HESI PNR 200/PNR200 Mental Health
Nursing V3 | Exit Exam Q&A with
Rationale | Fortis College
1. A client with bipolar disorder is experiencing a manic episode and is pacing the hallway,
shouting at other clients. Which intervention should the nurse implement first?
A. Administer a PRN dose of haloperidol as prescribed.
B. Escort the client to a quiet area away from others.
C. Ask the client to explain why they are angry.
D. Place the client in physical restraints for safety.
Correct Answer: B
Expert Explanation: In a manic state, decreasing environmental stimuli is the priority to
help the client regain control. Moving the client to a quiet area prevents further escalation
and protects the privacy of other clients. The nurse should always use the least restrictive
intervention before moving to chemical or physical restraints.
2. A client is prescribed lithium carbonate for the management of bipolar I disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum potassium levels
B. White blood cell count
C. Prothrombin time (PT)
,D. Serum sodium levels
Correct Answer: D
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium levels drop, the kidneys retain lithium, leading to potentially fatal
toxicity. The nurse must educate the client on maintaining consistent sodium and fluid
intake.
3. A nurse is caring for a client with schizophrenia who reports hearing voices saying, ‘You are
worthless and should jump out the window.’ Which is the best nursing response?
A. I understand the voices are real to you, but I do not hear them.
B. Why do you think the voices are saying that?
C. I don’t hear any voices; you are safe here.
D. Let’s go to the activity room to distract you from the voices.
Correct Answer: A
Expert Explanation: The nurse should acknowledge the client’s perception of the
hallucination without validating it as reality. This technique, known as presenting reality,
helps the client distinguish between internal and external stimuli. Acknowledging the
client’s feelings while stating the nurse’s own perception is a core therapeutic
communication skill.
, 4. A client admitted for depression tells the nurse, ‘My family would be better off if I weren’t
around anymore.’ What is the nurse’s priority action?
A. Document the statement in the client’s chart.
B. Ask the client, ‘Are you thinking of hurting yourself?’
C. Encourage the client to attend a group therapy session.
D. Notify the family that the client is feeling guilty.
Correct Answer: B
Expert Explanation: The nurse’s priority is to assess for suicidal ideation and intent when
a client makes a veiled threat. Direct questioning is necessary to determine the level of risk
and the need for immediate safety precautions. This proactive approach is essential in
preventing self-harm in high-risk psychiatric populations.
5. Which food choice indicates that a client taking a Monoamine Oxidase Inhibitor (MAOI)
understands the dietary restrictions?
A. Pepperoni pizza and a beer
B. Smoked salmon and cream cheese
C. Aged cheddar cheese and crackers
D. Grilled chicken breast and steamed broccoli
Correct Answer: D
Nursing V3 | Exit Exam Q&A with
Rationale | Fortis College
1. A client with bipolar disorder is experiencing a manic episode and is pacing the hallway,
shouting at other clients. Which intervention should the nurse implement first?
A. Administer a PRN dose of haloperidol as prescribed.
B. Escort the client to a quiet area away from others.
C. Ask the client to explain why they are angry.
D. Place the client in physical restraints for safety.
Correct Answer: B
Expert Explanation: In a manic state, decreasing environmental stimuli is the priority to
help the client regain control. Moving the client to a quiet area prevents further escalation
and protects the privacy of other clients. The nurse should always use the least restrictive
intervention before moving to chemical or physical restraints.
2. A client is prescribed lithium carbonate for the management of bipolar I disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum potassium levels
B. White blood cell count
C. Prothrombin time (PT)
,D. Serum sodium levels
Correct Answer: D
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium levels drop, the kidneys retain lithium, leading to potentially fatal
toxicity. The nurse must educate the client on maintaining consistent sodium and fluid
intake.
3. A nurse is caring for a client with schizophrenia who reports hearing voices saying, ‘You are
worthless and should jump out the window.’ Which is the best nursing response?
A. I understand the voices are real to you, but I do not hear them.
B. Why do you think the voices are saying that?
C. I don’t hear any voices; you are safe here.
D. Let’s go to the activity room to distract you from the voices.
Correct Answer: A
Expert Explanation: The nurse should acknowledge the client’s perception of the
hallucination without validating it as reality. This technique, known as presenting reality,
helps the client distinguish between internal and external stimuli. Acknowledging the
client’s feelings while stating the nurse’s own perception is a core therapeutic
communication skill.
, 4. A client admitted for depression tells the nurse, ‘My family would be better off if I weren’t
around anymore.’ What is the nurse’s priority action?
A. Document the statement in the client’s chart.
B. Ask the client, ‘Are you thinking of hurting yourself?’
C. Encourage the client to attend a group therapy session.
D. Notify the family that the client is feeling guilty.
Correct Answer: B
Expert Explanation: The nurse’s priority is to assess for suicidal ideation and intent when
a client makes a veiled threat. Direct questioning is necessary to determine the level of risk
and the need for immediate safety precautions. This proactive approach is essential in
preventing self-harm in high-risk psychiatric populations.
5. Which food choice indicates that a client taking a Monoamine Oxidase Inhibitor (MAOI)
understands the dietary restrictions?
A. Pepperoni pizza and a beer
B. Smoked salmon and cream cheese
C. Aged cheddar cheese and crackers
D. Grilled chicken breast and steamed broccoli
Correct Answer: D
