MENTAL HEALTH HESI EXAM
VERSION 4 QUESTIONS WITH
CORRECT DETAILED ANSWERS ||
ALREADY GRADED A+ < LATEST
VERSION >
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? - 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.
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? - 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.
3. When should the nurse begin assessing for withdrawal? - ANSWER 🗸
Within 8 to 12 hours of the client's last drink.
Rationale: Early alcohol withdrawal can begin as early as 4 to 6 hours after
substance use is stopped.
4. Which should the nurse anticipate if the client experiences symptoms of
early withdrawal from alcohol? - ANSWER 🗸 Tremors, nausea, and
vomiting.
Rationale: In addition to tremors, nausea, and vomiting, other symptoms of
early withdrawal include elevated vital signs, diaphoresis, insomnia,
combativeness, agitation, and decreased concentration.
5. What mechanism of action accounts for symptoms of alcohol withdrawal
delirium? - ANSWER 🗸 Increased dopamine.
Rationale: Alcohol intake represses gamma-aminobutyric acid (GABA),
which inhibits dopamine. When alcohol is eliminated, dopamine rebounds
above the normal level, resulting in excitation and alterations in thought,
perception, and orientation.
6. Eight hours after admission, a new nurse is assigned to care for the client.
After receiving report, the nurse reviews the recent information in the chart.
Vital Signs
Blood pressure 146/98 mmHg
Heart rate 100 beats/min
Respirations 22 breaths/min
Temperature 99.8° F (37.7° C)
Laboratory Data
AST: 80 U/L (1.34 µkat/L)
ALT: 96 U/L (1.60 µkat/L)
Sodium: 145 mEq/L (145 mmol/L)
Potassium: 3.6 mEq/L (3.6 mmol/L)
Prescriptions
1. Perform withdrawal assessment every 4 hours.
2. Lorazepam 2 mg PO every 6 hours prn per alcohol withdrawal protocol.
3. Continue suicide precautions.
, The nurse performs the withdrawal assessment and observes moderate
tremors. The client reports nausea.
Which interventions should the nurse implement? (Select all that apply.) -
ANSWER 🗸 Administer lorazepam 2 mg PO.
Rationale: The client has compromised liver function; therefore, a short-
acting benzodiazepine such as lorazepam is best to give for withdrawal
because it does not have active metabolites that can affect a diseased liver.
Lorazepam is often given if a client has known liver disease or decreased
liver function.
Reassess vital signs in 2 hours.
Rationale: The nurse can reassess the vital signs to monitor for changes.
Provide an antiemetic.
Rationale: The client reports feeling nauseous, so administering an
antiemetic is advised.
7. What is the therapeutic action of benzodiazepines? - ANSWER 🗸 Potentiate
the effects of GABA.
Rationale: Benzodiazepines potentiate the effects of GABA, which has a
calming effect.
8. What is the rationale for giving thiamine (B1) and a multivitamin? -
ANSWER 🗸 Reduce the risk of Wernicke disease.
Rationale: Vitamin B deficiency is common in clients diagnosed with
alcoholism. The small intestine is a major site of alcohol absorption, which
interferes with adequate thiamine and all B vitamin absorption. Vitamin B
deficiency can cause Wernicke disease.
9. A mental health technician arrives to help the client take a shower. The
technician gathers towels and shower items, then helps the client to the
shower. When entering the shower, the client slips and falls to the floor. The
technician reports the incident to the nurse. The nurse assesses the client
who denies suffering any injuries. The nurse documents the assessment,
which includes a full set of vital signs, and then notifies the healthcare
provider (HCP). The nurse knows an adverse event report must be
completed.
, Who should the nurse ask to complete the adverse event report? - ANSWER
🗸 The technician helping at the time of the accident needs to complete the
report.
Rationale: The nurse should ask the technician to complete the report
because the technician witnessed the client's fall.
10.After 3 days in the crisis stabilization unit, the client exhibits no further
withdrawal symptoms. The nurse collaborates with the social worker and the
HCP to determine discharge plans. The client wants to return to work as
soon as possible. The client describes work as being a trigger for drinking
and asks the nurse what can be done to prevent a relapse.
Which response by the nurse is accurate? - ANSWER 🗸 Disulfiram inhibits
absorption of alcohol.
Rationale: Disulfiram inhibits the absorption of alcohol and raises the level
of acetaldehyde, causing a severe reaction when alcohol is ingested.
11.Which nursing intervention is most important to implement before
disulfiram therapy? - ANSWER 🗸 Obtain the client's written consent to
comply with facility protocol.
Rationale: Informed consent must be obtained to receive disulfiram therapy,
or documentation can be noted in the chart that education was given about
potential serious complications that can occur if client does not abstain from
drinking.
12.What are the ramifications of drinking alcohol while taking disulfiram?
(Select all that apply.) - ANSWER 🗸 Severe headache.
Rationale: A severe headache is one of the unpleasant consequences of
drinking alcohol while taking disulfiram, an aldehyde dehydrogenase
inhibitor.
Nausea and vomiting.
Rationale: Nausea and vomiting are unpleasant consequences of drinking
alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor.
Chest pain.
Rationale: Chest pain is an unpleasant consequence of drinking alcohol
while taking disulfiram, an aldehyde dehydrogenase inhibitor.
Hypotension.
Rationale: Hypotension is an unpleasant consequence of drinking alcohol
while taking disulfiram, an aldehyde dehydrogenase inhibitor.
