University of Florida NUR 3535C Psychiatric/Mental Health
Nursing Comprehensive Exit final exam 2 HESI Examination
Preparation Guide 200 Original Multiple-Choice Questions with
Verified Rationales Covering All Psych/Mental Health Content
Areas
Questions 1-30: Foundations of Psychiatric Nursing and Therapeutic Communication
Question 1
A nurse is caring for a client with major depressive disorder who states, "I don't see the point in
going on anymore." Which nursing response is most therapeutic?
A. "You have so much to live for, think about your family."
B. "Are you thinking about harming yourself?"
C. "Everyone feels down sometimes, it will pass."
D. "Let's focus on the positive things in your life."
Correct answer: B
Rationale: The most therapeutic response is to directly assess for suicidal ideation by asking if
the client is thinking about harming themselves. This is a safety priority and demonstrates
nonjudgmental concern. Offering false reassurance, minimizing feelings, or redirecting to
positivity avoids the critical safety assessment and invalidates the client's emotional state.
Question 2
A client with schizophrenia tells the nurse, "The FBI is monitoring my thoughts through satellites."
The nurse should document this as which type of delusion?
A. Somatic delusion
B. Grandiose delusion
C. Persecutory delusion
D. Referential delusion
1
,Correct answer: C
Rationale: Persecutory delusions involve the belief that one is being targeted, harassed, or
monitored by external forces, such as the FBI. Somatic delusions involve bodily functions;
grandiose delusions involve exaggerated self-importance; referential delusions involve believing
that neutral events have personal meaning.
Question 3
A client with borderline personality disorder is manipulating staff members by splitting. Which
nursing intervention is most appropriate?
A. Confront the client about the manipulative behavior
B. Ignore the splitting behavior to avoid reinforcing it
C. Establish consistent unit rules and consequences
D. Allow the client to choose which staff member to work with
Correct answer: C
Rationale: Establishing consistent unit rules and consequences helps prevent splitting by
ensuring all staff respond uniformly to the client. Confrontation may escalate behavior; ignoring
may allow splitting to continue; allowing choice reinforces the splitting pattern.
Question 4
A client with acute alcohol withdrawal is experiencing tremors, diaphoresis, and a heart rate of
118 bpm. Which medication should the nurse anticipate administering?
A. Haloperidol
B. Lorazepam
C. Naltrexone
D. Disulfiram
Correct answer: B
2
,Rationale: Lorazepam is a benzodiazepine used to manage acute alcohol withdrawal symptoms,
including autonomic hyperactivity and seizure prevention. Haloperidol is an antipsychotic;
naltrexone and disulfiram are for relapse prevention, not acute withdrawal.
Question 5
A client with post-traumatic stress disorder is experiencing flashbacks. Which nursing
intervention is most therapeutic during a flashback?
A. Speak loudly to redirect attention
B. Encourage the client to describe the flashback in detail
C. Use grounding techniques to orient to the present
D. Leave the client alone to process the flashback
Correct answer: C
Rationale: Grounding techniques (e.g., naming objects in the room, focusing on breathing) help
the client reconnect with the present and reduce the intensity of the flashback. Speaking loudly
may increase distress; discussing the flashback in detail may intensify the experience; leaving the
client alone may increase feelings of isolation.
Question 6
A client with bipolar disorder is in the manic phase and is pacing rapidly, speaking loudly, and not
sleeping. The nurse should prioritize which intervention?
A. Encourage the client to participate in group therapy
B. Provide a quiet, low-stimulation environment
C. Challenge the client's grandiose beliefs
D. Allow the client to set their own activity schedule
Correct answer: B
Rationale: Providing a quiet, low-stimulation environment reduces external stimuli and helps
decrease manic symptoms. Group therapy may overstimulate the client; challenging grandiose
3
, beliefs may lead to agitation; the client in the manic phase requires structure and environmental
control.
Question 7
A client prescribed fluoxetine for depression reports sexual dysfunction. The nurse should explain
that:
A. This side effect is rare and will likely resolve
B. The medication should be discontinued immediately
C. This is a common side effect that should be reported to the provider
D. Sexual dysfunction only occurs with higher doses
Correct answer: C
Rationale: Sexual dysfunction is a common side effect of SSRIs, including fluoxetine. The nurse
should acknowledge the side effect and encourage the client to report it to the provider, who
may consider dose adjustment or medication change. Discontinuing abruptly can cause
withdrawal symptoms.
Question 8
A client with anxiety disorder is using defense mechanisms. Which behavior demonstrates the use
of sublimation?
A. Forgetting a scheduled appointment with the therapist
B. Channeling anxiety into painting and artwork
C. Blaming others for personal problems
D. Refusing to acknowledge a diagnosis
Correct answer: B
Rationale: Sublimation is a mature defense mechanism where unacceptable impulses are
channeled into socially acceptable behaviors, such as painting or other creative outlets.
Forgetting is repression; blaming is projection; refusing is denial.
