Psych-Mental Health Exit HESI -
Saunders2026 Questions and Verified
Answers (2026/2027 Updated) | Graded
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The nurse is monitoring a client with a diagnosis of schizophrenia. The nurse notes
that the client's emotional responses to situations occurring throughout the day
are incongruent with the tone of the situation. The nurse should document the
findings using which description of the client's behavioral response?
1. Flat affect
2. Bizarre affect
3. Blunted affect
4. Inappropriate affect - Correct Answer -4. Inappropriate affect
Rationale:
An inappropriate affect refers to an emotional response to a situation that is
incongruent with the tone of the situation. A flat affect is manifested as an
immobile facial expression or blank look. A bizarre affect such as grimacing,
laughing, and self-directed mumbling is marked when the client is unable to relate
logically to the environment. A blunted affect is a minimal emotional response or
outward affect that typically does not coincide with the client's inner emotions.
,A mental health nurse notes that a client with schizophrenia is exhibiting an
immobile facial expression and a blank look. Which should the nurse document in
the client's record?
1. The client has a flat affect.
2. The client has an inappropriate affect.
3. The client is exhibiting bizarre behavior.
4. The client's emotional responses exhibit a blunted affect. - Correct Answer -1.
The client has a flat affect.
Rationale:
A flat affect is manifested as an immobile facial expression or blank look. An
inappropriate affect refers to an emotional response to a situation that is
incongruent with the tone of the situation. A bizarre affect such as grimacing,
laughing, and self-directed mumbling is marked when the client is unable to relate
logically to the environment. A blunted affect is a minimal emotional response or
outward affect that typically does not coincide with the client's inner emotions.
The nurse is developing a plan of care for the client with a diagnosis of paranoia
and should include which interventions in the plan of care? Select all that apply.
1. Provide a warm approach to the client.
2. Ask permission before touching the client.
3. Eliminate physical contact with the client.
4. Defuse any anger or verbal attacks with a nondefensive stance.
,5. Use simple and clear language when communicating with the client. - Correct
Answer -2, 3, 4, 5
Rationale:
When caring for a client with paranoia, the nurse should ask permission if touch is
necessary because touch may be interpreted as a sexual or physical assault. The
nurse must eliminate any physical contact and not touch the client. The anger that
a paranoid client expresses often is displaced, and when a staff member becomes
defensive, both client and staff anger may escalate. Simple and clear language
should be used in speaking to the client to prevent misinterpretation and to clarify
the nurse's intent and action. The nurse should avoid a warm approach because
warmth can be frightening to a person who needs emotional distance.
The nurse is preparing a client for electroconvulsive therapy (ECT), which is
scheduled for the next morning. Which interventions would be included in the
preprocedural plan? Select all that apply.
1. Obtain an informed consent.
2. Have the client void before the procedure.
3. Remove dentures and contact lenses before the procedure.
4. Withhold food and fluids for 6 hours before the treatment.
5. Administer tap water enemas on the evening before the procedure. - Correct
Answer -1, 2, 3, 4
Rationale:
, Enemas are not a component of the pretreatment care for a client scheduled for
ECT. Options 1, 2, 3, and 4 are a part of the pretreatment plan. Additionally, the
nurse should teach the client and family what to expect with ECT and allow the
client to discuss his or her feelings regarding the procedure.
A hospitalized client is receiving clozapine (Clozaril) for the treatment of a
schizophrenic disorder. The nurse determines that the client may be having an
adverse reaction to the medication if abnormalities are noted on which laboratory
study?
1. Platelet count
2. Cholesterol level
3. Blood urea nitrogen
4. White blood cell (WBC) count - Correct Answer -4. White blood cell (WBC)
count
Rationale:
Clozapine is an antipsychotic medication. Clients taking clozapine can experience
hematological adverse effects, including agranulocytosis and mild leukopenia. The
WBC count should be assessed before initiation of treatment and should be
monitored closely during the use of this medication. The client also should be
monitored for signs indicating agranulocytosis, which may include sore throat,
malaise, and fever. Options 1, 2, and 3 are incorrect and unrelated to this
medication.
