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2025 HESI RN Mental Health Exit
Exam – Real Questions with 100%
Verified Answers and Detailed
Rationales | Latest Update
1. A client with schizophrenia reports hearing voices that command them to harm
themselves. What is the nurse’s priority action?
A. Administer an extra dose of the prescribed antipsychotic medication.
B. Place the client on one-to-one observation.
C. Encourage the client to ignore the voices.
D. Ask the client to describe their daily routine.
Correct Answer: B. Place the client on one-to-one observation.
Rationale: Command hallucinations pose an immediate risk of self-harm or
harm to others, making safety the priority. One-to-one observation ensures constant
monitoring to prevent the client from acting on the voices. Administering extra
medication is unsafe without a provider’s order, ignoring voices does not address
the immediate risk, and discussing daily routines is not a priority in this crisis
situation.
2. A client with major depressive disorder (MDD) expresses feelings of hopelessness and
suicidal ideation. Which nursing intervention is most appropriate?
A. Encourage the client to participate in group activities.
B. Develop a no-suicide contract with the client.
C. Administer a selective serotonin reuptake inhibitor (SSRI) immediately.
D. Teach the client coping skills for stress management.
Correct Answer: B. Develop a no-suicide contract with the client.
Rationale: Suicidal ideation indicates a high risk for self-harm, and a no-suicide
contract is a priority intervention to ensure the client’s safety by establishing a
verbal or written agreement to seek help instead of acting on suicidal thoughts.
Group activities and coping skills are not immediate priorities, and nurses cannot
administer medications without a prescription.
3. A client with bipolar disorder is in a manic phase and exhibits rapid speech and agitation.
Which intervention should the nurse implement first?
A. Administer a prescribed mood stabilizer.
B. Place the client in a seclusion room.
C. Provide a calm, low-stimulus environment.
D. Engage the client in a group therapy session.
Correct Answer: C. Provide a calm, low-stimulus environment.
Rationale: During a manic episode, reducing environmental stimuli helps de-
escalate agitation and promote safety. Administering medication may be necessary
but is not the first step without assessing the environment. Seclusion is a last resort,
and group therapy may overstimulate the client.
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4. A client with generalized anxiety disorder (GAD) reports difficulty sleeping and constant
worry. Which statement by the nurse demonstrates therapeutic communication?
A. “You need to stop worrying so much.”
B. “Tell me more about what’s been keeping you up at night.”
C. “Everyone feels anxious sometimes; it’s normal.”
D. “Try to focus on something else to distract yourself.”
Correct Answer: B. Tell me more about what’s been keeping you up at night.”
Rationale: This open-ended question encourages the client to express their
feelings, fostering trust and understanding. Option A is dismissive, option C
minimizes the client’s concerns, and option D offers nontherapeutic advice.
5. A client with post-traumatic stress disorder (PTSD) experiences a flashback during a
therapy session. What is the nurse’s best response?
A. Restrain the client to prevent injury.
B. Speak calmly and reorient the client to the present.
C. Administer a PRN antianxiety medication.
D. Leave the room to give the client space.
Correct Answer: B. Speak calmly and reorient the client to the present.
Rationale: During a flashback, the client may feel they are reliving the trauma.
Speaking calmly and reorienting them to the present helps ground them and reduce
distress. Restraining is inappropriate unless there is an immediate safety risk,
medication is not the first intervention, and leaving the client alone may increase
fear.
6. A client taking lithium carbonate for bipolar disorder reports nausea and tremors. What is
the nurse’s priority action?
A. Administer an antiemetic medication.
B. Check the client’s lithium levels.
C. Encourage the client to drink more water.
D. Document the symptoms as expected side effects.
Correct Answer: B. Check the client’s lithium levels.
Rationale: Nausea and tremors may indicate lithium toxicity, which requires
immediate assessment of serum lithium levels. Administering an antiemetic or
increasing water intake does not address the potential toxicity, and documenting
without investigation could delay critical intervention.
7. A client with obsessive-compulsive disorder (OCD) spends hours performing rituals.
Which nursing intervention is most effective?
A. Interrupt the rituals to break the cycle.
B. Allow the client unlimited time for rituals.
C. Set time limits for rituals with the client’s input.
D. Tell the client their rituals are unnecessary.
Correct Answer: C. Set time limits for rituals with the client’s input.
Rationale: Setting time limits collaboratively respects the client’s needs while
gradually reducing ritual time, promoting therapeutic progress. Interrupting rituals
may increase anxiety, allowing unlimited time reinforces the behavior, and
dismissing rituals is nontherapeutic.
