MENTAL HEALTH HESI EXAM VERSION 4 NEWEST 2024-2025 ACTUAL
EXAM COMPLETE 84 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS)
Study online at https://quizlet.com/_gcahy4
1. 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.
2. 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
depres-sion in which there is evidence of psychosis.
3. 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.
4. 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
, MENTAL HEALTH HESI EXAM VERSION 4 NEWEST 2024-2025 ACTUAL
EXAM COMPLETE 84 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS)
Study online at https://quizlet.com/_gcahy4
serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
5. 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.
6. 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. 7. 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.
8. 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?: Gas-trointestinal 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.
9. 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?: Risperidone will help the think more
clearly.
, Rationale: Antipsychotic medications target symptoms related to disorders of think-
ing such as psychosis and behaviors associated with agitation and disorganization
or speech and behavior.
EXAM COMPLETE 84 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS)
Study online at https://quizlet.com/_gcahy4
1. 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.
2. 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
depres-sion in which there is evidence of psychosis.
3. 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.
4. 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
, MENTAL HEALTH HESI EXAM VERSION 4 NEWEST 2024-2025 ACTUAL
EXAM COMPLETE 84 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS)
Study online at https://quizlet.com/_gcahy4
serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
5. 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.
6. 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. 7. 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.
8. 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?: Gas-trointestinal 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.
9. 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?: Risperidone will help the think more
clearly.
, Rationale: Antipsychotic medications target symptoms related to disorders of think-
ing such as psychosis and behaviors associated with agitation and disorganization
or speech and behavior.
