HESI RN MENTAL HEALTH EXIT EXAM
QUESTIONS AND 100% VERIFIED ANSWERS
WITH RATIONALES GRADED A+
GUARANTEED PASS ON THE FIRST ATTEMPT
1. A client with major depressive disorder states, “My family would be better off
without me.” What is the nurse’s priority response?
A. “Why do you feel that way?”
B. “Your family loves you very much.”
C. “Are you thinking about harming yourself?”
D. “Let’s focus on positive things in your life.”
Correct Answer: C
Rationale: Directly assessing suicidal ideation is the priority and does not increase
risk. It ensures immediate safety and guides further intervention.
2. A client receiving lithium therapy reports nausea and fine hand tremors. What is
the most appropriate nursing action?
A. Withhold the next dose
B. Assess serum lithium level
C. Encourage increased sodium intake
D. Administer an antiemetic
Correct Answer: B
Rationale: Mild tremors and nausea may indicate early lithium toxicity. Serum
levels must be assessed before further intervention.
,3. A client with schizophrenia is experiencing auditory hallucinations. Which
response by the nurse is most therapeutic?
A. “The voices are not real.”
B. “What are the voices saying to you?”
C. “You should ignore the voices.”
D. “Why do you think you hear voices?”
Correct Answer: B
Rationale: Exploring content assesses risk while acknowledging the client’s
experience without reinforcing the hallucination.
4. Which behavior best indicates the therapeutic use of self by the nurse?
A. Offering personal advice
B. Maintaining professional boundaries
C. Sharing similar life experiences
D. Redirecting emotional topics
Correct Answer: B
Rationale: Therapeutic use of self relies on professional boundaries, empathy, and
purposeful interaction.
5. A client with bipolar I disorder is exhibiting pressured speech, grandiosity, and
decreased need for sleep. Which medication is most likely prescribed?
A. Fluoxetine
B. Haloperidol
C. Lithium
D. Diazepam
Correct Answer: C
Rationale: Lithium is a first-line mood stabilizer for acute mania and long-term
management of bipolar disorder.
,6. A client with panic disorder reports chest pain and shortness of breath. What is
the nurse’s priority intervention?
A. Teach deep breathing
B. Obtain an ECG
C. Stay with the client
D. Administer PRN benzodiazepine
Correct Answer: C
Rationale: Remaining with the client provides reassurance and safety during acute
panic.
7. Which finding indicates a client with anorexia nervosa is improving?
A. Expresses fear of weight gain
B. Participates in group therapy
C. Gains 1 kg in one week
D. Requests laxatives
Correct Answer: B
Rationale: Engagement in therapy reflects psychological improvement and
readiness for recovery.
8. A nurse is caring for a client in restraints. Which action is required?
A. Reassess every 4 hours
B. Obtain a PRN order
C. Document client behavior
D. Release restraints every 8 hours
Correct Answer: C
Rationale: Accurate, ongoing documentation of behavior and need for restraints is
legally and ethically required.
, 9. A client with PTSD becomes agitated after hearing loud noises. What
intervention is most appropriate?
A. Encourage discussion of trauma
B. Provide a quiet environment
C. Administer antipsychotics
D. Apply physical restraints
Correct Answer: B
Rationale: Reducing environmental stimuli helps prevent escalation and promotes
a sense of safety.
10. Which statement by a client taking sertraline indicates correct understanding?
A. “I will stop taking it once I feel better.”
B. “It may take several weeks to work.”
C. “I should avoid all carbohydrates.”
D. “I can double the dose if I miss one.”
Correct Answer: B
Rationale: SSRIs require several weeks for full therapeutic effect; adherence is
essential.
11. A client with borderline personality disorder displays splitting behavior. What
is the best nursing approach?
A. Assign different nurses each shift
B. Set consistent limits
C. Provide frequent reassurance
D. Encourage dependency
Correct Answer: B
Rationale: Consistent limits and unified staff responses reduce manipulation and
promote stability.