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8. A client with schizophrenia is prescribed risperidone. Which side effect should the nurse
monitor for?
A. Weight loss
B. Extrapyramidal symptoms (EPS)
C. Increased libido
D. Hypotension
Correct Answer: B. Extrapyramidal symptoms (EPS)
Rationale: Risperidone, an atypical antipsychotic, can cause EPS such as
tremors, rigidity, or dystonia. Weight loss is not typical (weight gain is more
common), increased libido is not a known side effect, and while hypotension can
occur, EPS is a more significant concern requiring monitoring.
9. A nurse is caring for a client with anorexia nervosa who refuses to eat. What is the
priority nursing action?
A. Force-feed the client to ensure nutrition.
B. Monitor the client’s weight daily.
C. Establish a therapeutic relationship with the client.
D. Restrict the client’s physical activity.
Correct Answer: C. Establish a therapeutic relationship with the client.
Rationale: Building trust is essential to encourage the client to engage in
treatment and address underlying issues. Force-feeding is unethical and traumatic,
monitoring weight is important but not the priority, and restricting activity does not
address the immediate need for therapeutic rapport.
10. A client with substance use disorder is admitted for detoxification. Which assessment
finding requires immediate intervention?
A. Blood pressure of 120/80 mmHg
B. Tremors and diaphoresis
C. Mild anxiety
D. Heart rate of 80 bpm
Correct Answer: B. Tremors and diaphoresis
Rationale: Tremors and diaphoresis indicate potential withdrawal symptoms,
which can be life-threatening (e.g., delirium tremens in alcohol withdrawal).
Immediate intervention is needed to prevent complications. The other findings are
within normal limits or less urgent.
11. A client with borderline personality disorder (BPD) becomes angry and accuses the nurse
of not caring. What is the nurse’s best response?
A. “I’m doing my best to help you.”
B. “Your accusations are unfair.”
C. “I can see you’re upset; let’s talk about what’s going on.”
D. “You need to calm down before we can talk.”
Correct Answer: C. I can see you’re upset; let’s talk about what’s going on.”
Rationale: Acknowledging the client’s emotions and inviting discussion is
therapeutic and de-escalates the situation. Options A and B are defensive, and
option D dismisses the client’s feelings, potentially escalating anger.
12. A client with dementia is agitated and wandering. Which intervention should the nurse
implement?
2025 HESI RN Mental Health Exit
Exam – Real Questions with 100%
Verified Answers and Detailed
Rationales | Latest Update
1. A client with schizophrenia reports hearing voices that command them to harm
themselves. What is the nurse’s priority action?
A. Administer an extra dose of the prescribed antipsychotic medication.
B. Place the client on one-to-one observation.
C. Encourage the client to ignore the voices.
D. Ask the client to describe their daily routine.
Correct Answer: B. Place the client on one-to-one observation.
Rationale: Command hallucinations pose an immediate risk of self-harm or
harm to others, making safety the priority. One-to-one observation ensures constant
monitoring to prevent the client from acting on the voices. Administering extra
medication is unsafe without a provider’s order, ignoring voices does not address
the immediate risk, and discussing daily routines is not a priority in this crisis
situation.
2. A client with major depressive disorder (MDD) expresses feelings of hopelessness and
suicidal ideation. Which nursing intervention is most appropriate?
A. Encourage the client to participate in group activities.
B. Develop a no-suicide contract with the client.
C. Administer a selective serotonin reuptake inhibitor (SSRI) immediately.
D. Teach the client coping skills for stress management.
Correct Answer: B. Develop a no-suicide contract with the client.
Rationale: Suicidal ideation indicates a high risk for self-harm, and a no-suicide
contract is a priority intervention to ensure the client’s safety by establishing a
verbal or written agreement to seek help instead of acting on suicidal thoughts.
Group activities and coping skills are not immediate priorities, and nurses cannot
administer medications without a prescription.
3. A client with bipolar disorder is in a manic phase and exhibits rapid speech and agitation.
Which intervention should the nurse implement first?
A. Administer a prescribed mood stabilizer.
B. Place the client in a seclusion room.
C. Provide a calm, low-stimulus environment.
D. Engage the client in a group therapy session.
Correct Answer: C. Provide a calm, low-stimulus environment.
Rationale: During a manic episode, reducing environmental stimuli helps de-
escalate agitation and promote safety. Administering medication may be necessary
but is not the first step without assessing the environment. Seclusion is a last resort,
and group therapy may overstimulate the client.
, 2
4. A client with generalized anxiety disorder (GAD) reports difficulty sleeping and constant
worry. Which statement by the nurse demonstrates therapeutic communication?
