
D. Come with me to your room and I will sit with you - Answers :D. Come with me to
your room and I will sit with you
Rationale: (D) is the best response because it offers support without judgement or
demands.
A 45-year-old male client tells the nurse he used to believe he was Jesus Christ but now
he knows he is not. Which response is best for the nurse to make?
A. Did you really believe you were Jesus Christ?
B. I think you're getting well
C. Others have had similar thoughts when under stress
D. Why did you think you were Jesus Christ? - Answers :C. Others have had similar
thoughts when under stress
Rationale: (C) offers support by assuring the client that other have suffered as he has
(also the principle on with AA acts).
, A nurse working in the emergency room of a children hospital admits a child whose
injuries could have resulted from abuse. Which statement accurately describes the
nurse's responsibility in cases of suspected child abuse?
A. The nurse should obtain objective data such as x-rays before reporting suspicions to
authorities
B. The nurse should confirm any suspicions of child abuse with the health care provider
before reporting to the authorities.
C. The nurse should report any case of suspected child abuse to the charge nurse
D. The nurse should note in the client's record any suspicions of child abuse so that a
history of suspicions can be tracked. - Answers :C. The nurse should report any case of
suspected child abuse to the charge nurse
Rationale: It is the nurse's legal responsibility to report all suspected cases of child
abuse. Notifying the charge nurse starts the legal reporting.
A client who is being treated with lithium carbonate for bipolar disorder develops
diarrhea, vomiting, and drowsiness. What action should the nurse take?
A. Notify the healthcare provider. Immediately and prepare for administration of an
antidote
B. Notify the healthcare provider of the symptoms prior to the next administration of the
drug
C Record the symptoms as normal side effects and continue administration of
prescribed dosage.
D. Hold the medication and refuse to administer additional amount of the drug -
Answers :B. Notify the healthcare provider of the symptoms prior to the next
administration of the drug
Rationale: Early side effects of lithium carbonate (occurring with serum lithium levels
below 2.0 mEq per liter) generally follow a progressive pattern beginning with diarrhea,
vomiting, drowsiness, and muscular weakness. At higher levels, ataxia, tinnitus, blurred
vision, and large dilute urine output may occur. (B) is the best choice. Although these
are expected symptoms, the HCP should be notified prior to the next administration of
the drug.
A client on the psychiatric unit appears to imitate a certain nurse on the unit.. the client
seeks out this particular nurse and imitates her mannerisms.. the nurse knows that the
client is using which defense mechanism
A. Sublimation
B. Identification
C. Introjection
D. Repression - Answers :B. Identification
Rationale: Identification (B) is an attempt to be like someone or emulate the personality
traits of another.
