Updated HESI MENTAL HEALTH RN V1-
V3 2021/2022 TEST BANK TOP-RATED
DOCUMENT
SECTION I: FOUNDATIONS OF PSYCHIATRIC-MENTAL HEALTH NURSING (Questions 1–15)
1. A nurse is working on an inpatient psychiatric unit. Which of the following best describes
the purpose of the DSM-5?
A. It provides a framework for diagnosing mental disorders and guides treatment planning.
B. It outlines legal requirements for involuntary commitment.
C. It establishes reimbursement rates for psychiatric care.
D. It determines nursing diagnoses for psychiatric clients.
Correct Answer: A
Rationale: The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition)
is the standard classification system used by mental health professionals to diagnose mental
disorders. It provides diagnostic criteria, descriptions, and statistical information but does not
address legal commitment, reimbursement, or nursing diagnoses (which come from NANDA-I).
Options B, C, and D describe other systems or documents.
2. A nurse is assessing a client who reports experiencing "voices telling me I'm worthless."
The nurse documents this as:
A. Illusion
B. Hallucination
C. Delusion
D. Loose association
Correct Answer: B
Rationale: A hallucination is a sensory perception experienced without external stimuli.
Auditory hallucinations are the most common type in psychiatric disorders. An illusion (A) is a
,misinterpretation of a real external stimulus. A delusion (C) is a fixed false belief. Loose
association (D) is a thought disorder characterized by fragmented thinking.
3. SATA: A nurse is reviewing the components of a comprehensive psychiatric assessment.
Which elements should be included? (Select all that apply.)
A. Mental status examination
B. Suicide risk assessment
C. Medical history
D. Family psychiatric history
E. Client's financial portfolio
F. Substance use history
Correct Answers: A, B, C, D, F
Rationale: A comprehensive psychiatric assessment includes the mental status exam (A),
suicide risk assessment (B), medical history (C), family psychiatric history (D), and substance use
history (F). A client's financial portfolio (E) is not a standard component of a psychiatric
assessment, though financial concerns may be relevant to discharge planning.
4. A nurse is explaining the concept of "milieu therapy" to a new staff member. Which
statement best describes this concept?
A. "It involves one-on-one therapy sessions with a psychiatrist."
B. "It uses the total environment as a therapeutic tool to promote healing."
C. "It focuses primarily on medication management."
D. "It restricts all client interactions to prevent overstimulation."
Correct Answer: B
Rationale: Milieu therapy (therapeutic community) uses the entire treatment
environment—including physical setting, activities, and social interactions—as a therapeutic
tool. It promotes safety, structure, and social interaction. One-on-one therapy (A) is a specific
intervention, not milieu therapy. Medication management (C) is one component. Restriction (D)
is not the goal of milieu therapy.
5. A nurse observes a client pacing the hallway, wringing their hands, and repeatedly asking,
"When can I go home?" The client's behavior most likely indicates:
,A. Mania
B. Anxiety
C. Depression
D. Psychosis
Correct Answer: B
Rationale: Pacing, hand-wringing, and repeated questioning are classic behavioral
manifestations of anxiety. Mania (A) would include grandiosity, decreased need for sleep, and
pressured speech. Depression (C) typically presents with psychomotor retardation or agitation
with hopelessness. Psychosis (D) would involve hallucinations, delusions, or disorganized
thinking.
6. Which of the following is the most important initial nursing action when a client is admitted
to an inpatient psychiatric unit?
A. Administer prescribed medications
B. Orient the client to the unit and establish rapport
C. Complete the admission paperwork
D. Assign the client to a group therapy session
Correct Answer: B
Rationale: Establishing rapport and orienting the client to the unit are priority initial nursing
actions. This promotes trust, reduces anxiety, and helps the client feel safe. Medications (A) may
be administered after assessment. Paperwork (C) can be completed after the initial interaction.
Group therapy (D) is not appropriate until the client is oriented and stabilized.
