HESI Exit PN | HESI Exit PN Exam Version 4
Comprehensive Review | Questions with Correct
Answers and Expert Explanation for Each Question
| Nursing Exit Assessment
1. A client with major depression states, “Life is no longer worth living.” What is the
most therapeutic response by the nurse?
A. “Why do you feel that way today?”
B. “Are you thinking about hurting yourself?”
C. “I am sure things will look better tomorrow.”
D. “You have many people who care about you.”
Correct Answer: B
Expert Explanation: Directly asking the client about suicidal ideation is the priority
for safety. This approach allows the nurse to assess the immediate risk and
determine if a plan exists. Open and honest communication is essential when
dealing with potential self-harm. Avoiding false reassurances helps maintain a
professional and trusting relationship. This intervention is a critical component of
initial psychosocial assessment and crisis management.
2. A nurse is monitoring a client taking lithium carbonate for bipolar disorder. Which
finding indicates the client is experiencing lithium toxicity?
A. Coarse hand tremors
,B. Increased flatulence
C. Mild thirst
D. Occasional headache
Correct Answer: A
Expert Explanation: Coarse hand tremors are a significant sign of lithium toxicity
and should be reported immediately. The therapeutic range for lithium is narrow,
typically between 0.6 and 1.2 mEq/L. Toxicity can lead to serious neurological
complications if the dose is not adjusted or held. Mild thirst and occasional
headaches are common side effects that usually do not indicate toxicity. The nurse
must prioritize safety by monitoring for advanced signs like ataxia or blurred vision.
3. A client with schizophrenia is hearing voices that say, “The food is poisoned.” What
should the nurse say to the client?
A. “No one is trying to poison you, don’t be silly.”
B. “I know the voices seem real, but I do not hear them.”
C. “The voices are just your imagination playing tricks.”
D. “Why would anyone want to poison the food here?”
Correct Answer: B
,Expert Explanation: The nurse should acknowledge the client’s experience without
validating the hallucination. This technique is known as presenting reality while
being empathetic to the client’s distress. It is important not to argue with the client
about the validity of their voices. Direct confrontation can increase the client’s
anxiety and defensiveness. Focusing on the client’s feelings helps build a therapeutic
alliance during behavioral health management.
4. The nurse is caring for a client experiencing a panic attack. Which action should the
nurse take first?
A. Teach the client deep breathing exercises.
B. Administer a PRN dose of an antidepressant.
C. Stay with the client and remain calm.
D. Ask the client to describe the cause of the panic.
Correct Answer: C
Expert Explanation: The immediate priority during a panic attack is to ensure the
client is not left alone. Staying with the client provides a sense of security and safety
during extreme distress. The nurse should use a calm, low-pitched voice and
provide brief, clear instructions. Attempting to teach new skills or explore causes is
ineffective while the client is in a state of panic. Once the client is stable, further
therapeutic interventions and education can be introduced.
, 5. Which dietary restriction is essential for a client prescribed a monoamine oxidase
inhibitor (MAOI)?
A. Low-sodium diet
B. Tyramine-restricted diet
C. Gluten-free diet
D. High-protein diet
Correct Answer: B
Expert Explanation: Clients taking MAOIs must avoid foods high in tyramine to
prevent a hypertensive crisis. Tyramine is found in aged cheeses, cured meats, red
wine, and fermented products. This interaction can cause a dangerous increase in
blood pressure and potentially lead to a stroke. Educating the client on safe food
choices is a critical nursing responsibility for medication safety. The nurse should
provide a detailed list of prohibited items to ensure patient compliance.
6. A nurse is caring for a client with anorexia nervosa. Which intervention is most
appropriate during mealtime?
A. Observe the client for one hour after meals.
B. Allow the client to eat alone to reduce anxiety.
C. Discuss the nutritional content of the food.
Comprehensive Review | Questions with Correct
Answers and Expert Explanation for Each Question
| Nursing Exit Assessment
1. A client with major depression states, “Life is no longer worth living.” What is the
most therapeutic response by the nurse?
A. “Why do you feel that way today?”
B. “Are you thinking about hurting yourself?”
C. “I am sure things will look better tomorrow.”
D. “You have many people who care about you.”
Correct Answer: B
Expert Explanation: Directly asking the client about suicidal ideation is the priority
for safety. This approach allows the nurse to assess the immediate risk and
determine if a plan exists. Open and honest communication is essential when
dealing with potential self-harm. Avoiding false reassurances helps maintain a
professional and trusting relationship. This intervention is a critical component of
initial psychosocial assessment and crisis management.
2. A nurse is monitoring a client taking lithium carbonate for bipolar disorder. Which
finding indicates the client is experiencing lithium toxicity?
A. Coarse hand tremors
,B. Increased flatulence
C. Mild thirst
D. Occasional headache
Correct Answer: A
Expert Explanation: Coarse hand tremors are a significant sign of lithium toxicity
and should be reported immediately. The therapeutic range for lithium is narrow,
typically between 0.6 and 1.2 mEq/L. Toxicity can lead to serious neurological
complications if the dose is not adjusted or held. Mild thirst and occasional
headaches are common side effects that usually do not indicate toxicity. The nurse
must prioritize safety by monitoring for advanced signs like ataxia or blurred vision.
3. A client with schizophrenia is hearing voices that say, “The food is poisoned.” What
should the nurse say to the client?
A. “No one is trying to poison you, don’t be silly.”
B. “I know the voices seem real, but I do not hear them.”
C. “The voices are just your imagination playing tricks.”
D. “Why would anyone want to poison the food here?”
Correct Answer: B
,Expert Explanation: The nurse should acknowledge the client’s experience without
validating the hallucination. This technique is known as presenting reality while
being empathetic to the client’s distress. It is important not to argue with the client
about the validity of their voices. Direct confrontation can increase the client’s
anxiety and defensiveness. Focusing on the client’s feelings helps build a therapeutic
alliance during behavioral health management.
4. The nurse is caring for a client experiencing a panic attack. Which action should the
nurse take first?
A. Teach the client deep breathing exercises.
B. Administer a PRN dose of an antidepressant.
C. Stay with the client and remain calm.
D. Ask the client to describe the cause of the panic.
Correct Answer: C
Expert Explanation: The immediate priority during a panic attack is to ensure the
client is not left alone. Staying with the client provides a sense of security and safety
during extreme distress. The nurse should use a calm, low-pitched voice and
provide brief, clear instructions. Attempting to teach new skills or explore causes is
ineffective while the client is in a state of panic. Once the client is stable, further
therapeutic interventions and education can be introduced.
, 5. Which dietary restriction is essential for a client prescribed a monoamine oxidase
inhibitor (MAOI)?
A. Low-sodium diet
B. Tyramine-restricted diet
C. Gluten-free diet
D. High-protein diet
Correct Answer: B
Expert Explanation: Clients taking MAOIs must avoid foods high in tyramine to
prevent a hypertensive crisis. Tyramine is found in aged cheeses, cured meats, red
wine, and fermented products. This interaction can cause a dangerous increase in
blood pressure and potentially lead to a stroke. Educating the client on safe food
choices is a critical nursing responsibility for medication safety. The nurse should
provide a detailed list of prohibited items to ensure patient compliance.
6. A nurse is caring for a client with anorexia nervosa. Which intervention is most
appropriate during mealtime?
A. Observe the client for one hour after meals.
B. Allow the client to eat alone to reduce anxiety.
C. Discuss the nutritional content of the food.
