HESI PN MENTAL HEALTH CERTIFICATION
EXAM QUESTIONS AND VERIFIED ANSWERS
2026
⏺ What is a priority nursing intervention to prevent falls for an older adult
client with multiple chronic diseases?
A) Requesting that a family member remain with the client to assist in
ambulation
B) Keeping all four siderails up while the client is in bed
C) Placing the client in restraints to prevent movement without assistance
D) Providing assistance to the client in getting out of the bed or chair?
Answer:D
Advanced age and multiple illnesses, particularly those that result in
alterations in sensation, such as diabetes, predispose this client to falls.
The nurse should provide assistance to the client with transfer and
ambulation to prevent falls. The client should not be restrained or
maintained on bedrest without adequate indication. Although family
members are encouraged to visit, their presence around the clock is not
necessary at this point.
⏺ The nurse is caring for four clients. Which client assessment is the most
indicative of having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision? Answer:B
At times clients are unable to verbalize that they are in pain but there are
indicators that the client may have acute pain such as increased heart rate,
increased blood pressure, increased respirations, sweating, restlessness,
,and overall distress. All the other distractors could indicate clients who
have the potential for being in pain, but restlessness with tachycardia is the
most indicative.
⏺ The Institute for Healthcare Improvement (IHI) identified interventions to
save client lives. Which actions are within the scope of nursing practice to
improve quality of care?
A) Prescribe aspirin for a client who presents with an acute myocardial
infarction
B) Insert a central line to give intravenous fluid to a dehydrated client.
C) Use sterile technique when changing dressings on a new surgical site.
D) Intubate a client whose oxygen saturation is 92%.? Answer:C
The only intervention identified within the scope of nursing practice is to
use sterile technique. Central line insertion, intubation, and prescription are
functions of the physician.
⏺ Which is most indicative of pain in an older client who is confused?
(Select all that apply).
A) Screaming
B) Decreased blood pressure
C) Crying
D) Decreased respirations
E) Facial grimace
F) Restlessness? Answer:A,C,E,F
No one scale has been found to be the best tool to use in pain assessment
for adults with cognitive impairment. Facial expression, motor behavior,
mood, socialization, and vocalization are common indicators of pain in
cognitively impaired adults. In acute pain, nonverbal indicators of pain
could include increased blood pressure and respirations.
⏺ The nursery nurse identifies a newborn at significant risk for hypothermic
alteration in thermoregulation because the patient is:
A) large for gestational age.
B) well nourished.
C) born at term.
,D) low birth weight.? Answer:D
Low birth weight and poorly nourished infants (particularly premature
infants) and children are at greatest risk for hypothermia. A large for
gestational age infant would not be malnourished. An infant born at term is
not considered at significant risk. A well nourished infant is not at significant
risk.
⏺ The nurse is assessing a patient's functional ability. Which activities most
closely match the definition of functional ability?
A) Healthy individual, college educated, travels frequently, can balance a
checkbook
B) Healthy individual, works out, reads well, cooks and cleans house
C) Healthy individual, volunteers at church, works part time, takes care of
family and house
D) Healthy individual, works outside the home, uses a cane, well groomed?
Answer:C
Functional ability refers to the individual's ability to perform the normal daily
activities required to meet basic needs; fulfill usual roles in the family,
workplace, and community; and maintain health and well-being. The other
options are good; however, each option has advanced or independent
activities in the context of the option.
⏺ Which action demonstrates that the nurse understands the purpose of
the Rapid Response Team?
A) Documenting all changes observed in the client and maintaining a
postoperative flow sheet
B) Monitoring the client for changes in postoperative status such as wound
infection
C) Notifying the physician of the client's change in blood pressure from 140
to 88 mm Hg systolic
D) Notifying the physician of the client's increase in restlessness after
medication change? Answer:C
The Rapid Response Team (RRT) saves lives and decreases the risk for
harm by providing care to clients before a respiratory or cardiac arrest
occurs. Although the RRT does not replace the Code Team, which
, responds to client arrests, it intervenes rapidly for those who are beginning
to decline clinically. It would be appropriate for the RRT to intervene when
the client has experienced a 52-point drop in blood pressure. Monitoring
the client's postoperative status, maintaining a postoperative flow sheet,
and notifying the physician of a change in the client's status after a
medication change would not be considered activities of the Rapid
Response Team.
⏺ An older client just returned from surgery and is rating pain as "8" on a 0
to 10 scale. Which medications are unsafe choices for treatment of severe
pain in this older adult? (Select all that apply.)
A) Morphine (Durmorph)
B) Meperidine (Demerol)
C) Propoxyphene (Darvocet)
D) Methadone (Dolophine)
E) Codeine? Answer:B,C,D,E
Meperidine, propoxyphene, and codeine are not recommended for older
clients because toxic metabolites may accumulate. Codeine may cause
constipation as well. Methadone has an extremely long half-life (24 to 36
hours) and has a high potential for sedation and respiratory depression.
Morphine is considered the gold standard and may be used in the older
adult while monitoring for sedation and respiratory depression is
conducted.
⏺ An emergency department (ED) nurse gives report on a client who is
being transferred to the medical-surgical floor. Because of an identified risk
for suicide, the ED nurse suggests that the floor nurse contact a sitter and
behavioral health. This statement represents which part of the SBAR hand-
off?
