HESI PN MENTAL HEALTH EXAM REVIEW
QUESTIONS WITH ACCURATE SOLUTIONS
2026
⏺ The client was given 15 mg of morphine IM for postsurgical pain. When
the nurse checks the client for pain relief 1 hour later, the client is sleeping
and has a respiratory rate of 10 breaths/min. What is the nurse's first
action?
A) Administering oxygen by nasal cannula
B) Documenting the findings and continuing to monitor
C) Arousing the client by calling his or her name
D) Administering naloxone (Narcan) IV push? Answer:C
Many clients experience some degree of respiratory depression with opioid
analgesics. If the client can be aroused with minimally intrusive techniques
and the rate of respiration is increased spontaneously, no further
intervention is required.
⏺ The physician orders Lanoxin(digoxin)0.375 mg po every day. On hand
you have 0.25mg/5 mL. How many mL would you give your patient?
A) 8 mL
B) 7.5 mL
C) 7 mL
D) 5.5 mL? Answer:B
⏺ The nurse is admitting an older adult with decompensated congestive
heart failure. The nursing assessment reveals adventitious lung sounds,
dyspnea, and orthopnea. The nurse should question which doctor's order?
A) KCl 20 mEq PO two times per day
B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
C) Oxygen via face mask at 8 L/min
D) Furosemide (Lasix) 20 mg PO now? Answer:B
,A patient with decompensated heart failure has extracellular fluid volume
(ECV) excess. The IV of 0.9% NaCl is normal saline, which should be
questioned because it would expand ECV and place an additional load on
the failing heart. Diuretics such as furosemide are appropriate to decrease
the ECV during heart failure. Increasing the potassium intake with KCl is
appropriate, because furosemide increases potassium excretion. Oxygen
administration is appropriate in this situation of near pulmonary edema from
ECV excess.
⏺ The priority nursing intervention for a patient suspected to be
hypothermic would be to:
A) hydrate with intravenous (IV) fluids.
B) remove wet clothes.
C) assess vital signs.
D) provide a warm blanket.? Answer:B
The first thing to do with a patient suspected to be hypothermic is to
remove wet clothes, because heat loss is five times greater when clothing
is wet. Assessing vital signs is important, but the wet clothes should be
removed first. Hydration is very important with hyperthermia and the
associated danger of dehydration, but there is not a similar risk with
hypothermia. A warm blanket over wet clothes would not be an effective
warming strategy.
⏺ The nurse admitting a patient to the emergency department on a very hot
summer day would suspect hyperthermia when the patient demonstrates:
A) slow capillary refill.
B) red, sweaty skin.
C) low pulse rate.
D) decreased respirations.? Answer:B
With hyperthermia, vasodilatation occurs causing the skin to appear
flushed and warm or hot to touch. There is an increased respiration rate
with hyperthermia. The heart rate increases with hyperthermia. With
hypothermia there is slow capillary refill.
⏺ Why does the nurse always ask the client his or her pain level after
taking routine vital signs?
,A) To follow McCaffery's guidelines on pain management
B) To ensure that pain assessment occurs on a regular basis
C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart rate?
Answer:B
Making pain the fifth vital sign allows more frequent and accurate
assessment, which can contribute to better pain management.
⏺ The nurse observes skin tenting on the back of the older adult client's
hand. Which action by the nurse is most appropriate?
A) Examine dependent body areas.
B) Notify the physician.
C) Document the finding and continue to monitor.
D) Assess turgor on the client's forehead.? Answer:D
Skin turgor cannot be accurately assessed on an older adult client's hands
because of age-related loss of tissue elasticity in this area. Areas that more
accurately show skin turgor status on an older client include the skin of the
forehead, chest, and abdomen. These should also be assessed, rather
than merely examining dependent body areas. Further assessment is
needed rather than only documenting, monitoring, and notifying the
physician.
⏺ The nurse is assessing a client who has undergone a transurethral
resection of the prostate (TURP). Which assessment finding requires
immediate action by the nurse?
