HESI RN Mental Health Exit Exam:
Complete Review of Key Concepts,
Medications, and Nursing
Interventions
A client with major depressive disorder has been prescribed fluoxetine
(Prozac). Which instruction should the nurse include in the teaching plan?
Answer: Take the medication in the morning to minimize insomnia.
Rationale: Fluoxetine is an SSRI with activating properties that can cause
insomnia. Taking it in the morning helps minimize sleep disturbances while
maintaining therapeutic levels throughout the day. The full therapeutic
effect may take 4-6 weeks.
A client diagnosed with bipolar disorder is experiencing acute mania. Which
nursing intervention is most appropriate?
Answer: Provide a quiet environment with minimal stimulation.
Rationale: Clients in acute mania are highly sensitive to environmental
stimuli. A quiet, low-stimulation environment reduces sensory overload and
helps decrease agitation. Structured activities should be non-competitive
and simple.
,A client with schizophrenia tells the nurse, "The FBI is monitoring my
thoughts through satellites." This statement is an example of what type of
delusion?
Answer: Thought broadcasting.
Rationale: Thought broadcasting is the delusional belief that one's
thoughts are being transmitted to others or monitored by external forces.
This differs from paranoia (persecutory delusions), grandiosity, or thought
insertion.
The nurse is assessing a client with dementia who is displaying sundowning
syndrome. Which intervention should the nurse implement?
Answer: Maintain a consistent daily routine and provide adequate lighting
in the evening.
Rationale: Sundowning refers to increased confusion and agitation in the
late afternoon and evening. Consistency in routine reduces anxiety from
unpredictability, while adequate lighting decreases shadows that may cause
misperceptions.
A client with generalized anxiety disorder is prescribed buspirone (BuSpar).
Which statement indicates the client understands the medication teaching?
Answer: "This medication will take several weeks to become effective."
Rationale: Buspirone requires 2-4 weeks of consistent use to achieve
therapeutic effect. It is not a PRN medication for acute anxiety and does not
cause significant sedation or dependence like benzodiazepines.
The nurse is caring for a client who has just been diagnosed with pancreatic
cancer. The client states, "I don't believe it. The lab results must be wrong."
Which defense mechanism is the client using?
,Answer: Denial.
Rationale: Denial is the unconscious refusal to accept reality, allowing the
client to protect against overwhelming anxiety. This is common in the initial
stages of receiving a serious diagnosis and serves as a protective
mechanism.
A client with obsessive-compulsive disorder (OCD) spends 45 minutes
washing hands after touching any surface. What is the priority nursing
intervention?
Answer: Set limits on the behavior and redirect to other activities.
Rationale: The nurse should gently set limits on compulsive behaviors
while providing alternative activities. The goal is to decrease ritualistic
behaviors without increasing anxiety to an intolerable level.
The client with post-traumatic stress disorder (PTSD) reports frequent
nightmares and flashbacks. Which medication class is most commonly
prescribed for these symptoms?
Answer: SSRIs (Selective Serotonin Reuptake Inhibitors).
Rationale: SSRIs such as sertraline and paroxetine are FDA-approved for
PTSD and are first-line treatment for reducing core symptoms including
intrusive thoughts, nightmares, and hyperarousal.
A client with borderline personality disorder has just been admitted to the
unit following a suicide attempt. Which nursing intervention is most
important?
Answer: Establish a therapeutic relationship with consistent boundaries.
, Rationale: Clients with borderline personality disorder require clear,
consistent boundaries to decrease manipulative behaviors. Maintaining a
therapeutic relationship with firm limits provides safety and predictability.
The nurse is performing a mental status examination. Which finding would
indicate a disturbance in thought process?
Answer: Loose associations.
Rationale: Loose associations (derailment) represent a thought disorder
where ideas shift from one topic to another unrelated topic. This is
characteristic of schizophrenia and other psychotic disorders.
A client with alcohol use disorder is receiving disulfiram (Antabuse). Which
statement indicates the client understands the medication's purpose?
Answer: "I cannot drink alcohol or use products containing alcohol while
taking this medication."
Rationale: Disulfiram works by producing unpleasant effects (flushing,
nausea, palpitations) when alcohol is consumed. It is a deterrent medication
that requires client commitment to abstinence. Even small amounts of
alcohol in products can trigger a reaction.
The nurse is planning care for a client experiencing alcohol withdrawal.
Which finding should be reported to the healthcare provider immediately?
Answer: Seizure activity.
Rationale: Seizures are a serious complication of alcohol withdrawal that
can progress to life-threatening status epilepticus or delirium tremens.
Immediate medical intervention is required.
A client with anorexia nervosa has a BMI of 16.5. Which laboratory finding
would the nurse expect?