7. A nurse is assessing a client's judgment. Which question would best evaluate this area?
A. "What day of the week is it today?"
B. "What would you do if you found a wallet on the street?"
C. "Can you repeat these three words: apple, table, penny?"
D. "Who is the current president of the United States?"
Correct Answer: B
Rationale: Judgment is the ability to make sound decisions and understand consequences.
Asking what the client would do in a hypothetical situation (B) assesses judgment. Orientation
, to time (A) assesses orientation. Repeating words (C) assesses immediate memory. Identifying
the president (D) assesses general knowledge/orientation.
8. SATA: A nurse is teaching a client about the purpose of a psychiatric advance directive.
Which statements by the client indicate understanding? (Select all that apply.)
A. "It lets me document my preferences for treatment if I become unable to make decisions."
B. "It can name someone to make decisions for me."
C. "It guarantees I will never be hospitalized against my will."
D. "It can specify which medications I prefer or refuse."
E. "It replaces the need for a living will."
Correct Answers: A, B, D
Rationale: A psychiatric advance directive allows clients to document treatment preferences
(A), designate a decision-maker (B), and specify medication preferences (D). It does not
guarantee against involuntary hospitalization (C) if the client meets legal criteria. It does not
replace a living will (E), which addresses medical care at end of life.
9. A nurse is caring for a client who has been prescribed haloperidol (Haldol). Which adverse
effect should the nurse monitor for most closely?
A. Hypotension
B. Extrapyramidal symptoms
C. Weight gain
D. Sedation
Correct Answer: B
Rationale: Haloperidol is a typical (first-generation) antipsychotic. Extrapyramidal symptoms
(EPS)—including dystonia, parkinsonism, and akathisia—are the most significant adverse effects
due to dopamine blockade. While hypotension (A), weight gain (C), and sedation (D) can occur,
EPS is the hallmark adverse effect of typical antipsychotics.
10. A client asks the nurse, "What is the difference between a psychiatrist and a
psychologist?" Which response by the nurse is most accurate?
V3 2021/2022 TEST BANK TOP-RATED
DOCUMENT
SECTION I: FOUNDATIONS OF PSYCHIATRIC-MENTAL HEALTH NURSING (Questions 1–15)
1. A nurse is working on an inpatient psychiatric unit. Which of the following best describes
the purpose of the DSM-5?
A. It provides a framework for diagnosing mental disorders and guides treatment planning.
B. It outlines legal requirements for involuntary commitment.
C. It establishes reimbursement rates for psychiatric care.
D. It determines nursing diagnoses for psychiatric clients.
Correct Answer: A
Rationale: The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition)
is the standard classification system used by mental health professionals to diagnose mental
disorders. It provides diagnostic criteria, descriptions, and statistical information but does not
address legal commitment, reimbursement, or nursing diagnoses (which come from NANDA-I).
Options B, C, and D describe other systems or documents.
2. A nurse is assessing a client who reports experiencing "voices telling me I'm worthless."
The nurse documents this as:
A. Illusion
B. Hallucination
C. Delusion
D. Loose association
Correct Answer: B
Rationale: A hallucination is a sensory perception experienced without external stimuli.
Auditory hallucinations are the most common type in psychiatric disorders. An illusion (A) is a
,misinterpretation of a real external stimulus. A delusion (C) is a fixed false belief. Loose
association (D) is a thought disorder characterized by fragmented thinking.
3. SATA: A nurse is reviewing the components of a comprehensive psychiatric assessment.
Which elements should be included? (Select all that apply.)
A. Mental status examination
B. Suicide risk assessment
C. Medical history
D. Family psychiatric history
E. Client's financial portfolio
F. Substance use history
Correct Answers: A, B, C, D, F
Rationale: A comprehensive psychiatric assessment includes the mental status exam (A),
suicide risk assessment (B), medical history (C), family psychiatric history (D), and substance use
history (F). A client's financial portfolio (E) is not a standard component of a psychiatric
assessment, though financial concerns may be relevant to discharge planning.