A) Having the urge to void continuously while the catheter is inserted
B) Passing small blood clots after catheter removal
C) Having bright red drainage with multiple blood clots
D) Experiencing urinary frequency after catheter removal? Answer:C
A client who undergoes a TURP is at risk for bleeding during the first 24
hours after surgery. Passage of small blood clots and tissue debris, urinary
frequency and leakage, and the urge to void continuously while the client
still has the catheter inserted are all considered to be expected
complications of the procedure. They will resolve as the client continues to
, recover and the catheter is removed. However, the presence of bright red
blood with clots indicates arterial bleeding and should be reported to the
provider.
⏺ Which finding puts a client at greatest risk for wound infection?
A) Presence of a deep wound
B) Coexisting medical conditions
C) Immune compromised status
D) Severely reddened skin? Answer:C
A compromised immune system puts a client at greatest risk for infection.
Although all the other options might increase the client's susceptibility, the
one with the greatest potential impact is being immune compromised.
⏺ The nurse is assessing a client with an early onset of multiple sclerosis
(MS). Which clinical manifestations does the nurse expect to see?
A) Nystagmus & Diplopia
B) Hyperresponsive reflexes
C) Excessive somnolence
D) Heat intolerance? Answer:A
Early signs and symptoms of MS include changes in motor skills, vision,
and sensation. The other manifestations are later signs of MS.
⏺ The nurse determines that a client has a Braden Scale score of 9. Which
is the nurse's best intervention related to this assessment?
A) Increase the client's fluid intake.
B) Consult with the health care provider.
C) Reassess the client in 3 days.
D) Document the finding per protocol.? Answer:B
A score of 11 or less on the Braden Scale indicates severe risk for pressure
ulcer development in terms of decreased sensory perception, exposure to
moisture, decreased independent activity, decreased mobility, poor
nutrition, and chronic exposure to friction and shear. The nurse needs to
consult with the health care provider to relay this information and to obtain
more aggressive skin protection measures than are currently provided.
QUESTIONS WITH ACCURATE SOLUTIONS
2026
⏺ The client was given 15 mg of morphine IM for postsurgical pain. When
the nurse checks the client for pain relief 1 hour later, the client is sleeping
and has a respiratory rate of 10 breaths/min. What is the nurse's first
action?
A) Administering oxygen by nasal cannula
B) Documenting the findings and continuing to monitor
C) Arousing the client by calling his or her name
D) Administering naloxone (Narcan) IV push? Answer:C
Many clients experience some degree of respiratory depression with opioid
analgesics. If the client can be aroused with minimally intrusive techniques
and the rate of respiration is increased spontaneously, no further
intervention is required.
⏺ The physician orders Lanoxin(digoxin)0.375 mg po every day. On hand
you have 0.25mg/5 mL. How many mL would you give your patient?
A) 8 mL
B) 7.5 mL
C) 7 mL
D) 5.5 mL? Answer:B
⏺ The nurse is admitting an older adult with decompensated congestive
heart failure. The nursing assessment reveals adventitious lung sounds,
dyspnea, and orthopnea. The nurse should question which doctor's order?
A) KCl 20 mEq PO two times per day
B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
C) Oxygen via face mask at 8 L/min
D) Furosemide (Lasix) 20 mg PO now? Answer:B
,A patient with decompensated heart failure has extracellular fluid volume
(ECV) excess. The IV of 0.9% NaCl is normal saline, which should be
questioned because it would expand ECV and place an additional load on
the failing heart. Diuretics such as furosemide are appropriate to decrease
the ECV during heart failure. Increasing the potassium intake with KCl is
appropriate, because furosemide increases potassium excretion. Oxygen
administration is appropriate in this situation of near pulmonary edema from
ECV excess.
⏺ The priority nursing intervention for a patient suspected to be
hypothermic would be to:
A) hydrate with intravenous (IV) fluids.
B) remove wet clothes.
C) assess vital signs.
