HESI MENTAL HEALTH TEST
QUESTIONS AND ANSWERS 19
A 4-year-old child is referred to a mental health clinic for evaluation of hyperactivity and
impulsive behaviors. At the first visit, nursing staff begin observing and assessing the child's
behavior. Which developmental task should the child have achieved by this age? - ANSWERSA
sense of autonomy.
Satisfactory relationships with peers.
The ability to establish goals.
Separation from parents and the ability to socialize.
Rationale:A 4-year-old child should have attained the developmental task of autonomy.
According to Erikson's eight stages of development theory, the second stage is autonomy versus
shame and doubt, which should occur between the ages of 1 and 1/2 to 3 years old.
Unsuccessful resolution of the developmental task at this stage could lead to severe feelings of
self-doubt and an internal independence/fear conflict.
A client seeks assistance at a crisis center. The client describes being extremely anxious and
unable to sleep since helping with clean-up duties at a school where a student fatally shot a
teacher and some classmates. Which intervention is the priority when assisting this client? -
ANSWERSAllow ventilation of feelings.
Refer the client to a member of the clergy.
Advise the client to avoid going near the school for at least six weeks.
Send the client to an emergency department for further evaluation.
Rationale: The client is feeling overwhelmed by feelings associated the crisis. Before initiating
other interventions, the nurse should allow the client to freely express troubling emotions
before exploring habitual coping styles and assisting with problem solving.
,Which interventions should the nurse encourage the client to do to improve their mood? -
ANSWERSParticipate in daily cardio aerobic exercises.
Increase intake of fruits and vegetables.
Create an environment that promotes restful sleep.
Rationale: A well balanced diet, adequate uninterrupted sleep and exercise facilitates stress
reduction and improves physical well-being which in turn positively affects an individual's mood.
A client with stage 3 Alzheimer's disease is living with his son and daughter-in-law. The visiting
nurse is educating the family about the progression of the illness, including "sundown
syndrome," and is assisting with care planning and comfort measures. Which statement by the
daughter-in-law reflects that the teaching has been effective? - ANSWERS"We will have locks
placed at the top of all the outside doors."
Rationale: Placing locks at the top of the doors is an important safety intervention. The term
"sundown syndrome" refers to behaviors that become more pronounced in the evening. Clients
with late stage dementia are prone to wandering, especially at night.
Which nursing diagnosis is the priority for a client who is being treated with lithium? -
ANSWERSRisk for fluid imbalance.
Rationale: Lithium has a narrow therapeutic window in which blood levels should range
between 0.4 and 1.3 mEq/L; levels of 2 mEq/L or greater can result in a life-threatening
emergency. Blood levels are dependent on kidney function, and any change in sodium and
hydration levels affects the excretion of lithium. A decrease in sodium levels can cause an
increase in lithium levels leading to toxicity.
The family and friends of a client with a heroin addiction are planning an intervention meeting
to convince the client to seek help. Which strategy should the group employ to help ensure a
, successful intervention? - ANSWERSMake notes on what to say to the client and rehearse
before the meeting.
Rationale: An intervention is a useful tool to help an addict who is resistant to treatment.
Members of the intervention team should prepare ahead of time, and each member should
write down and rehearse what is to be said to the client.
A client diagnosed with oppositional defiant disorder (ODD) states, "I can't do anything right. I
am worthless." Which is the priority nursing intervention? - ANSWERSAsk the client, "Are you
thinking about harming yourself?"
Rationale: The priority intervention is to determine a client's potential for suicide, so the nurse
should ask the client if self-harm is being considered. If the nurse determines that the client is at
risk, the priority nursing intervention would then include initiating suicide precautions and
notifying the treatment team.
A student nurse working as an aide in a memory care facility asks the charge nurse if there is a
neurobiological basis for the deterioration in cognitive function in Alzheimer's disease. Which
explanation by the nurse is correct regarding the etiology of neurocognitive decline? -
ANSWERS"Decreases in neurotransmitters affect parts of the brain responsible for memory."
Rationale: Neurocognitive decline is associated with changes in neurotransmitter concentration.
Alzheimer's disease has been linked with a decrease in the production and function of
acetylcholine (ACh). Alzheimer's disease affects an area of the brain called the nucleus basalis,
which contains cholinergic neurons. These neurons provide ACh to areas of the brain
responsible for memory and learning.
A client with long-term alcohol addiction is admitted to the emergency department. Which
medications should the nurse anticipate the healthcare provider will prescribe for this client? -
ANSWERSDiazepam.
Multivitamins.
