HESI RN MENTAL HEALTH EXAM 2026/2027. EXAM
SET WITH 100% VERIFIED ANSWERS AND
RATIONALES.
1 .Which step(s) should the nurse take when administering ear drops to an adult
client? (Select all that apply.)
A. Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
A, B
Rationale: The correct answers (A and B) are the appropriate administration of
ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A
cotton ball should be placed in the outermost canal (D). The auricle is pulled
down and back for a child younger than 3 years of age, but not an adult (E).
2. The nurse is using the Glasgow Coma Scale to perform a neurologic
assessment. A comatose client winces and pulls away from a painful stimulus.
Which action should the nurse take next?
A. Document that the client responds to painful stimulus.
B. Observe the client's response to verbal stimulation.
C. Place the client on seizure precautions for 24 hours.
D. Report decorticate posturing to the health care provider
.A
Rationale: The client has demonstrated a purposeful response to pain, which
should be documented as such. Response to painful stimulus is assessed after
response to verbal stimulus, not before. There is no indication for placing the
client on seizure precautions. Reporting decorticate posturing to the health care
provider is non purposeful movement
3 .A client's blood pressure reading is 156/94 mm Hg. Which action should the
nurse take first?
A. Tell the client that the blood pressure is high and that the reading needs to be
verified by another nurse.
B. Contact the health care provider to report the reading and obtain a prescription
for an antihypertensive medication.
,C. Replace the cuff with a larger one to ensure an ample fit for the client to
increase arm comfort.
D. Compare the current reading with the client's previously documented blood
pressure readings.
D
Rationale: Comparing this reading with previous readings will provide
information about what is normal for this client; this action should be taken first.
Option A might unnecessarily alarm the client. Option B is premature. Further
assessment is needed to determine if the reading is abnormal for this client.
Option C could falsely decrease the reading and is not the correct procedure for
obtaining a blood pressure reading
4 .In completing a client's preoperative routine, the nurse finds that the operative
permit is not signed. The client begins to ask more questions about the surgical
procedure. Which action should the nurse take next?
A. Witness the client's signature to the permit.
B. Answer the client's questions about the surgery.
C. Inform the surgeon that the operative permit is not signed and the client has
questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before the
anesthesia is administered.
C
Rationale: The surgeon should be informed immediately that the permit is not
signed. It is the surgeon's responsibility to explain the procedure to the client and
obtain the client's signature on the permit. Although the nurse can witness an
operative permit, the procedure must first be explained by the health care
provider or surgeon, including answering the client's questions. The client's
questions should be addressed before the permit is signed.
5
The nurse is assessing several clients prior to surgery. Which factor in a client's
history poses the greatest threat for complications to occur during surgery?
A. Taking birth control pills for the past 2 years
B. Taking anticoagulants for the past year
C. Recently completing antibiotic therapy
D. Having taken laxatives PRN for the last 6 months
B
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a
threat for the development of surgical complications. The health care provider
should be informed that the client is taking these drugs. Although clients who
take birth control pills may be more susceptible to the development of thrombi,
such problems usually occur postoperatively. A client with option C or D is at
less of a surgical risk than with option B.
, 6
When assisting a client from the bed to a chair, which procedure is best for the
nurse to follow?
A. Place the chair parallel to the bed, with its back toward the head of the bed and
assist the client in moving to the chair.
B. With the nurse's feet spread apart and knees aligned with the client's knees,
stand and pivot the client into the chair.
C. Assist the client to a standing position by gently lifting upward, underneath the
axillae.
D. Stand beside the client, place the client's arms around the nurse's neck, and
gently move the client to the chair.
B
Rationale: Option B describes the correct positioning of the nurse and affords the
nurse a wide base of support while stabilizing the client's knees when assisting
to a standing position. The chair should be placed at a 45-degree angle to the
bed, with the back of the chair toward the head of the bed. Clients should never
be lifted under the axillae; this could damage nerves and strain the nurse's back.
The client should be instructed to use the arms of the chair and should never
place his or her arms around the nurse's neck; this places undue stress on the
nurse's neck and back and increases the risk for a fall.
7 .When turning an immobile bedridden client without assistance, which action by
the nurse best ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly.
B
Rationale: Because the nurse can only stand on one side of the bed, bed rails
should be up on the opposite side to ensure that the client does not fall out of
bed. Option A can cause client injury to the skin or joint. Options C and D are
useful techniques while turning a client but have less priority in terms of safety
than use of the bed rails.
8
The nurse is instructing a client in the proper use of a metered-dose inhaler.
Which instruction should the nurse provide the client to ensure the optimal
benefits from the drug?
A. "Fill your lungs with air through your mouth and then compress the inhaler."
B. "Compress the inhaler while slowly breathing in through your mouth."
C. "Compress the inhaler while inhaling quickly through your nose."
D. "Exhale completely after compressing the inhaler and then inhale."
B
Rationale: The medication should be inhaled through the mouth simultaneously
with compression of the inhaler. This will facilitate the desired destination of the
SET WITH 100% VERIFIED ANSWERS AND
RATIONALES.
