HESI MENTAL HEALTH NCLEX-RN WITH
RATIONALES
I. A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of
major depression. The initial nursing care plan includes the goal "Assist client to express
feelings of guilt." What is true about the goal statement referring to the client's depression?
A. Implementation of the goal should be deferred until
further data can be gathered.
B. The depression will dissipate once the client
becomes accustomed to retirement.
C. Depressed clients may be unaware of guilt feelings
and should be encouraged to increase
self-awareness.
D. Nursing goals should be approved by the
treatment team before they are initiated.
Rationale:
Depression is associated with feelings of guilt, and clients are often not aware of these feelings.
Awareness is the first step in dealing with guilt (or any other feeling), so the nurse's efforts
should be directed toward increasing the client's awareness of feelings. Although a goal may be
changed based on an evaluation of interventions to meet the goal, a goal should never be
ignored. Option B dismisses
, the client's symptoms as age-related. Setting goals for the nursing care plan is a function of the
nurse, although the nurse can collaborate with the treatment team.
II. A 22-year-old client is admitted to the psychiatric unit from the medical unit following a
suicide attempt with an overdose of diazepam. When developing the nursing care plan for
this client, which intervention would be most important for the nurse to include?
A. Assist client to focus on personal strengths.
B. Set limits on self-defacing comments.
C. Remind the client of daily activities in the milieu.
D. Assist the client to identify why he or she was
self-destructive.
Rationale:
Encouraging the client to focus on his or her strengths helps the client become aware of positive
qualities, assists in improving self-image, and aids in coping with past and present situations.
Although nursing actions should assist the client in decreasing self-defacing comments and
informing the client of daily activities in the milieu, these interventions are not priorities at this
time. Option D is not as important as assisting the client to overcome the depression, which
resulted in the overdose, and asking "why" is not therapeutic.
III. A client mumbles out loud whether anyone is talking to her or not, and the client also
mumbles in group when others are talking. The nurse determines that the client is
experiencing hallucinations. Which intervention should the nurse implement?
A. Respond to the client's feelings rather than the
illogical thoughts.
B. Identify beliefs and thoughts about what the client
is experiencing.
C. Provide the client with hope that the voices will
eventually go away.
D. Ask the client how she has previously managed
the voices.
, Rationale:
The nurse should promote symptom management and determine how the client previously
managed the voices. Options A and B are interventions that are useful with clients who are
experiencing delusions. Option C is important, but the most important intervention is to promote
symptom management.
1. The nurse reviews the laboratory findings for a client's urine drug screen that is positive for
cocaine. Which client behavior should be expected during cocaine withdrawal?
A. Psychomotor agitation
B. Restlessness and hyperactivity
C. Detachment from reality and drowsiness
D. Distorted perceptions and hallucinations
Rationale:
During cocaine withdrawal, the nurse should expect option A and a pattern of withdrawal
symptoms similar to those of one who uses amphetamines. Options B, C, and D are signs and
symptoms of a person who is high on cocaine rather than one who is experiencing withdrawal
from cocaine.
2. A middle-aged adult was discharged from a treatment center 6 weeks ago following treatment
for suicide ideation and alcohol abuse. In a follow-up visit to the mental health clinic, the
client complains of lethargy, apathy, irritability, and anxiety. Which question is most
important for the nurse to ask?
A. "Are you taking prescribed antidepressants?"
B. "How much alcohol do you consume daily?"
C. "What seems to precipitate the anxious feelings?"
D. "How many hours do you sleep per day?"
Rationale:
First, and most importantly, the client's use of alcohol should be determined because further
treatment is dependent on the client's sobriety, and asking how much alcohol is being consumed
is a better question than asking if the client is drinking, which is a "yes-no" answer that does not
, promote dialogue. Options A, C, and D provide worthwhile assessment data, but first the nurse
should determine if
RATIONALES
I. A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of
major depression. The initial nursing care plan includes the goal "Assist client to express
feelings of guilt." What is true about the goal statement referring to the client's depression?
A. Implementation of the goal should be deferred until
further data can be gathered.
B. The depression will dissipate once the client
becomes accustomed to retirement.
C. Depressed clients may be unaware of guilt feelings
and should be encouraged to increase
self-awareness.
D. Nursing goals should be approved by the
treatment team before they are initiated.
Rationale:
Depression is associated with feelings of guilt, and clients are often not aware of these feelings.
Awareness is the first step in dealing with guilt (or any other feeling), so the nurse's efforts
should be directed toward increasing the client's awareness of feelings. Although a goal may be
changed based on an evaluation of interventions to meet the goal, a goal should never be
ignored. Option B dismisses
, the client's symptoms as age-related. Setting goals for the nursing care plan is a function of the
nurse, although the nurse can collaborate with the treatment team.
II. A 22-year-old client is admitted to the psychiatric unit from the medical unit following a
suicide attempt with an overdose of diazepam. When developing the nursing care plan for
this client, which intervention would be most important for the nurse to include?
A. Assist client to focus on personal strengths.
B. Set limits on self-defacing comments.
C. Remind the client of daily activities in the milieu.
D. Assist the client to identify why he or she was
self-destructive.
Rationale:
Encouraging the client to focus on his or her strengths helps the client become aware of positive
qualities, assists in improving self-image, and aids in coping with past and present situations.
Although nursing actions should assist the client in decreasing self-defacing comments and
informing the client of daily activities in the milieu, these interventions are not priorities at this
time. Option D is not as important as assisting the client to overcome the depression, which
resulted in the overdose, and asking "why" is not therapeutic.
III. A client mumbles out loud whether anyone is talking to her or not, and the client also
mumbles in group when others are talking. The nurse determines that the client is
experiencing hallucinations. Which intervention should the nurse implement?
A. Respond to the client's feelings rather than the
illogical thoughts.
B. Identify beliefs and thoughts about what the client
is experiencing.
C. Provide the client with hope that the voices will
eventually go away.
D. Ask the client how she has previously managed
the voices.
, Rationale:
The nurse should promote symptom management and determine how the client previously
managed the voices. Options A and B are interventions that are useful with clients who are
experiencing delusions. Option C is important, but the most important intervention is to promote
symptom management.
1. The nurse reviews the laboratory findings for a client's urine drug screen that is positive for
cocaine. Which client behavior should be expected during cocaine withdrawal?
A. Psychomotor agitation
B. Restlessness and hyperactivity
C. Detachment from reality and drowsiness
D. Distorted perceptions and hallucinations
Rationale:
During cocaine withdrawal, the nurse should expect option A and a pattern of withdrawal
symptoms similar to those of one who uses amphetamines. Options B, C, and D are signs and
symptoms of a person who is high on cocaine rather than one who is experiencing withdrawal
from cocaine.
2. A middle-aged adult was discharged from a treatment center 6 weeks ago following treatment
for suicide ideation and alcohol abuse. In a follow-up visit to the mental health clinic, the
client complains of lethargy, apathy, irritability, and anxiety. Which question is most
important for the nurse to ask?
A. "Are you taking prescribed antidepressants?"
B. "How much alcohol do you consume daily?"
C. "What seems to precipitate the anxious feelings?"
D. "How many hours do you sleep per day?"
Rationale:
First, and most importantly, the client's use of alcohol should be determined because further
treatment is dependent on the client's sobriety, and asking how much alcohol is being consumed
is a better question than asking if the client is drinking, which is a "yes-no" answer that does not
, promote dialogue. Options A, C, and D provide worthwhile assessment data, but first the nurse
should determine if
