Mental Health HESI Newest Actual Exam Version
4 Complete 84 Questions with Correct Detailed
Verified Answers latest update 2025
The nurse completes a physical assessment. When asked what brought
her to the hospital, the client replies that things just aren't right and
begins to cry. After further conversation, the client describes her
mood as very sad now. She rarely goes out or invites friends to visit.
She admits that she feels like strangers are saying bad things about
her. Sometimes she hears a man's voice that is a little bit scary.
What is the priority focused nursing assessment? --- correct answer ---
Determine how long the client has been hearing the voice and what it
is saying.
Rationale: Determining if voices are being heard and the type of
voices are priority. The nurse must assess the content of the auditory
hallucinations for the presence of command hallucinations. Command
hallucinations may be telling the client to harm herself or others.
The client is assessed by the nurse, a social worker, and the
healthcare provider (HCP). Based on their assessments,
hospitalization is recommended for psychotic depression.
,Which behavior is inconsistent with depression? --- correct answer ---
Hearing a man's voice.
Rationale: Auditory hallucinations are inconsistent with depression
and are more likely to occur with psychoses. However, clients may
experience a psychotic depression in which there is evidence of
psychosis.
The nurse asks the client to sign the consent for treatment.
If the client refuses treatment, which behaviors justify short-term
involuntary treatment? (Select all that apply. One, some, or all options
may be correct.) --- correct answer ---Unable to meet basic self-care
needs.
Rationale: Involuntary treatment can be initiated if the client is
unable to meet basic self-care needs in such a way that he or she is a
danger to self.
States she has a plan to harm herself.
Rationale: Short-term involuntary care may be initiated to protect the
client if she has a plan to harm herself. It can also be initiated if she
presents an intentional danger to others.
The client signs the treatment form and is admitted to the mental
health unit. During the first days of hospitalization, she begins
antidepressant therapy with fluoxetine 10 mg.
,In what classification of drugs is the antidepressant fluoxetine? ---
correct answer ---Selective serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
What is the major action of SSRI antidepressants? --- correct answer --
-Increase availability of serotonin.
Rationale: The major action of SSRIs is to selectively inhibit the
reuptake of serotonin and increase the availability of serotonin.
The nurse understands that SSRIs are now more widely prescribed
than tricyclics for antidepressant therapy. What is the rationale? ---
correct answer ---Tricyclics have more dangerous side effects.
Rationale: SSRIs are more widely prescribed than tricyclics because
they have fewer side effects, and tricyclics can be lethal in an
overdose because they are cardiotoxic.
When the client receives fluoxetine, the nurse must explain the
purpose and when to expect therapeutic effectiveness. What should
the nurse tell the client regarding when she will begin to feel less
depressed? --- correct answer ---Generally within 1 to 4 weeks.
Rationale: In general, it takes 2 to 4 weeks for antidepressant effects
to begin. However, it depends on the individual, and some clients may
feel effects start as soon as 1 week or as late as 4 weeks. It is
suggested that depression occurs when a depletion of
neurotransmitters in the synapse cause the transmitter receptors to
increase. As the antidepressants make more transmitters available, it
, takes the receptors several weeks to return their numbers back to
normal and allow normal synaptic activity.
The nurse should be aware of common side effects of SSRI
antidepressants such as fluoxetine. Which side effect should be
communicated to the client that commonly occur in clients who are
taking SSRI antidepressants? --- correct answer ---Gastrointestinal
disturbances.
Rationale: GI disturbances such as nausea and diarrhea, as well as
genitourinary side effects such as sexual dysfunction, are common
with SSRIs. SSRIs do not have significant anticholinergic,
cardiovascular, or sedative side effects.
The client also begins an atypical antipsychotic, risperidone, because
she reports hearing a "scary voice" upon admission. Although the
client remains very withdrawn and noncommunicative, the nurse
must explain the purpose of risperidone. Which explanation is best? --
- correct answer ---Risperidone will help the think more clearly.
Rationale: Antipsychotic medications target symptoms related to
disorders of thinking such as psychosis and behaviors associated with
agitation and disorganization or speech and behavior.
The nurse is reviewing the client's admission lab work on the third
day of hospitalization. Admission labs include thyroid profile,
urinalysis, chemistry panel, pregnancy test, urine drug screen, and
VDRL (RPR) which tests for venereal disease.