QUESTIONS AND 100% VERIFIED ANSWERS
WITH RATIONALES GRADED A+
GUARANTEED PASS ON THE FIRST ATTEMPT
1. A client with major depressive disorder states, “My family would be better off
without me.” What is the nurse’s priority response?
A. “Why do you feel that way?”
B. “Your family loves you very much.”
C. “Are you thinking about harming yourself?”
D. “Let’s focus on positive things in your life.”
Correct Answer: C
Rationale: Directly assessing suicidal ideation is the priority and does not increase
risk. It ensures immediate safety and guides further intervention.
2. A client receiving lithium therapy reports nausea and fine hand tremors. What is
the most appropriate nursing action?
A. Withhold the next dose
B. Assess serum lithium level
C. Encourage increased sodium intake
D. Administer an antiemetic
Correct Answer: B
Rationale: Mild tremors and nausea may indicate early lithium toxicity. Serum
levels must be assessed before further intervention.
,3. A client with schizophrenia is experiencing auditory hallucinations. Which
response by the nurse is most therapeutic?
A. “The voices are not real.”
B. “What are the voices saying to you?”
C. “You should ignore the voices.”
D. “Why do you think you hear voices?”
Correct Answer: B
Rationale: Exploring content assesses risk while acknowledging the client’s
experience without reinforcing the hallucination.
4. Which behavior best indicates the therapeutic use of self by the nurse?
A. Offering personal advice
B. Maintaining professional boundaries
C. Sharing similar life experiences
D. Redirecting emotional topics
Correct Answer: B
Rationale: Therapeutic use of self relies on professional boundaries, empathy, and
purposeful interaction.
5. A client with bipolar I disorder is exhibiting pressured speech, grandiosity, and
decreased need for sleep. Which medication is most likely prescribed?
A. Fluoxetine
B. Haloperidol
C. Lithium
D. Diazepam
Correct Answer: C
Rationale: Lithium is a first-line mood stabilizer for acute mania and long-term
management of bipolar disorder.
,6. A client with panic disorder reports chest pain and shortness of breath. What is
the nurse’s priority intervention?
A. Teach deep breathing
B. Obtain an ECG
C. Stay with the client
D. Administer PRN benzodiazepine
Correct Answer: C
Rationale: Remaining with the client provides reassurance and safety during acute
panic.
7. Which finding indicates a client with anorexia nervosa is improving?
A. Expresses fear of weight gain
B. Participates in group therapy
C. Gains 1 kg in one week
D. Requests laxatives
Correct Answer: B
Rationale: Engagement in therapy reflects psychological improvement and
readiness for recovery.
8. A nurse is caring for a client in restraints. Which action is required?
A. Reassess every 4 hours
B. Obtain a PRN order
C. Document client behavior
D. Release restraints every 8 hours
Correct Answer: C
Rationale: Accurate, ongoing documentation of behavior and need for restraints is
legally and ethically required.
, 9. A client with PTSD becomes agitated after hearing loud noises. What
intervention is most appropriate?
A. Encourage discussion of trauma
B. Provide a quiet environment
C. Administer antipsychotics
D. Apply physical restraints
Correct Answer: B
Rationale: Reducing environmental stimuli helps prevent escalation and promotes
a sense of safety.
10. Which statement by a client taking sertraline indicates correct understanding?
A. “I will stop taking it once I feel better.”
B. “It may take several weeks to work.”
C. “I should avoid all carbohydrates.”
D. “I can double the dose if I miss one.”
Correct Answer: B
Rationale: SSRIs require several weeks for full therapeutic effect; adherence is
essential.
11. A client with borderline personality disorder displays splitting behavior. What
is the best nursing approach?
A. Assign different nurses each shift
B. Set consistent limits
C. Provide frequent reassurance
D. Encourage dependency
Correct Answer: B
Rationale: Consistent limits and unified staff responses reduce manipulation and
promote stability.