VERSION 4 QUESTIONS WITH
CORRECT DETAILED ANSWERS ||
ALREADY GRADED A+ < LATEST
VERSION >
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? - 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.
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? - 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.
3. When should the nurse begin assessing for withdrawal? - ANSWER 🗸
Within 8 to 12 hours of the client's last drink.
Rationale: Early alcohol withdrawal can begin as early as 4 to 6 hours after
substance use is stopped.
4. Which should the nurse anticipate if the client experiences symptoms of
early withdrawal from alcohol? - ANSWER 🗸 Tremors, nausea, and
vomiting.
Rationale: In addition to tremors, nausea, and vomiting, other symptoms of
early withdrawal include elevated vital signs, diaphoresis, insomnia,
combativeness, agitation, and decreased concentration.
5. What mechanism of action accounts for symptoms of alcohol withdrawal
delirium? - ANSWER 🗸 Increased dopamine.
Rationale: Alcohol intake represses gamma-aminobutyric acid (GABA),
which inhibits dopamine. When alcohol is eliminated, dopamine rebounds
above the normal level, resulting in excitation and alterations in thought,
perception, and orientation.
6. Eight hours after admission, a new nurse is assigned to care for the client.
After receiving report, the nurse reviews the recent information in the chart.
Vital Signs
Blood pressure 146/98 mmHg
Heart rate 100 beats/min
Respirations 22 breaths/min
Temperature 99.8° F (37.7° C)
Laboratory Data
AST: 80 U/L (1.34 µkat/L)
ALT: 96 U/L (1.60 µkat/L)
Sodium: 145 mEq/L (145 mmol/L)
Potassium: 3.6 mEq/L (3.6 mmol/L)
Prescriptions
1. Perform withdrawal assessment every 4 hours.
2. Lorazepam 2 mg PO every 6 hours prn per alcohol withdrawal protocol.
3. Continue suicide precautions.
, The nurse performs the withdrawal assessment and observes moderate
tremors. The client reports nausea.
Which interventions should the nurse implement? (Select all that apply.) -
ANSWER 🗸 Administer lorazepam 2 mg PO.
Rationale: The client has compromised liver function; therefore, a short-
acting benzodiazepine such as lorazepam is best to give for withdrawal
because it does not have active metabolites that can affect a diseased liver.
Lorazepam is often given if a client has known liver disease or decreased
liver function.
Reassess vital signs in 2 hours.
Rationale: The nurse can reassess the vital signs to monitor for changes.
Provide an antiemetic.
Rationale: The client reports feeling nauseous, so administering an
antiemetic is advised.
7. What is the therapeutic action of benzodiazepines? - ANSWER 🗸 Potentiate
the effects of GABA.
Rationale: Benzodiazepines potentiate the effects of GABA, which has a
calming effect.
8. What is the rationale for giving thiamine (B1) and a multivitamin? -
ANSWER 🗸 Reduce the risk of Wernicke disease.
Rationale: Vitamin B deficiency is common in clients diagnosed with
alcoholism. The small intestine is a major site of alcohol absorption, which
interferes with adequate thiamine and all B vitamin absorption. Vitamin B
deficiency can cause Wernicke disease.
9. A mental health technician arrives to help the client take a shower. The
technician gathers towels and shower items, then helps the client to the
shower. When entering the shower, the client slips and falls to the floor. The
technician reports the incident to the nurse. The nurse assesses the client
who denies suffering any injuries. The nurse documents the assessment,
which includes a full set of vital signs, and then notifies the healthcare
provider (HCP). The nurse knows an adverse event report must be
completed.
, Who should the nurse ask to complete the adverse event report? - ANSWER
🗸 The technician helping at the time of the accident needs to complete the
report.
Rationale: The nurse should ask the technician to complete the report
because the technician witnessed the client's fall.
10.After 3 days in the crisis stabilization unit, the client exhibits no further
withdrawal symptoms. The nurse collaborates with the social worker and the
HCP to determine discharge plans. The client wants to return to work as
soon as possible. The client describes work as being a trigger for drinking
and asks the nurse what can be done to prevent a relapse.
Which response by the nurse is accurate? - ANSWER 🗸 Disulfiram inhibits
absorption of alcohol.
Rationale: Disulfiram inhibits the absorption of alcohol and raises the level
of acetaldehyde, causing a severe reaction when alcohol is ingested.
11.Which nursing intervention is most important to implement before
disulfiram therapy? - ANSWER 🗸 Obtain the client's written consent to
comply with facility protocol.
Rationale: Informed consent must be obtained to receive disulfiram therapy,
or documentation can be noted in the chart that education was given about
potential serious complications that can occur if client does not abstain from
drinking.
12.What are the ramifications of drinking alcohol while taking disulfiram?
(Select all that apply.) - ANSWER 🗸 Severe headache.
Rationale: A severe headache is one of the unpleasant consequences of
drinking alcohol while taking disulfiram, an aldehyde dehydrogenase
inhibitor.
Nausea and vomiting.
Rationale: Nausea and vomiting are unpleasant consequences of drinking
alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor.
Chest pain.
Rationale: Chest pain is an unpleasant consequence of drinking alcohol
while taking disulfiram, an aldehyde dehydrogenase inhibitor.
Hypotension.
Rationale: Hypotension is an unpleasant consequence of drinking alcohol
while taking disulfiram, an aldehyde dehydrogenase inhibitor.
