HESI PNR 200/PNR200 Mental Health
Nursing V2 | Exit Exam Q&A with
Rationale | Fortis College
1. A nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder
(OCD). The client spends several hours a day washing their hands. What is the most
appropriate initial nursing intervention?
A. Limit the amount of time the client can spend at the sink.
B. Provide the client with a detailed schedule of alternative activities.
C. Inform the client that handwashing is unnecessary.
D. Allow the client enough time to perform the ritual initially.
Correct Answer: D
Expert Explanation: Initially, the nurse should allow the client to perform the ritual to
avoid increasing anxiety levels to an unmanageable point. Stopping the ritual abruptly
without alternative coping mechanisms can cause panic. As the treatment plan progresses,
the nurse will work with the client to gradually reduce the time spent on rituals through
cognitive-behavioral therapy techniques.
2. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which of the
following instructions should the nurse include in the teaching plan?
A. Limit fluid intake to less than 1 liter per day.
,B. Maintain a consistent intake of dietary sodium.
C. Expect a weight loss of 5 to 10 pounds in the first month.
D. Stop taking the medication if fine hand tremors occur.
Correct Answer: B
Expert Explanation: Lithium is a salt, and its excretion is closely related to sodium levels
in the body. If sodium intake is decreased or if the client becomes dehydrated, the kidneys
may retain lithium, leading to toxicity. Therefore, the client must maintain a consistent
intake of salt and fluids to keep blood levels stable.
3. A nurse is assessing a client who is experiencing alcohol withdrawal. Which of the following
findings should the nurse expect?
A. Bradycardia and hypotension.
B. Increased appetite and somnolence.
C. Fine tremors, tachycardia, and diaphoresis.
D. Pinpoint pupils and decreased respiratory rate.
Correct Answer: C
Expert Explanation: Alcohol withdrawal typically manifests as autonomic hyperactivity,
which includes symptoms such as tremors, sweating, and an elevated heart rate. These
symptoms usually begin 6 to 24 hours after the last drink. Monitoring these signs is crucial
as they can progress to more severe complications like seizures or delirium tremens.
, 4. A client with schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me to hurt myself.’ What is the nurse’s priority action?
A. Ask the client to describe what the voices sound like.
B. Initiate one-on-one observation for the client.
C. Tell the client that the voices are not real.
D. Administer an extra dose of an antipsychotic medication.
Correct Answer: B
Expert Explanation: The safety of the client is the highest priority when command
hallucinations involving self-harm are reported. One-on-one observation ensures that the
client is supervised at all times to prevent them from acting on the voices. This intervention
provides immediate safety while the medical team adjusts the treatment plan.
5. A nurse is caring for a client with anorexia nervosa. Which of the following nursing
interventions is the highest priority?
A. Discussing the client’s distorted body image.
B. Monitoring the client’s weight once a week.
C. Supervising the client during and after meals.
D. Allowing the client to choose their own meal times.
Correct Answer: C
Nursing V2 | Exit Exam Q&A with
Rationale | Fortis College
1. A nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder
(OCD). The client spends several hours a day washing their hands. What is the most
appropriate initial nursing intervention?
A. Limit the amount of time the client can spend at the sink.
B. Provide the client with a detailed schedule of alternative activities.
C. Inform the client that handwashing is unnecessary.
D. Allow the client enough time to perform the ritual initially.
Correct Answer: D
Expert Explanation: Initially, the nurse should allow the client to perform the ritual to
avoid increasing anxiety levels to an unmanageable point. Stopping the ritual abruptly
without alternative coping mechanisms can cause panic. As the treatment plan progresses,
the nurse will work with the client to gradually reduce the time spent on rituals through
cognitive-behavioral therapy techniques.
2. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which of the
following instructions should the nurse include in the teaching plan?
A. Limit fluid intake to less than 1 liter per day.
,B. Maintain a consistent intake of dietary sodium.
C. Expect a weight loss of 5 to 10 pounds in the first month.
D. Stop taking the medication if fine hand tremors occur.
Correct Answer: B
Expert Explanation: Lithium is a salt, and its excretion is closely related to sodium levels
in the body. If sodium intake is decreased or if the client becomes dehydrated, the kidneys
may retain lithium, leading to toxicity. Therefore, the client must maintain a consistent
intake of salt and fluids to keep blood levels stable.
3. A nurse is assessing a client who is experiencing alcohol withdrawal. Which of the following
findings should the nurse expect?
A. Bradycardia and hypotension.
B. Increased appetite and somnolence.
C. Fine tremors, tachycardia, and diaphoresis.
D. Pinpoint pupils and decreased respiratory rate.
Correct Answer: C
Expert Explanation: Alcohol withdrawal typically manifests as autonomic hyperactivity,
which includes symptoms such as tremors, sweating, and an elevated heart rate. These
symptoms usually begin 6 to 24 hours after the last drink. Monitoring these signs is crucial
as they can progress to more severe complications like seizures or delirium tremens.
, 4. A client with schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me to hurt myself.’ What is the nurse’s priority action?
A. Ask the client to describe what the voices sound like.
B. Initiate one-on-one observation for the client.
C. Tell the client that the voices are not real.
D. Administer an extra dose of an antipsychotic medication.
Correct Answer: B
Expert Explanation: The safety of the client is the highest priority when command
hallucinations involving self-harm are reported. One-on-one observation ensures that the
client is supervised at all times to prevent them from acting on the voices. This intervention
provides immediate safety while the medical team adjusts the treatment plan.
5. A nurse is caring for a client with anorexia nervosa. Which of the following nursing
interventions is the highest priority?
A. Discussing the client’s distorted body image.
B. Monitoring the client’s weight once a week.
C. Supervising the client during and after meals.
D. Allowing the client to choose their own meal times.
Correct Answer: C