1 .Which step(s) should the nurse take when administering ear drops to an adult
client? (Select all that apply.)
A. Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
A, B
Rationale: The correct answers (A and B) are the appropriate administration of
ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A
cotton ball should be placed in the outermost canal (D). The auricle is pulled
down and back for a child younger than 3 years of age, but not an adult (E).
2. The nurse is using the Glasgow Coma Scale to perform a neurologic
assessment. A comatose client winces and pulls away from a painful stimulus.
Which action should the nurse take next?
A. Document that the client responds to painful stimulus.
B. Observe the client's response to verbal stimulation.
C. Place the client on seizure precautions for 24 hours.
D. Report decorticate posturing to the health care provider
.A
Rationale: The client has demonstrated a purposeful response to pain, which
should be documented as such. Response to painful stimulus is assessed after
response to verbal stimulus, not before. There is no indication for placing the
client on seizure precautions. Reporting decorticate posturing to the health care
provider is non purposeful movement
3 .A client's blood pressure reading is 156/94 mm Hg. Which action should the
nurse take first?
A. Tell the client that the blood pressure is high and that the reading needs to be
verified by another nurse.
B. Contact the health care provider to report the reading and obtain a prescription
for an antihypertensive medication.
,C. Replace the cuff with a larger one to ensure an ample fit for the client to
increase arm comfort.
D. Compare the current reading with the client's previously documented blood
pressure readings.
D
Rationale: Comparing this reading with previous readings will provide
information about what is normal for this client; this action should be taken first.
Option A might unnecessarily alarm the client. Option B is premature. Further
assessment is needed to determine if the reading is abnormal for this client.
Option C could falsely decrease the reading and is not the correct procedure for
obtaining a blood pressure reading
4 .In completing a client's preoperative routine, the nurse finds that the operative
permit is not signed. The client begins to ask more questions about the surgical
procedure. Which action should the nurse take next?
A. Witness the client's signature to the permit.
B. Answer the client's questions about the surgery.
C. Inform the surgeon that the operative permit is not signed and the client has
questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before the
anesthesia is administered.
C
Rationale: The surgeon should be informed immediately that the permit is not
signed. It is the surgeon's responsibility to explain the procedure to the client and
obtain the client's signature on the permit. Although the nurse can witness an
operative permit, the procedure must first be explained by the health care
provider or surgeon, including answering the client's questions. The client's
questions should be addressed before the permit is signed.
5
The nurse is assessing several clients prior to surgery. Which factor in a client's
history poses the greatest threat for complications to occur during surgery?
A. Taking birth control pills for the past 2 years
B. Taking anticoagulants for the past year
C. Recently completing antibiotic therapy
D. Having taken laxatives PRN for the last 6 months
B
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a
threat for the development of surgical complications. The health care provider
should be informed that the client is taking these drugs. Although clients who
take birth control pills may be more susceptible to the development of thrombi,
such problems usually occur postoperatively. A client with option C or D is at
less of a surgical risk than with option B.
, 6
When assisting a client from the bed to a chair, which procedure is best for the
nurse to follow?
A. Place the chair parallel to the bed, with its back toward the head of the bed and
assist the client in moving to the chair.
B. With the nurse's feet spread apart and knees aligned with the client's knees,
stand and pivot the client into the chair.
C. Assist the client to a standing position by gently lifting upward, underneath the
axillae.
D. Stand beside the client, place the client's arms around the nurse's neck, and
gently move the client to the chair.
B
Rationale: Option B describes the correct positioning of the nurse and affords the
nurse a wide base of support while stabilizing the client's knees when assisting
to a standing position. The chair should be placed at a 45-degree angle to the
bed, with the back of the chair toward the head of the bed. Clients should never
be lifted under the axillae; this could damage nerves and strain the nurse's back.
The client should be instructed to use the arms of the chair and should never
place his or her arms around the nurse's neck; this places undue stress on the
nurse's neck and back and increases the risk for a fall.
7 .When turning an immobile bedridden client without assistance, which action by
the nurse best ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly.
B
Rationale: Because the nurse can only stand on one side of the bed, bed rails
should be up on the opposite side to ensure that the client does not fall out of
bed. Option A can cause client injury to the skin or joint. Options C and D are
useful techniques while turning a client but have less priority in terms of safety
than use of the bed rails.
8
The nurse is instructing a client in the proper use of a metered-dose inhaler.
Which instruction should the nurse provide the client to ensure the optimal
benefits from the drug?
A. "Fill your lungs with air through your mouth and then compress the inhaler."
B. "Compress the inhaler while slowly breathing in through your mouth."
C. "Compress the inhaler while inhaling quickly through your nose."
D. "Exhale completely after compressing the inhaler and then inhale."
B
Rationale: The medication should be inhaled through the mouth simultaneously
with compression of the inhaler. This will facilitate the desired destination of the
