Mental Health HESI 2 Exam Practice
Questions with Answers and
Rationales
## Safety and Risk Assessment Questions (1-30)
**1. A client with depression remains in bed most of the day and
declines activities. Which nursing problem has the greatest priority for
this client?**
A. Loss of interest in diversional activity
B. Social isolation
C. Refusal to address nutritional needs
D. Low self-esteem
**Answer: C. Refusal to address nutritional needs**
,**Rationale:** Basic physiological needs (nutrition) take priority over
psychosocial concerns according to Maslow's hierarchy. The client's
refusal to eat represents an immediate threat to physical health that
must be addressed before focusing on self-esteem or social issues .
---
**2. A client who recently experienced the death of a significant other
arrives at the mental health center. The client reports loss of interest in
usual activities, expresses a wish to be with the deceased, has been
eating very little, and has not slept for several days. Which client
statement is most important for the RN to explore at this time?**
A. "What should I do? Nothing seems to help."
B. "I have been so tired lately and needed to sleep."
C. "I really think that I don't need to be here."
D. "I don't want to walk. Nothing matters anymore."
**Answer: D. "I don't want to walk. Nothing matters anymore."**
**Rationale:** This statement suggests profound hopelessness and
possible suicidal ideation. The expression "nothing matters anymore" is
a red flag for suicide risk and requires immediate assessment and
intervention. Safety concerns always take priority .
,---
**3. A male client comes to the emergency center because he has an
erection that will not resolve. The client reports that he is taking
trazodone (Desyrel) for insomnia. Which information is most important
for the nurse to ask the client?**
A. When was the last time you drank alcoholic beverage?
B. Have you taken any medications for erectile dysfunction?
C. Are you having any other sexual dysfunctions or problems?
D. Do you have a history of angina or high blood pressure?
**Answer: B. Have you taken any medications for erectile
dysfunction?**
**Rationale:** Priapism (prolonged erection) is a rare but serious side
effect of trazodone. It is critical to determine if the client has taken
other medications (especially ED medications) that could interact and
worsen the condition. This is a medical emergency requiring immediate
intervention .
---
**4. The RN is working with a male client at a community mental health
center when the client reports hearing voices that tell him to get a knife
, from the kitchen and hurt himself. What intervention is most important
for the RN to implement?**
A. Assign the UAP to remain with the client at all times
B. Ask the client if he plans to follow the command
C. Document the client's statements in the medical record
D. Notify the healthcare provider of the client's statements
**Answer: A. Assign the UAP to remain with the client at all times**
**Rationale:** Command hallucinations instructing self-harm
represent an imminent safety risk requiring constant observation. The
priority is ensuring the client's physical safety through continuous
supervision. Removing access to potential weapons and maintaining 1:1
observation are essential .
---
**5. A male client with schizophrenia is admitted to the psychiatric care
unit for aggressive behavior, auditory hallucinations, and potential for
self-harm. The client has not been taking medications as prescribed and
insists that the food has been poisoned and refuses to eat. What
intervention should the RN implement?**
A. Assure the client that all food served in the hospital is safe to eat
Questions with Answers and
Rationales
## Safety and Risk Assessment Questions (1-30)
**1. A client with depression remains in bed most of the day and
declines activities. Which nursing problem has the greatest priority for
this client?**
A. Loss of interest in diversional activity
B. Social isolation
C. Refusal to address nutritional needs
D. Low self-esteem
**Answer: C. Refusal to address nutritional needs**
,**Rationale:** Basic physiological needs (nutrition) take priority over
psychosocial concerns according to Maslow's hierarchy. The client's
refusal to eat represents an immediate threat to physical health that
must be addressed before focusing on self-esteem or social issues .
---
**2. A client who recently experienced the death of a significant other
arrives at the mental health center. The client reports loss of interest in
usual activities, expresses a wish to be with the deceased, has been
eating very little, and has not slept for several days. Which client
statement is most important for the RN to explore at this time?**
A. "What should I do? Nothing seems to help."
B. "I have been so tired lately and needed to sleep."
C. "I really think that I don't need to be here."
D. "I don't want to walk. Nothing matters anymore."
**Answer: D. "I don't want to walk. Nothing matters anymore."**
**Rationale:** This statement suggests profound hopelessness and
possible suicidal ideation. The expression "nothing matters anymore" is
a red flag for suicide risk and requires immediate assessment and
intervention. Safety concerns always take priority .
,---
**3. A male client comes to the emergency center because he has an
erection that will not resolve. The client reports that he is taking
trazodone (Desyrel) for insomnia. Which information is most important
for the nurse to ask the client?**
A. When was the last time you drank alcoholic beverage?
B. Have you taken any medications for erectile dysfunction?
C. Are you having any other sexual dysfunctions or problems?
D. Do you have a history of angina or high blood pressure?
**Answer: B. Have you taken any medications for erectile
dysfunction?**
**Rationale:** Priapism (prolonged erection) is a rare but serious side
effect of trazodone. It is critical to determine if the client has taken
other medications (especially ED medications) that could interact and
worsen the condition. This is a medical emergency requiring immediate
intervention .
---
**4. The RN is working with a male client at a community mental health
center when the client reports hearing voices that tell him to get a knife
, from the kitchen and hurt himself. What intervention is most important
for the RN to implement?**
A. Assign the UAP to remain with the client at all times
B. Ask the client if he plans to follow the command
C. Document the client's statements in the medical record
D. Notify the healthcare provider of the client's statements
**Answer: A. Assign the UAP to remain with the client at all times**
**Rationale:** Command hallucinations instructing self-harm
represent an imminent safety risk requiring constant observation. The
priority is ensuring the client's physical safety through continuous
supervision. Removing access to potential weapons and maintaining 1:1
observation are essential .
---
**5. A male client with schizophrenia is admitted to the psychiatric care
unit for aggressive behavior, auditory hallucinations, and potential for
self-harm. The client has not been taking medications as prescribed and
insists that the food has been poisoned and refuses to eat. What
intervention should the RN implement?**
A. Assure the client that all food served in the hospital is safe to eat
