MENTAL HEALTH HESI EXAM VERSION 4 NEWEST 2024-2025 ACTUAL
EXAM COMPLETE 84 QUESTIONS AND CORRECT DETAILED ANSWER
(VERIFIED ANSWERS)
Study online at https://quizlet.com/_fqh3gl
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 ANSWER
(VERIFIED ANSWERS)
Study online at https://quizlet.com/_fqh3gl
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.
, MENTAL HEALTH HESI EXAM VERSION 4 NEWEST 2024-2025 ACTUAL
EXAM COMPLETE 84 QUESTIONS AND CORRECT DETAILED ANSWER
(VERIFIED ANSWERS)
Study online at https://quizlet.com/_fqh3gl
10. The nurse is reviewing the client's admission lab work on the third day of
hospitalization. Admission labs include thyroid profile, urinalysis, chemistry
panel, pregnancy test, urine drug screen, and VDRL (RPR) which tests for
venereal disease.
A thyroid profile is important for several reasons. What role do thyroid levels
play in depression?: Hypothyroidism can lead to feeling sluggish and depressed.
Rationale: Thyroid levels can help detect hypothyroidism, which can lead to depres-
sion.
11. The nurse understands that a VDRL is routinely done on admission for
which reason?: It is a screening test for syphilis.
Rationale: A VDRL (RPR) is a serum screening test for syphilis, which can be
undetected and dormant and can cause cognitive impairment in later stages. If
the screening serum test is positive, a more specific test is required to make the
diagnosis of syphilis.
12. When the client awakens in the morning, she sits for periods of time at the
edge of her bed. She does not initiate combing her hair, getting dressed, or
going to breakfast. Which intervention should the nurse implement?: Help the
client with daily activities.
Rationale: When a client is very depressed, it is necessary to assist with daily
activities because the client has decreased energy. Physical care is more important
with severe depression.
13. Since the client has decreased energy, which additional intervention
should the nurse implement?: Plan a scheduled rest period.
Rationale: It is best to plan rest periods according to the client's energy level because
some clients feel best in the morning and others feel best in the evening.
14. As the nurse initially communicates with the client, which communication
technique is important?: Acknowledge the client's courage in seeking help, then
offer to sit quietly with the client.
Rationale: Offering nonjudgmental acceptance and companionship will help develop
trust. Acknowledging the step the client took in seeking help may restore the client's
sense of control over her situation.
15. According to the nursing progress notes, the client demonstrates de-
creased social interaction, she rarely talks, she needs assistance to her room
and appears confused. The client only slept 30 minutes in the past 24 hours,
and the daily graphics indicate that she has slept an average of 2 hours in the
past week. She is eating 50% of her meals.