4 Complete 84 Questions with Correct Detailed
Verified Answers latest update 2025
The nurse completes a physical assessment. When asked what brought
her to the hospital, the client replies that things just aren't right and
begins to cry. After further conversation, the client describes her
mood as very sad now. She rarely goes out or invites friends to visit.
She admits that she feels like strangers are saying bad things about
her. Sometimes she hears a man's voice that is a little bit scary.
What is the priority focused nursing assessment? --- correct answer ---
Determine how long the client has been hearing the voice and what it
is saying.
Rationale: Determining if voices are being heard and the type of
voices are priority. The nurse must assess the content of the auditory
hallucinations for the presence of command hallucinations. Command
hallucinations may be telling the client to harm herself or others.
The client is assessed by the nurse, a social worker, and the
healthcare provider (HCP). Based on their assessments,
hospitalization is recommended for psychotic depression.
,Which behavior is inconsistent with depression? --- correct answer ---
Hearing a man's voice.
Rationale: Auditory hallucinations are inconsistent with depression
and are more likely to occur with psychoses. However, clients may
experience a psychotic depression in which there is evidence of
psychosis.
The nurse asks the client to sign the consent for treatment.
If the client refuses treatment, which behaviors justify short-term
involuntary treatment? (Select all that apply. One, some, or all options
may be correct.) --- correct answer ---Unable to meet basic self-care
needs.
Rationale: Involuntary treatment can be initiated if the client is
unable to meet basic self-care needs in such a way that he or she is a
danger to self.
States she has a plan to harm herself.
Rationale: Short-term involuntary care may be initiated to protect the
client if she has a plan to harm herself. It can also be initiated if she
presents an intentional danger to others.
The client signs the treatment form and is admitted to the mental
health unit. During the first days of hospitalization, she begins
antidepressant therapy with fluoxetine 10 mg.
,In what classification of drugs is the antidepressant fluoxetine? ---
correct answer ---Selective serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
What is the major action of SSRI antidepressants? --- correct answer --
-Increase availability of serotonin.
Rationale: The major action of SSRIs is to selectively inhibit the
reuptake of serotonin and increase the availability of serotonin.
The nurse understands that SSRIs are now more widely prescribed
than tricyclics for antidepressant therapy. What is the rationale? ---
correct answer ---Tricyclics have more dangerous side effects.
Rationale: SSRIs are more widely prescribed than tricyclics because
they have fewer side effects, and tricyclics can be lethal in an
overdose because they are cardiotoxic.
When the client receives fluoxetine, the nurse must explain the
purpose and when to expect therapeutic effectiveness. What should
the nurse tell the client regarding when she will begin to feel less
depressed? --- correct answer ---Generally within 1 to 4 weeks.
Rationale: In general, it takes 2 to 4 weeks for antidepressant effects
to begin. However, it depends on the individual, and some clients may
feel effects start as soon as 1 week or as late as 4 weeks. It is
suggested that depression occurs when a depletion of
neurotransmitters in the synapse cause the transmitter receptors to
increase. As the antidepressants make more transmitters available, it
, takes the receptors several weeks to return their numbers back to
normal and allow normal synaptic activity.
The nurse should be aware of common side effects of SSRI
antidepressants such as fluoxetine. Which side effect should be
communicated to the client that commonly occur in clients who are
taking SSRI antidepressants? --- correct answer ---Gastrointestinal
disturbances.
Rationale: GI disturbances such as nausea and diarrhea, as well as
genitourinary side effects such as sexual dysfunction, are common
with SSRIs. SSRIs do not have significant anticholinergic,
cardiovascular, or sedative side effects.
The client also begins an atypical antipsychotic, risperidone, because
she reports hearing a "scary voice" upon admission. Although the
client remains very withdrawn and noncommunicative, the nurse
must explain the purpose of risperidone. Which explanation is best? --
- correct answer ---Risperidone will help the think more clearly.
Rationale: Antipsychotic medications target symptoms related to
disorders of thinking such as psychosis and behaviors associated with
agitation and disorganization or speech and behavior.
The nurse is reviewing the client's admission lab work on the third
day of hospitalization. Admission labs include thyroid profile,
urinalysis, chemistry panel, pregnancy test, urine drug screen, and
VDRL (RPR) which tests for venereal disease.
