HESI MENTAL HEALTH EXAMINATION
2025/2026
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? - 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? - 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.) -
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? - Selective
serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
What is the major action of SSRI antidepressants? - 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? - 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? - 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? - 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
2025/2026
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? - 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? - 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.) -
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? - Selective
serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
What is the major action of SSRI antidepressants? - 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? - 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? - 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? - 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