A) Situation
B) Recommendation
C) Background
D) Assessment? Answer:B
The ED nurse is giving recommendations to the medical-surgical floor
nurse about interventions to start for the client who is being transferred. No
EXAM QUESTIONS AND VERIFIED ANSWERS
2026
⏺ What is a priority nursing intervention to prevent falls for an older adult
client with multiple chronic diseases?
A) Requesting that a family member remain with the client to assist in
ambulation
B) Keeping all four siderails up while the client is in bed
C) Placing the client in restraints to prevent movement without assistance
D) Providing assistance to the client in getting out of the bed or chair?
Answer:D
Advanced age and multiple illnesses, particularly those that result in
alterations in sensation, such as diabetes, predispose this client to falls.
The nurse should provide assistance to the client with transfer and
ambulation to prevent falls. The client should not be restrained or
maintained on bedrest without adequate indication. Although family
members are encouraged to visit, their presence around the clock is not
necessary at this point.
⏺ The nurse is caring for four clients. Which client assessment is the most
indicative of having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision? Answer:B
At times clients are unable to verbalize that they are in pain but there are
indicators that the client may have acute pain such as increased heart rate,
increased blood pressure, increased respirations, sweating, restlessness,
,and overall distress. All the other distractors could indicate clients who
have the potential for being in pain, but restlessness with tachycardia is the
most indicative.
⏺ The Institute for Healthcare Improvement (IHI) identified interventions to
save client lives. Which actions are within the scope of nursing practice to
improve quality of care?
A) Prescribe aspirin for a client who presents with an acute myocardial
infarction
B) Insert a central line to give intravenous fluid to a dehydrated client.
C) Use sterile technique when changing dressings on a new surgical site.
D) Intubate a client whose oxygen saturation is 92%.? Answer:C
The only intervention identified within the scope of nursing practice is to
use sterile technique. Central line insertion, intubation, and prescription are
functions of the physician.
⏺ Which is most indicative of pain in an older client who is confused?
(Select all that apply).
A) Screaming
B) Decreased blood pressure
C) Crying
D) Decreased respirations
E) Facial grimace
F) Restlessness? Answer:A,C,E,F
No one scale has been found to be the best tool to use in pain assessment
for adults with cognitive impairment. Facial expression, motor behavior,
mood, socialization, and vocalization are common indicators of pain in
cognitively impaired adults. In acute pain, nonverbal indicators of pain
could include increased blood pressure and respirations.
⏺ The nursery nurse identifies a newborn at significant risk for hypothermic
alteration in thermoregulation because the patient is:
A) large for gestational age.
B) well nourished.
C) born at term.
,D) low birth weight.? Answer:D
Low birth weight and poorly nourished infants (particularly premature
infants) and children are at greatest risk for hypothermia. A large for
gestational age infant would not be malnourished. An infant born at term is
not considered at significant risk. A well nourished infant is not at significant
risk.
⏺ The nurse is assessing a patient's functional ability. Which activities most
closely match the definition of functional ability?
A) Healthy individual, college educated, travels frequently, can balance a
checkbook
B) Healthy individual, works out, reads well, cooks and cleans house
C) Healthy individual, volunteers at church, works part time, takes care of
family and house
D) Healthy individual, works outside the home, uses a cane, well groomed?
Answer:C
Functional ability refers to the individual's ability to perform the normal daily
activities required to meet basic needs; fulfill usual roles in the family,
workplace, and community; and maintain health and well-being. The other
options are good; however, each option has advanced or independent
activities in the context of the option.
⏺ Which action demonstrates that the nurse understands the purpose of
the Rapid Response Team?
A) Documenting all changes observed in the client and maintaining a
postoperative flow sheet
B) Monitoring the client for changes in postoperative status such as wound
infection
C) Notifying the physician of the client's change in blood pressure from 140
to 88 mm Hg systolic
D) Notifying the physician of the client's increase in restlessness after
medication change? Answer:C
The Rapid Response Team (RRT) saves lives and decreases the risk for
harm by providing care to clients before a respiratory or cardiac arrest
occurs. Although the RRT does not replace the Code Team, which
, responds to client arrests, it intervenes rapidly for those who are beginning
to decline clinically. It would be appropriate for the RRT to intervene when
the client has experienced a 52-point drop in blood pressure. Monitoring
the client's postoperative status, maintaining a postoperative flow sheet,
and notifying the physician of a change in the client's status after a
medication change would not be considered activities of the Rapid
Response Team.
⏺ An older client just returned from surgery and is rating pain as "8" on a 0
to 10 scale. Which medications are unsafe choices for treatment of severe
pain in this older adult? (Select all that apply.)
A) Morphine (Durmorph)
B) Meperidine (Demerol)
C) Propoxyphene (Darvocet)
D) Methadone (Dolophine)
E) Codeine? Answer:B,C,D,E
Meperidine, propoxyphene, and codeine are not recommended for older
clients because toxic metabolites may accumulate. Codeine may cause
constipation as well. Methadone has an extremely long half-life (24 to 36
hours) and has a high potential for sedation and respiratory depression.
Morphine is considered the gold standard and may be used in the older
adult while monitoring for sedation and respiratory depression is
conducted.
⏺ An emergency department (ED) nurse gives report on a client who is
being transferred to the medical-surgical floor. Because of an identified risk
for suicide, the ED nurse suggests that the floor nurse contact a sitter and
behavioral health. This statement represents which part of the SBAR hand-
off?
A) Situation
B) Recommendation
C) Background
D) Assessment? Answer:B
The ED nurse is giving recommendations to the medical-surgical floor
nurse about interventions to start for the client who is being transferred. No
