All the Versions of HESI RN Mental Heath

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Sample questions from All the Versions of HESI RN Mental Heath

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 24-year-old client in the emergency department says, "I have enough pills at home to end everything tonight." The client appears calm, has a heart rate of 88/min, and asks to leave. Which action should the nurse take first?

   • A.Ask the client to sign an agreement not to attempt suicide.
   • B.Initiate continuous observation and secure potential means of self-harm.
   • C.Arrange a routine outpatient appointment for the next morning.
   • D.Encourage the client to describe three reasons for living.

   Rationale: A specific suicide plan, available means, and stated timing require immediate safety precautions and urgent evaluation. A safety agreement does not reliably prevent suicide, and routine outpatient follow-up is inadequate for this level of risk. Exploring reasons for living can support treatment but must not delay protection. The exam takeaway is to prioritize immediate safety over apparent calmness or verbal reassurance.

2. 2.A 46-year-old client hospitalized for major depressive disorder has spent a week withdrawn and expressing hopelessness. Today, the client is energetic, gives away a favorite watch, and says, "My problems will be over soon." Vital signs are stable. Which response is the priority?

   • A.Document the behavior as evidence that antidepressant treatment is effective.
   • B.Encourage participation in an afternoon recreation group.
   • C.Ask directly about suicidal thoughts, intent, and access to means.
   • D.Discuss discharge arrangements with the client's family.

   Rationale: Increased energy, giving away possessions, and statements suggesting finality warrant direct suicide assessment. These findings should not automatically be interpreted as recovery or used to justify discharge planning. Group participation does not address the immediate risk. The exam takeaway is that suicide risk can increase when energy improves before hopelessness resolves.

3. 3.A 31-year-old client in an inpatient psychiatric unit reports, "The voice says I must stab my roommate before midnight." The client is pacing and repeatedly looking toward the roommate's room. Which nursing action is most appropriate?

   • A.Assess intent and ability to resist the command while maintaining observation and separating the clients.
   • B.Explain that voices are not real and ask the client to stop listening.
   • C.Offer headphones and allow the client to remain alone until the voice subsides.
   • D.Ask the roommate whether the client has made similar statements before.

   Rationale: Command hallucinations involving harm require immediate protection and assessment of intent, means, and ability to resist. Arguing about the voice's reality may damage trust without reducing risk. Distraction alone and leaving the client unobserved are unsafe, while questioning the roommate delays direct intervention. The exam takeaway is to assess the dangerous content of hallucinations while protecting everyone involved.

4. 4.A 39-year-old client receiving treatment for schizophrenia refuses lunch and says, "The government poisoned this tray." Temperature is 98.6 F, heart rate is 82/min, and the client has eaten little today. Which response is therapeutic?

   • A.The government has no interest in poisoning you.
   • B.I will taste your food to prove it is safe.
   • C.Tell me which government officials arranged this.
   • D.That sounds frightening. I do not see evidence of poisoning; would you like a sealed food package?

   Answer and rationale are in the full material.

5. 5.A 28-year-old client admitted with acute mania has slept 2 hours in 3 days, walks continuously, and leaves meals after one bite. Heart rate is 108/min and blood pressure is 132/78 mm Hg. Which plan best meets the client's immediate nutritional needs?

   • A.Require the client to finish each meal before leaving the dining room.
   • B.Provide portable, calorie-dense foods and frequent fluids in a low-stimulation area.
   • C.Offer caffeinated beverages to help the client remain focused during meals.
   • D.Schedule a large evening meal after the client becomes tired.

   Answer and rationale are in the full material.