A. “You need to stop worrying so much.”
B. “Tell me more about what’s been keeping you up at night.”
C. “Everyone feels anxious sometimes; it’s normal.”
D. “Try to focus on something else to distract yourself.”
Correct Answer: B. Tell me more about what’s been keeping you up at night.”
Rationale: This open-ended question encourages the client to express their
feelings, fostering trust and understanding. Option A is dismissive, option C
minimizes the client’s concerns, and option D offers nontherapeutic advice.
5. A client with post-traumatic stress disorder (PTSD) experiences a flashback during a
therapy session. What is the nurse’s best response?
A. Restrain the client to prevent injury.
B. Speak calmly and reorient the client to the present.
C. Administer a PRN antianxiety medication.
D. Leave the room to give the client space.
Correct Answer: B. Speak calmly and reorient the client to the present.
Rationale: During a flashback, the client may feel they are reliving the trauma.
Speaking calmly and reorienting them to the present helps ground them and reduce
distress. Restraining is inappropriate unless there is an immediate safety risk,
medication is not the first intervention, and leaving the client alone may increase
fear.
6. A client taking lithium carbonate for bipolar disorder reports nausea and tremors. What is
the nurse’s priority action?
A. Administer an antiemetic medication.
B. Check the client’s lithium levels.
C. Encourage the client to drink more water.
D. Document the symptoms as expected side effects.
Correct Answer: B. Check the client’s lithium levels.
Rationale: Nausea and tremors may indicate lithium toxicity, which requires
immediate assessment of serum lithium levels. Administering an antiemetic or
increasing water intake does not address the potential toxicity, and documenting
without investigation could delay critical intervention.
7. A client with obsessive-compulsive disorder (OCD) spends hours performing rituals.
Which nursing intervention is most effective?
A. Interrupt the rituals to break the cycle.
B. Allow the client unlimited time for rituals.
C. Set time limits for rituals with the client’s input.
D. Tell the client their rituals are unnecessary.
Correct Answer: C. Set time limits for rituals with the client’s input.
Rationale: Setting time limits collaboratively respects the client’s needs while
gradually reducing ritual time, promoting therapeutic progress. Interrupting rituals
may increase anxiety, allowing unlimited time reinforces the behavior, and
dismissing rituals is nontherapeutic.
, 3
8. A client with schizophrenia is prescribed risperidone. Which side effect should the nurse
monitor for?
A. Weight loss
B. Extrapyramidal symptoms (EPS)
C. Increased libido
D. Hypotension
Correct Answer: B. Extrapyramidal symptoms (EPS)
Rationale: Risperidone, an atypical antipsychotic, can cause EPS such as
tremors, rigidity, or dystonia. Weight loss is not typical (weight gain is more
common), increased libido is not a known side effect, and while hypotension can
occur, EPS is a more significant concern requiring monitoring.
9. A nurse is caring for a client with anorexia nervosa who refuses to eat. What is the
priority nursing action?
A. Force-feed the client to ensure nutrition.
B. Monitor the client’s weight daily.
C. Establish a therapeutic relationship with the client.
D. Restrict the client’s physical activity.
Correct Answer: C. Establish a therapeutic relationship with the client.
Rationale: Building trust is essential to encourage the client to engage in
treatment and address underlying issues. Force-feeding is unethical and traumatic,
monitoring weight is important but not the priority, and restricting activity does not
address the immediate need for therapeutic rapport.
10. A client with substance use disorder is admitted for detoxification. Which assessment
finding requires immediate intervention?
A. Blood pressure of 120/80 mmHg
B. Tremors and diaphoresis
C. Mild anxiety
D. Heart rate of 80 bpm
Correct Answer: B. Tremors and diaphoresis
Rationale: Tremors and diaphoresis indicate potential withdrawal symptoms,
which can be life-threatening (e.g., delirium tremens in alcohol withdrawal).
Immediate intervention is needed to prevent complications. The other findings are
within normal limits or less urgent.
11. A client with borderline personality disorder (BPD) becomes angry and accuses the nurse
of not caring. What is the nurse’s best response?
A. “I’m doing my best to help you.”
B. “Your accusations are unfair.”
C. “I can see you’re upset; let’s talk about what’s going on.”
D. “You need to calm down before we can talk.”
Correct Answer: C. I can see you’re upset; let’s talk about what’s going on.”
Rationale: Acknowledging the client’s emotions and inviting discussion is
therapeutic and de-escalates the situation. Options A and B are defensive, and
option D dismisses the client’s feelings, potentially escalating anger.
12. A client with dementia is agitated and wandering. Which intervention should the nurse
implement?