4. A nurse is explaining the concept of "milieu therapy" to a new staff member. Which
statement best describes this concept?
A. "It involves one-on-one therapy sessions with a psychiatrist."
B. "It uses the total environment as a therapeutic tool to promote healing."
C. "It focuses primarily on medication management."
D. "It restricts all client interactions to prevent overstimulation."
Correct Answer: B
Rationale: Milieu therapy (therapeutic community) uses the entire treatment
environment—including physical setting, activities, and social interactions—as a therapeutic
tool. It promotes safety, structure, and social interaction. One-on-one therapy (A) is a specific
intervention, not milieu therapy. Medication management (C) is one component. Restriction (D)
is not the goal of milieu therapy.
5. A nurse observes a client pacing the hallway, wringing their hands, and repeatedly asking,
"When can I go home?" The client's behavior most likely indicates:
,A. Mania
B. Anxiety
C. Depression
D. Psychosis
Correct Answer: B
Rationale: Pacing, hand-wringing, and repeated questioning are classic behavioral
manifestations of anxiety. Mania (A) would include grandiosity, decreased need for sleep, and
pressured speech. Depression (C) typically presents with psychomotor retardation or agitation
with hopelessness. Psychosis (D) would involve hallucinations, delusions, or disorganized
thinking.
6. Which of the following is the most important initial nursing action when a client is admitted
to an inpatient psychiatric unit?
A. Administer prescribed medications
B. Orient the client to the unit and establish rapport
C. Complete the admission paperwork
D. Assign the client to a group therapy session
Correct Answer: B
Rationale: Establishing rapport and orienting the client to the unit are priority initial nursing
actions. This promotes trust, reduces anxiety, and helps the client feel safe. Medications (A) may
be administered after assessment. Paperwork (C) can be completed after the initial interaction.
Group therapy (D) is not appropriate until the client is oriented and stabilized.
7. A nurse is assessing a client's judgment. Which question would best evaluate this area?
A. "What day of the week is it today?"
B. "What would you do if you found a wallet on the street?"
C. "Can you repeat these three words: apple, table, penny?"
D. "Who is the current president of the United States?"
Correct Answer: B
Rationale: Judgment is the ability to make sound decisions and understand consequences.
Asking what the client would do in a hypothetical situation (B) assesses judgment. Orientation
, to time (A) assesses orientation. Repeating words (C) assesses immediate memory. Identifying
the president (D) assesses general knowledge/orientation.
8. SATA: A nurse is teaching a client about the purpose of a psychiatric advance directive.
Which statements by the client indicate understanding? (Select all that apply.)
A. "It lets me document my preferences for treatment if I become unable to make decisions."
B. "It can name someone to make decisions for me."
C. "It guarantees I will never be hospitalized against my will."
D. "It can specify which medications I prefer or refuse."
E. "It replaces the need for a living will."
Correct Answers: A, B, D
Rationale: A psychiatric advance directive allows clients to document treatment preferences
(A), designate a decision-maker (B), and specify medication preferences (D). It does not
guarantee against involuntary hospitalization (C) if the client meets legal criteria. It does not
replace a living will (E), which addresses medical care at end of life.
9. A nurse is caring for a client who has been prescribed haloperidol (Haldol). Which adverse
effect should the nurse monitor for most closely?
A. Hypotension
B. Extrapyramidal symptoms
C. Weight gain
D. Sedation
Correct Answer: B
Rationale: Haloperidol is a typical (first-generation) antipsychotic. Extrapyramidal symptoms
(EPS)—including dystonia, parkinsonism, and akathisia—are the most significant adverse effects
due to dopamine blockade. While hypotension (A), weight gain (C), and sedation (D) can occur,
EPS is the hallmark adverse effect of typical antipsychotics.
10. A client asks the nurse, "What is the difference between a psychiatrist and a
psychologist?" Which response by the nurse is most accurate?