Thiamine (vitamin B1).
QUESTIONS AND ANSWERS 19
A 4-year-old child is referred to a mental health clinic for evaluation of hyperactivity and
impulsive behaviors. At the first visit, nursing staff begin observing and assessing the child's
behavior. Which developmental task should the child have achieved by this age? - ANSWERSA
sense of autonomy.
Satisfactory relationships with peers.
The ability to establish goals.
Separation from parents and the ability to socialize.
Rationale:A 4-year-old child should have attained the developmental task of autonomy.
According to Erikson's eight stages of development theory, the second stage is autonomy versus
shame and doubt, which should occur between the ages of 1 and 1/2 to 3 years old.
Unsuccessful resolution of the developmental task at this stage could lead to severe feelings of
self-doubt and an internal independence/fear conflict.
A client seeks assistance at a crisis center. The client describes being extremely anxious and
unable to sleep since helping with clean-up duties at a school where a student fatally shot a
teacher and some classmates. Which intervention is the priority when assisting this client? -
ANSWERSAllow ventilation of feelings.
Refer the client to a member of the clergy.
Advise the client to avoid going near the school for at least six weeks.
Send the client to an emergency department for further evaluation.
Rationale: The client is feeling overwhelmed by feelings associated the crisis. Before initiating
other interventions, the nurse should allow the client to freely express troubling emotions
before exploring habitual coping styles and assisting with problem solving.
,Which interventions should the nurse encourage the client to do to improve their mood? -
ANSWERSParticipate in daily cardio aerobic exercises.
Increase intake of fruits and vegetables.
Create an environment that promotes restful sleep.
Rationale: A well balanced diet, adequate uninterrupted sleep and exercise facilitates stress
reduction and improves physical well-being which in turn positively affects an individual's mood.
A client with stage 3 Alzheimer's disease is living with his son and daughter-in-law. The visiting
nurse is educating the family about the progression of the illness, including "sundown
syndrome," and is assisting with care planning and comfort measures. Which statement by the
daughter-in-law reflects that the teaching has been effective? - ANSWERS"We will have locks
placed at the top of all the outside doors."
Rationale: Placing locks at the top of the doors is an important safety intervention. The term
"sundown syndrome" refers to behaviors that become more pronounced in the evening. Clients
with late stage dementia are prone to wandering, especially at night.
Which nursing diagnosis is the priority for a client who is being treated with lithium? -
ANSWERSRisk for fluid imbalance.
Rationale: Lithium has a narrow therapeutic window in which blood levels should range
between 0.4 and 1.3 mEq/L; levels of 2 mEq/L or greater can result in a life-threatening
emergency. Blood levels are dependent on kidney function, and any change in sodium and
hydration levels affects the excretion of lithium. A decrease in sodium levels can cause an
increase in lithium levels leading to toxicity.
The family and friends of a client with a heroin addiction are planning an intervention meeting
to convince the client to seek help. Which strategy should the group employ to help ensure a
, successful intervention? - ANSWERSMake notes on what to say to the client and rehearse
before the meeting.
Rationale: An intervention is a useful tool to help an addict who is resistant to treatment.
Members of the intervention team should prepare ahead of time, and each member should
write down and rehearse what is to be said to the client.
A client diagnosed with oppositional defiant disorder (ODD) states, "I can't do anything right. I
am worthless." Which is the priority nursing intervention? - ANSWERSAsk the client, "Are you
thinking about harming yourself?"
Rationale: The priority intervention is to determine a client's potential for suicide, so the nurse
should ask the client if self-harm is being considered. If the nurse determines that the client is at
risk, the priority nursing intervention would then include initiating suicide precautions and
notifying the treatment team.
A student nurse working as an aide in a memory care facility asks the charge nurse if there is a
neurobiological basis for the deterioration in cognitive function in Alzheimer's disease. Which
explanation by the nurse is correct regarding the etiology of neurocognitive decline? -
ANSWERS"Decreases in neurotransmitters affect parts of the brain responsible for memory."
Rationale: Neurocognitive decline is associated with changes in neurotransmitter concentration.
Alzheimer's disease has been linked with a decrease in the production and function of
acetylcholine (ACh). Alzheimer's disease affects an area of the brain called the nucleus basalis,
which contains cholinergic neurons. These neurons provide ACh to areas of the brain
responsible for memory and learning.
A client with long-term alcohol addiction is admitted to the emergency department. Which
medications should the nurse anticipate the healthcare provider will prescribe for this client? -
ANSWERSDiazepam.
Multivitamins.
Thiamine (vitamin B1).