Complete Review of Key Concepts,
Medications, and Nursing
Interventions
A client with major depressive disorder has been prescribed fluoxetine
(Prozac). Which instruction should the nurse include in the teaching plan?
Answer: Take the medication in the morning to minimize insomnia.
Rationale: Fluoxetine is an SSRI with activating properties that can cause
insomnia. Taking it in the morning helps minimize sleep disturbances while
maintaining therapeutic levels throughout the day. The full therapeutic
effect may take 4-6 weeks.
A client diagnosed with bipolar disorder is experiencing acute mania. Which
nursing intervention is most appropriate?
Answer: Provide a quiet environment with minimal stimulation.
Rationale: Clients in acute mania are highly sensitive to environmental
stimuli. A quiet, low-stimulation environment reduces sensory overload and
helps decrease agitation. Structured activities should be non-competitive
and simple.
,A client with schizophrenia tells the nurse, "The FBI is monitoring my
thoughts through satellites." This statement is an example of what type of
delusion?
Answer: Thought broadcasting.
Rationale: Thought broadcasting is the delusional belief that one's
thoughts are being transmitted to others or monitored by external forces.
This differs from paranoia (persecutory delusions), grandiosity, or thought
insertion.
The nurse is assessing a client with dementia who is displaying sundowning
syndrome. Which intervention should the nurse implement?
Answer: Maintain a consistent daily routine and provide adequate lighting
in the evening.
Rationale: Sundowning refers to increased confusion and agitation in the
late afternoon and evening. Consistency in routine reduces anxiety from
unpredictability, while adequate lighting decreases shadows that may cause
misperceptions.
A client with generalized anxiety disorder is prescribed buspirone (BuSpar).
Which statement indicates the client understands the medication teaching?
Answer: "This medication will take several weeks to become effective."
Rationale: Buspirone requires 2-4 weeks of consistent use to achieve
therapeutic effect. It is not a PRN medication for acute anxiety and does not
cause significant sedation or dependence like benzodiazepines.
The nurse is caring for a client who has just been diagnosed with pancreatic
cancer. The client states, "I don't believe it. The lab results must be wrong."
Which defense mechanism is the client using?
,Answer: Denial.
Rationale: Denial is the unconscious refusal to accept reality, allowing the
client to protect against overwhelming anxiety. This is common in the initial
stages of receiving a serious diagnosis and serves as a protective
mechanism.
A client with obsessive-compulsive disorder (OCD) spends 45 minutes
washing hands after touching any surface. What is the priority nursing
intervention?
Answer: Set limits on the behavior and redirect to other activities.
Rationale: The nurse should gently set limits on compulsive behaviors
while providing alternative activities. The goal is to decrease ritualistic
behaviors without increasing anxiety to an intolerable level.
The client with post-traumatic stress disorder (PTSD) reports frequent
nightmares and flashbacks. Which medication class is most commonly
prescribed for these symptoms?
Answer: SSRIs (Selective Serotonin Reuptake Inhibitors).
Rationale: SSRIs such as sertraline and paroxetine are FDA-approved for
PTSD and are first-line treatment for reducing core symptoms including
intrusive thoughts, nightmares, and hyperarousal.
A client with borderline personality disorder has just been admitted to the
unit following a suicide attempt. Which nursing intervention is most
important?
Answer: Establish a therapeutic relationship with consistent boundaries.
, Rationale: Clients with borderline personality disorder require clear,
consistent boundaries to decrease manipulative behaviors. Maintaining a
therapeutic relationship with firm limits provides safety and predictability.
The nurse is performing a mental status examination. Which finding would
indicate a disturbance in thought process?
Answer: Loose associations.
Rationale: Loose associations (derailment) represent a thought disorder
where ideas shift from one topic to another unrelated topic. This is
characteristic of schizophrenia and other psychotic disorders.
A client with alcohol use disorder is receiving disulfiram (Antabuse). Which
statement indicates the client understands the medication's purpose?
Answer: "I cannot drink alcohol or use products containing alcohol while
taking this medication."
Rationale: Disulfiram works by producing unpleasant effects (flushing,
nausea, palpitations) when alcohol is consumed. It is a deterrent medication
that requires client commitment to abstinence. Even small amounts of
alcohol in products can trigger a reaction.
The nurse is planning care for a client experiencing alcohol withdrawal.
Which finding should be reported to the healthcare provider immediately?
Answer: Seizure activity.
Rationale: Seizures are a serious complication of alcohol withdrawal that
can progress to life-threatening status epilepticus or delirium tremens.
Immediate medical intervention is required.
A client with anorexia nervosa has a BMI of 16.5. Which laboratory finding
would the nurse expect?
