HESI MENTAL HEALTH COMPREHENSIVE EXAM
QUESTIONS AND SOLUTIONS GRADED A+
✔✔A client with schizophrenia approaches the practical nurse (PN) and says, " The
voices are bothering me. They're yelling and telling me I'm bad. Can't you hear them?"
Which responses should the PN provide?
A. "Do you hear the voices often?"
B. "Have you been taking your medication regularly?"
C. "I can't hear the voices, but I can see that you're upset."
D. "Dismiss the voices and ask someone to play cards with you." - ✔✔C. "I can't hear
the voices, but I can see that you're upset."
rationale:
A response based in reality should be given in response to the client. Since the
experience is real for the client, acknowledging the distress encourages the client to
identify feelings associated with the experience (C). The client can't respond to (A or B)
while in an agitated state. (D) is not therapeutic.
✔✔Which nursing intervention is best to help a female client with progressive memory
deficit?
A. Promote the client's sense of humor by telling jokes and discussing cartoons
B. Avoid frustrating the client by performing routine activities of daily living for her
C. Stimulate the client intellectually by bringing new topics to her attention
D. Assist the client to perform simple tasks by giving step by step directions - ✔✔D.
Assist the client to perform simple tasks by giving step by step directions
rationale:
When simple directions are given in a step by step fashion (D), a client with memory
deficit can process information and perform simple tasks. Clients with memory or
cognitive impairment should be encouraged to perform all tasks they are capable of
doing for themselves, not (B). (A and C) may be frustrating and counterproductive for
the client.
✔✔A client diagnosed with Stage 3 Alzheimer's disease is experiencing difficulty
toileting appropriately. What instruction is best for the practical nurse (PN) to provide the
family?
A. Label the client's bathroom door
B. Place the client in disposable diapers
C. Make sure the client does not eat nonfood items
D. Question the client often about the urge to void or defecate. - ✔✔A. Label the client's
bathroom door
rationale:
A client with Stage 3 (mild decline) Alzheimer's disease has memory loss that begins to
interfere with activities of daily living and may benefit from the use of environmental
,cues such as labels to compensate for memory loss. (B,C, and D) do not address the
concepts of client dignity, advocacy, and collarboration.
✔✔A male client with dementia who lives in an extended care facility is placed in a
wheelchair each day and positioned in the hall where he kicks people who walk past
him. Which intervention should the practical nurse (PN) implement?
A. Move him to a busier hall with more people
B. Ask the client every half hour what he needs
C. Call him by name until he focuses his attention
D. Approach the client from behind to apply a restraint - ✔✔C. Call him by name until he
focuses his attention
rationale:
Obtaining the client's attention (C) is fundamental when intervening because he focuses
on the nurse and excludes the surrounding distractions that contributing to his behavior.
(A and B) are forms of stimulation that may increase his agitated behavior. (D) is not
indicated.
✔✔A female client arrives in the clinic carrying a duffle bag and is wearing torn and dirty
clothes. She tells the practical nurse (PN) she has no place to go. The PN takes her
vital signs and observes leg ulcers on both lower extremities. What additional
information should the practical nurse obtain to determine if she is homeless?
A. Ask the client directly about her living arrangements
B. Question whether the client brought someone with her
C. Elicit her home address during the mental status exam
D. Avoid discussing her living arrangements during care - ✔✔A. Ask the client directly
about her living arrangements
rationale:
If the PN suspects the client is homeless, the best way to obtain the information is to
ask the client directly (A) so care and social services can be provided. (B, C, and D) do
not obtain direct information from the client.
✔✔When implementing the plan of care for a client who is recovering from an overdose
of clomipramine (Anafranil), the practical nurse (PN) recognized that it is essential to
monitor the client for which side effects?
A. Excess salivation and drooling
B. Muscle rigidity and restlessness
C. Polyuria and extreme hand tremors
D. Orthostatic hypotension and constipation - ✔✔D. Orthostatic hypotension and
constipation
rationale:
Clomipramine (Anafranil) is a tricyclic antidepressant with anticholinergic side effects,
such as orthostatic hypotension and constipation (D). (A) are extrapyramidal syndrome
, side effects of some antipsychotic medications. (B) is indicative of neuroleptic malignant
syndrome related to antipsychotic medications. (C) are signs of lithium toxicity.