4
Nursing Comprehensive Exit final exam 2 HESI Examination
Preparation Guide 200 Original Multiple-Choice Questions with
Verified Rationales Covering All Psych/Mental Health Content
Areas
Questions 1-30: Foundations of Psychiatric Nursing and Therapeutic Communication
Question 1
A nurse is caring for a client with major depressive disorder who states, "I don't see the point in
going on anymore." Which nursing response is most therapeutic?
A. "You have so much to live for, think about your family."
B. "Are you thinking about harming yourself?"
C. "Everyone feels down sometimes, it will pass."
D. "Let's focus on the positive things in your life."
Correct answer: B
Rationale: The most therapeutic response is to directly assess for suicidal ideation by asking if
the client is thinking about harming themselves. This is a safety priority and demonstrates
nonjudgmental concern. Offering false reassurance, minimizing feelings, or redirecting to
positivity avoids the critical safety assessment and invalidates the client's emotional state.
Question 2
A client with schizophrenia tells the nurse, "The FBI is monitoring my thoughts through satellites."
The nurse should document this as which type of delusion?
A. Somatic delusion
B. Grandiose delusion
C. Persecutory delusion
D. Referential delusion
1
,Correct answer: C
Rationale: Persecutory delusions involve the belief that one is being targeted, harassed, or
monitored by external forces, such as the FBI. Somatic delusions involve bodily functions;
grandiose delusions involve exaggerated self-importance; referential delusions involve believing
that neutral events have personal meaning.
Question 3
A client with borderline personality disorder is manipulating staff members by splitting. Which
nursing intervention is most appropriate?
A. Confront the client about the manipulative behavior
B. Ignore the splitting behavior to avoid reinforcing it
C. Establish consistent unit rules and consequences
D. Allow the client to choose which staff member to work with
Correct answer: C
Rationale: Establishing consistent unit rules and consequences helps prevent splitting by
ensuring all staff respond uniformly to the client. Confrontation may escalate behavior; ignoring
may allow splitting to continue; allowing choice reinforces the splitting pattern.
Question 4
A client with acute alcohol withdrawal is experiencing tremors, diaphoresis, and a heart rate of
118 bpm. Which medication should the nurse anticipate administering?
A. Haloperidol
B. Lorazepam
C. Naltrexone
D. Disulfiram
Correct answer: B
2
,Rationale: Lorazepam is a benzodiazepine used to manage acute alcohol withdrawal symptoms,
including autonomic hyperactivity and seizure prevention. Haloperidol is an antipsychotic;
naltrexone and disulfiram are for relapse prevention, not acute withdrawal.
Question 5
A client with post-traumatic stress disorder is experiencing flashbacks. Which nursing
intervention is most therapeutic during a flashback?
A. Speak loudly to redirect attention
B. Encourage the client to describe the flashback in detail
C. Use grounding techniques to orient to the present
D. Leave the client alone to process the flashback
Correct answer: C
Rationale: Grounding techniques (e.g., naming objects in the room, focusing on breathing) help
the client reconnect with the present and reduce the intensity of the flashback. Speaking loudly
may increase distress; discussing the flashback in detail may intensify the experience; leaving the
client alone may increase feelings of isolation.
Question 6
A client with bipolar disorder is in the manic phase and is pacing rapidly, speaking loudly, and not
sleeping. The nurse should prioritize which intervention?
A. Encourage the client to participate in group therapy
B. Provide a quiet, low-stimulation environment
C. Challenge the client's grandiose beliefs
D. Allow the client to set their own activity schedule
Correct answer: B
Rationale: Providing a quiet, low-stimulation environment reduces external stimuli and helps
decrease manic symptoms. Group therapy may overstimulate the client; challenging grandiose
3
, beliefs may lead to agitation; the client in the manic phase requires structure and environmental
control.
Question 7
A client prescribed fluoxetine for depression reports sexual dysfunction. The nurse should explain
that:
A. This side effect is rare and will likely resolve
B. The medication should be discontinued immediately
C. This is a common side effect that should be reported to the provider
D. Sexual dysfunction only occurs with higher doses
Correct answer: C
Rationale: Sexual dysfunction is a common side effect of SSRIs, including fluoxetine. The nurse
should acknowledge the side effect and encourage the client to report it to the provider, who
may consider dose adjustment or medication change. Discontinuing abruptly can cause
withdrawal symptoms.
Question 8
A client with anxiety disorder is using defense mechanisms. Which behavior demonstrates the use
of sublimation?
A. Forgetting a scheduled appointment with the therapist
B. Channeling anxiety into painting and artwork
C. Blaming others for personal problems
D. Refusing to acknowledge a diagnosis
Correct answer: B
Rationale: Sublimation is a mature defense mechanism where unacceptable impulses are
channeled into socially acceptable behaviors, such as painting or other creative outlets.
Forgetting is repression; blaming is projection; refusing is denial.
4
