HESI PNR 200/PNR200 Mental Health
Nursing V1 | Exit Exam Q&A with
Rationale | Fortis College
1. A client diagnosed with bipolar I disorder is experiencing a manic episode and is
hyperactive, loud, and disruptive to other clients. Which nursing intervention is most
appropriate?
A. Place the client in a quiet area with low stimulation.
B. Encourage the client to join a group therapy session.
C. Ask the client to explain why they are being disruptive.
D. Set strict limits on all behaviors immediately.
Correct Answer: A
Expert Explanation: During a manic episode, clients are easily overstimulated by their
environment. Providing a quiet area with low stimulation helps reduce the intensity of the
manic symptoms and promotes safety. Group therapy is often too demanding and
stimulating for a client in an acute manic phase.
2. A nurse is caring for a client who has a prescription for lithium carbonate. Which laboratory
result should the nurse prioritize reviewing before administering the next dose?
A. Serum glucose levels
B. Hemoglobin and hematocrit
,C. Liver function tests
D. Serum sodium levels
Correct Answer: D
Expert Explanation: Sodium levels have a direct impact on lithium excretion by the
kidneys. If sodium levels are low, the kidneys retain lithium, which significantly increases
the risk of toxicity. Monitoring electrolyte balance is a standard requirement for patients on
lithium therapy.
3. The nurse is assessing a client who is suspected of having alcohol withdrawal delirium.
Which clinical manifestation should the nurse expect to observe?
A. Hypotension and bradycardia
B. Hypertension, tachycardia, and diaphoresis
C. Lethargy and decreased muscle tone
D. Increased appetite and somnolence
Correct Answer: B
Expert Explanation: Alcohol withdrawal delirium is a medical emergency characterized
by autonomic hyperactivity. This includes increased heart rate, elevated blood pressure,
and profuse sweating. The nurse must monitor these vital signs closely to prevent
complications such as seizures or cardiac collapse.
, 4. A client is admitted to the psychiatric unit after a suicide attempt. What is the priority
nursing action during the first 24 hours of admission?
A. Allow the client to have private time for reflection.
B. Implement one-on-one observation at all times.
C. Begin teaching the client about antidepressant medications.
D. Encourage the client to participate in all unit activities.
Correct Answer: B
Expert Explanation: Safety is the absolute priority for a client who has recently attempted
suicide. Continuous one-on-one observation ensures that the client cannot harm
themselves while in the facility. Therapeutic activities and education are important, but
only after the client’s immediate safety is secured.
5. A client with schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me I am a bad person.’ Which response by the nurse is therapeutic?
A. ‘There are no voices; you are just imagining things.’
B. ‘Why do you think the voices are saying that?’
C. ‘Don’t worry, the voices will go away once the medicine works.’
D. ‘I do not hear the voices, but I understand they are real to you.’
Correct Answer: D
Nursing V1 | Exit Exam Q&A with
Rationale | Fortis College
1. A client diagnosed with bipolar I disorder is experiencing a manic episode and is
hyperactive, loud, and disruptive to other clients. Which nursing intervention is most
appropriate?
A. Place the client in a quiet area with low stimulation.
B. Encourage the client to join a group therapy session.
C. Ask the client to explain why they are being disruptive.
D. Set strict limits on all behaviors immediately.
Correct Answer: A
Expert Explanation: During a manic episode, clients are easily overstimulated by their
environment. Providing a quiet area with low stimulation helps reduce the intensity of the
manic symptoms and promotes safety. Group therapy is often too demanding and
stimulating for a client in an acute manic phase.
2. A nurse is caring for a client who has a prescription for lithium carbonate. Which laboratory
result should the nurse prioritize reviewing before administering the next dose?
A. Serum glucose levels
B. Hemoglobin and hematocrit
,C. Liver function tests
D. Serum sodium levels
Correct Answer: D
Expert Explanation: Sodium levels have a direct impact on lithium excretion by the
kidneys. If sodium levels are low, the kidneys retain lithium, which significantly increases
the risk of toxicity. Monitoring electrolyte balance is a standard requirement for patients on
lithium therapy.
3. The nurse is assessing a client who is suspected of having alcohol withdrawal delirium.
Which clinical manifestation should the nurse expect to observe?
A. Hypotension and bradycardia
B. Hypertension, tachycardia, and diaphoresis
C. Lethargy and decreased muscle tone
D. Increased appetite and somnolence
Correct Answer: B
Expert Explanation: Alcohol withdrawal delirium is a medical emergency characterized
by autonomic hyperactivity. This includes increased heart rate, elevated blood pressure,
and profuse sweating. The nurse must monitor these vital signs closely to prevent
complications such as seizures or cardiac collapse.
, 4. A client is admitted to the psychiatric unit after a suicide attempt. What is the priority
nursing action during the first 24 hours of admission?
A. Allow the client to have private time for reflection.
B. Implement one-on-one observation at all times.
C. Begin teaching the client about antidepressant medications.
D. Encourage the client to participate in all unit activities.
Correct Answer: B
Expert Explanation: Safety is the absolute priority for a client who has recently attempted
suicide. Continuous one-on-one observation ensures that the client cannot harm
themselves while in the facility. Therapeutic activities and education are important, but
only after the client’s immediate safety is secured.
5. A client with schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me I am a bad person.’ Which response by the nurse is therapeutic?
A. ‘There are no voices; you are just imagining things.’
B. ‘Why do you think the voices are saying that?’
C. ‘Don’t worry, the voices will go away once the medicine works.’
D. ‘I do not hear the voices, but I understand they are real to you.’
Correct Answer: D