Saunders2026 Questions and Verified
Answers (2026/2027 Updated) | Graded
A+ | 100% Success
The nurse is monitoring a client with a diagnosis of schizophrenia. The nurse notes
that the client's emotional responses to situations occurring throughout the day
are incongruent with the tone of the situation. The nurse should document the
findings using which description of the client's behavioral response?
1. Flat affect
2. Bizarre affect
3. Blunted affect
4. Inappropriate affect - Correct Answer -4. Inappropriate affect
Rationale:
An inappropriate affect refers to an emotional response to a situation that is
incongruent with the tone of the situation. A flat affect is manifested as an
immobile facial expression or blank look. A bizarre affect such as grimacing,
laughing, and self-directed mumbling is marked when the client is unable to relate
logically to the environment. A blunted affect is a minimal emotional response or
outward affect that typically does not coincide with the client's inner emotions.
,A mental health nurse notes that a client with schizophrenia is exhibiting an
immobile facial expression and a blank look. Which should the nurse document in
the client's record?
1. The client has a flat affect.
2. The client has an inappropriate affect.
3. The client is exhibiting bizarre behavior.
4. The client's emotional responses exhibit a blunted affect. - Correct Answer -1.
The client has a flat affect.
Rationale:
A flat affect is manifested as an immobile facial expression or blank look. An
inappropriate affect refers to an emotional response to a situation that is
incongruent with the tone of the situation. A bizarre affect such as grimacing,
laughing, and self-directed mumbling is marked when the client is unable to relate
logically to the environment. A blunted affect is a minimal emotional response or
outward affect that typically does not coincide with the client's inner emotions.
The nurse is developing a plan of care for the client with a diagnosis of paranoia
and should include which interventions in the plan of care? Select all that apply.
1. Provide a warm approach to the client.
2. Ask permission before touching the client.
3. Eliminate physical contact with the client.
4. Defuse any anger or verbal attacks with a nondefensive stance.
,5. Use simple and clear language when communicating with the client. - Correct
Answer -2, 3, 4, 5
Rationale:
When caring for a client with paranoia, the nurse should ask permission if touch is
necessary because touch may be interpreted as a sexual or physical assault. The
nurse must eliminate any physical contact and not touch the client. The anger that
a paranoid client expresses often is displaced, and when a staff member becomes
defensive, both client and staff anger may escalate. Simple and clear language
should be used in speaking to the client to prevent misinterpretation and to clarify
the nurse's intent and action. The nurse should avoid a warm approach because
warmth can be frightening to a person who needs emotional distance.
The nurse is preparing a client for electroconvulsive therapy (ECT), which is
scheduled for the next morning. Which interventions would be included in the
preprocedural plan? Select all that apply.
1. Obtain an informed consent.
2. Have the client void before the procedure.
3. Remove dentures and contact lenses before the procedure.
4. Withhold food and fluids for 6 hours before the treatment.
5. Administer tap water enemas on the evening before the procedure. - Correct
Answer -1, 2, 3, 4
Rationale:
, Enemas are not a component of the pretreatment care for a client scheduled for
ECT. Options 1, 2, 3, and 4 are a part of the pretreatment plan. Additionally, the
nurse should teach the client and family what to expect with ECT and allow the
client to discuss his or her feelings regarding the procedure.
A hospitalized client is receiving clozapine (Clozaril) for the treatment of a
schizophrenic disorder. The nurse determines that the client may be having an
adverse reaction to the medication if abnormalities are noted on which laboratory
study?
1. Platelet count
2. Cholesterol level
3. Blood urea nitrogen
4. White blood cell (WBC) count - Correct Answer -4. White blood cell (WBC)
count
Rationale:
Clozapine is an antipsychotic medication. Clients taking clozapine can experience
hematological adverse effects, including agranulocytosis and mild leukopenia. The
WBC count should be assessed before initiation of treatment and should be
monitored closely during the use of this medication. The client also should be
monitored for signs indicating agranulocytosis, which may include sore throat,
malaise, and fever. Options 1, 2, and 3 are incorrect and unrelated to this
medication.