D) provide a warm blanket.? Answer:B
The first thing to do with a patient suspected to be hypothermic is to
remove wet clothes, because heat loss is five times greater when clothing
is wet. Assessing vital signs is important, but the wet clothes should be
removed first. Hydration is very important with hyperthermia and the
associated danger of dehydration, but there is not a similar risk with
hypothermia. A warm blanket over wet clothes would not be an effective
warming strategy.
⏺ The nurse admitting a patient to the emergency department on a very hot
summer day would suspect hyperthermia when the patient demonstrates:
A) slow capillary refill.
B) red, sweaty skin.
C) low pulse rate.
D) decreased respirations.? Answer:B
With hyperthermia, vasodilatation occurs causing the skin to appear
flushed and warm or hot to touch. There is an increased respiration rate
with hyperthermia. The heart rate increases with hyperthermia. With
hypothermia there is slow capillary refill.
⏺ Why does the nurse always ask the client his or her pain level after
taking routine vital signs?
,A) To follow McCaffery's guidelines on pain management
B) To ensure that pain assessment occurs on a regular basis
C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart rate?
Answer:B
Making pain the fifth vital sign allows more frequent and accurate
assessment, which can contribute to better pain management.
⏺ The nurse observes skin tenting on the back of the older adult client's
hand. Which action by the nurse is most appropriate?
A) Examine dependent body areas.
B) Notify the physician.
C) Document the finding and continue to monitor.
D) Assess turgor on the client's forehead.? Answer:D
Skin turgor cannot be accurately assessed on an older adult client's hands
because of age-related loss of tissue elasticity in this area. Areas that more
accurately show skin turgor status on an older client include the skin of the
forehead, chest, and abdomen. These should also be assessed, rather
than merely examining dependent body areas. Further assessment is
needed rather than only documenting, monitoring, and notifying the
physician.
⏺ The nurse is assessing a client who has undergone a transurethral
resection of the prostate (TURP). Which assessment finding requires
immediate action by the nurse?
A) Having the urge to void continuously while the catheter is inserted
B) Passing small blood clots after catheter removal
C) Having bright red drainage with multiple blood clots
D) Experiencing urinary frequency after catheter removal? Answer:C
A client who undergoes a TURP is at risk for bleeding during the first 24
hours after surgery. Passage of small blood clots and tissue debris, urinary
frequency and leakage, and the urge to void continuously while the client
still has the catheter inserted are all considered to be expected
complications of the procedure. They will resolve as the client continues to
, recover and the catheter is removed. However, the presence of bright red
blood with clots indicates arterial bleeding and should be reported to the
provider.
⏺ Which finding puts a client at greatest risk for wound infection?
A) Presence of a deep wound
B) Coexisting medical conditions
C) Immune compromised status
D) Severely reddened skin? Answer:C
A compromised immune system puts a client at greatest risk for infection.
Although all the other options might increase the client's susceptibility, the
one with the greatest potential impact is being immune compromised.
⏺ The nurse is assessing a client with an early onset of multiple sclerosis
(MS). Which clinical manifestations does the nurse expect to see?
A) Nystagmus & Diplopia
B) Hyperresponsive reflexes
C) Excessive somnolence
D) Heat intolerance? Answer:A
Early signs and symptoms of MS include changes in motor skills, vision,
and sensation. The other manifestations are later signs of MS.
⏺ The nurse determines that a client has a Braden Scale score of 9. Which
is the nurse's best intervention related to this assessment?
A) Increase the client's fluid intake.
B) Consult with the health care provider.
C) Reassess the client in 3 days.
D) Document the finding per protocol.? Answer:B
A score of 11 or less on the Braden Scale indicates severe risk for pressure
ulcer development in terms of decreased sensory perception, exposure to
moisture, decreased independent activity, decreased mobility, poor
nutrition, and chronic exposure to friction and shear. The nurse needs to
consult with the health care provider to relay this information and to obtain
more aggressive skin protection measures than are currently provided.
