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HESI MENTAL HEALTH
COMPREHENSIVE UPDATED EXAM
WITH VERIFIED SOLUTIONS.
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? - correct
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.
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.
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Which behavior is inconsistent with depression? - correct 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.
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.) - correct answer-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.
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.
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In what classification of drugs is the antidepressant fluoxetine? -
correct answer-Selective serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
What is the major action of SSRI antidepressants? - correct
answer-Increase availability of serotonin.
Rationale: The major action of SSRIs is to selectively inhibit the
reuptake of serotonin and increase the availability of serotonin.
The nurse understands that SSRIs are now more widely
prescribed than tricyclics for antidepressant therapy. What is the
rationale? - correct answer-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.
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? - correct answer-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
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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.
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? - correct answer-
Gastrointestinal 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.
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? - correct answer-
Risperidone will help the think more clearly.
Rationale: Antipsychotic medications target symptoms related to
disorders of thinking such as psychosis and behaviors associated
with agitation and disorganization or speech and behavior.
HESI MENTAL HEALTH
COMPREHENSIVE UPDATED EXAM
WITH VERIFIED SOLUTIONS.
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? - correct
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.
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.
, Page | 2
Which behavior is inconsistent with depression? - correct 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.
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.) - correct answer-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.
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.
, Page | 3
In what classification of drugs is the antidepressant fluoxetine? -
correct answer-Selective serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
What is the major action of SSRI antidepressants? - correct
answer-Increase availability of serotonin.
Rationale: The major action of SSRIs is to selectively inhibit the
reuptake of serotonin and increase the availability of serotonin.
The nurse understands that SSRIs are now more widely
prescribed than tricyclics for antidepressant therapy. What is the
rationale? - correct answer-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.
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? - correct answer-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
, Page | 4
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.
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? - correct answer-
Gastrointestinal 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.
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? - correct answer-
Risperidone will help the think more clearly.
Rationale: Antipsychotic medications target symptoms related to
disorders of thinking such as psychosis and behaviors associated
with agitation and disorganization or speech and behavior.