✔✔The practical nurse (PN) is caring for a female client with chronic psychosis who
repeatedly tells the PN that her arm is missing and she can't participate in the group
activities. Which response should the PN offer when providing reality validation with the
client?
A. I see your arm is right there.
B. Let's not focus on that right now.
C. If your arm is missing, how can you feed yourself?
D. Do you mean, it feels like your arm is missing? - ✔✔D. Do you mean, it feels like
your arm is missing?
rationale:
(D) is the most therapeutic response because the nurse is asking the client to describe
her feelings. (A and C) challenge the client's unrealistic beliefs, and the client may feel
threatened. (B) is an attempt by the nurse to change the subject and ignores what the
client is saying.
✔✔A 20-year-old male client who is admitted to the mental health unit for an adjustment
disorder is telling the practical nurse (PN) that he wants to find an apartment, but he is
afraid he does not make enough money to move out of his parent's home. Using
Erikson's theory of psychosocial development, which development stage should the PN
explore with this client?
A. Physical and social losses
B. Feelings of guilt or frustration
C. Mastery of physical motor skills
D. Sense of freedom in the community - ✔✔D. Sense of freedom in the community
rationale:
According to Erikson, the young adult is in the intimacy-versus-isolation stage of
development. This is the time in which he can participate in the social role of young
adulthood, so encouraging the client to talk about his sense of adult freedom and
responsibility (D) addresses his adjustment in this stage of development. (A,B, and C)
do not focus on the young adult's development tasks.
✔✔Which finding should the practical nurse (PN) identify in a 10-year-old client who is
diagnosed with attention deficit hyperactivity disorder (ADHD)?
A. Crying when separated from parents and siblings
B. Refusing to pick up toys as instructed by parents
C. Fascination with spinning and moving toys and objects
D. Inability to concentrate long enough to complete school work - ✔✔D. Inability to
concentrate long enough to complete school work
rationale:
QUESTIONS AND SOLUTIONS GRADED A+
✔✔A client with schizophrenia approaches the practical nurse (PN) and says, " The
voices are bothering me. They're yelling and telling me I'm bad. Can't you hear them?"
Which responses should the PN provide?
A. "Do you hear the voices often?"
B. "Have you been taking your medication regularly?"
C. "I can't hear the voices, but I can see that you're upset."
D. "Dismiss the voices and ask someone to play cards with you." - ✔✔C. "I can't hear
the voices, but I can see that you're upset."
rationale:
A response based in reality should be given in response to the client. Since the
experience is real for the client, acknowledging the distress encourages the client to
identify feelings associated with the experience (C). The client can't respond to (A or B)
while in an agitated state. (D) is not therapeutic.
✔✔Which nursing intervention is best to help a female client with progressive memory
deficit?
A. Promote the client's sense of humor by telling jokes and discussing cartoons
B. Avoid frustrating the client by performing routine activities of daily living for her
C. Stimulate the client intellectually by bringing new topics to her attention
D. Assist the client to perform simple tasks by giving step by step directions - ✔✔D.
Assist the client to perform simple tasks by giving step by step directions
rationale:
When simple directions are given in a step by step fashion (D), a client with memory
deficit can process information and perform simple tasks. Clients with memory or
cognitive impairment should be encouraged to perform all tasks they are capable of
doing for themselves, not (B). (A and C) may be frustrating and counterproductive for
the client.
✔✔A client diagnosed with Stage 3 Alzheimer's disease is experiencing difficulty
toileting appropriately. What instruction is best for the practical nurse (PN) to provide the
family?
A. Label the client's bathroom door
B. Place the client in disposable diapers
C. Make sure the client does not eat nonfood items
D. Question the client often about the urge to void or defecate. - ✔✔A. Label the client's
bathroom door
rationale:
A client with Stage 3 (mild decline) Alzheimer's disease has memory loss that begins to
interfere with activities of daily living and may benefit from the use of environmental
,cues such as labels to compensate for memory loss. (B,C, and D) do not address the
concepts of client dignity, advocacy, and collarboration.
✔✔A male client with dementia who lives in an extended care facility is placed in a
wheelchair each day and positioned in the hall where he kicks people who walk past
him. Which intervention should the practical nurse (PN) implement?
A. Move him to a busier hall with more people
B. Ask the client every half hour what he needs
C. Call him by name until he focuses his attention
D. Approach the client from behind to apply a restraint - ✔✔C. Call him by name until he
focuses his attention
rationale:
Obtaining the client's attention (C) is fundamental when intervening because he focuses
on the nurse and excludes the surrounding distractions that contributing to his behavior.
(A and B) are forms of stimulation that may increase his agitated behavior. (D) is not
indicated.
✔✔A female client arrives in the clinic carrying a duffle bag and is wearing torn and dirty
clothes. She tells the practical nurse (PN) she has no place to go. The PN takes her
vital signs and observes leg ulcers on both lower extremities. What additional
information should the practical nurse obtain to determine if she is homeless?
A. Ask the client directly about her living arrangements
B. Question whether the client brought someone with her
C. Elicit her home address during the mental status exam
D. Avoid discussing her living arrangements during care - ✔✔A. Ask the client directly
about her living arrangements
rationale:
If the PN suspects the client is homeless, the best way to obtain the information is to
ask the client directly (A) so care and social services can be provided. (B, C, and D) do
not obtain direct information from the client.
✔✔When implementing the plan of care for a client who is recovering from an overdose
of clomipramine (Anafranil), the practical nurse (PN) recognized that it is essential to
monitor the client for which side effects?
A. Excess salivation and drooling
B. Muscle rigidity and restlessness
C. Polyuria and extreme hand tremors
D. Orthostatic hypotension and constipation - ✔✔D. Orthostatic hypotension and
constipation
rationale:
Clomipramine (Anafranil) is a tricyclic antidepressant with anticholinergic side effects,
such as orthostatic hypotension and constipation (D). (A) are extrapyramidal syndrome
, side effects of some antipsychotic medications. (B) is indicative of neuroleptic malignant
syndrome related to antipsychotic medications. (C) are signs of lithium toxicity.
✔✔The practical nurse (PN) is caring for a female client with chronic psychosis who
repeatedly tells the PN that her arm is missing and she can't participate in the group
activities. Which response should the PN offer when providing reality validation with the
client?
A. I see your arm is right there.
B. Let's not focus on that right now.
C. If your arm is missing, how can you feed yourself?
D. Do you mean, it feels like your arm is missing? - ✔✔D. Do you mean, it feels like
your arm is missing?
rationale:
(D) is the most therapeutic response because the nurse is asking the client to describe
her feelings. (A and C) challenge the client's unrealistic beliefs, and the client may feel
threatened. (B) is an attempt by the nurse to change the subject and ignores what the
client is saying.
✔✔A 20-year-old male client who is admitted to the mental health unit for an adjustment
disorder is telling the practical nurse (PN) that he wants to find an apartment, but he is
afraid he does not make enough money to move out of his parent's home. Using
Erikson's theory of psychosocial development, which development stage should the PN
explore with this client?
A. Physical and social losses
B. Feelings of guilt or frustration
C. Mastery of physical motor skills
D. Sense of freedom in the community - ✔✔D. Sense of freedom in the community
rationale:
According to Erikson, the young adult is in the intimacy-versus-isolation stage of
development. This is the time in which he can participate in the social role of young
adulthood, so encouraging the client to talk about his sense of adult freedom and
responsibility (D) addresses his adjustment in this stage of development. (A,B, and C)
do not focus on the young adult's development tasks.
✔✔Which finding should the practical nurse (PN) identify in a 10-year-old client who is
diagnosed with attention deficit hyperactivity disorder (ADHD)?
A. Crying when separated from parents and siblings
B. Refusing to pick up toys as instructed by parents
C. Fascination with spinning and moving toys and objects
D. Inability to concentrate long enough to complete school work - ✔✔D. Inability to
concentrate long enough to complete school work
rationale:
