HESI Mental Health Exam 2024 WELL
WRITTEN QUESTIONS
WITH(VERIFIEND ) ANSWERS GRADED
A+ FOR ALL STUDENTS
The nurse completes a physical assessment. When
asked what brought her to the hospital, the client
replies that things just aren't right and begins to cry.
After further conversation, the client describes her
mood as very sad now. She rarely goes out or invites
friends to visit. She admits that she feels like
strangers are saying bad things about her.
Sometimes she hears a man's voice that is a little bit
scary.
What is the priority focused nursing assessment? -
ANSWER-Determine how long the client has been
hearing the voice and what it is saying.
Rationale: Determining if voices are being heard and
the type of voices are priority. The nurse must assess
the content of the auditory hallucinations for the
presence of command hallucinations. Command
hallucinations may be telling the client to harm
herself or others.
,The client is assessed by the nurse, a social worker,
and the healthcare provider (HCP). Based on their
assessments, hospitalization is recommended for
psychotic depression.
Which behavior is inconsistent with depression? -
ANSWER-Hearing a man's voice.
Rationale: Auditory hallucinations are inconsistent
with depression and are more likely to occur with
psychoses. However, clients may experience a
psychotic depression in which there is evidence of
psychosis.
The nurse asks the client to sign the consent for
treatment.
If the client refuses treatment, which behaviors justify
short-term involuntary treatment? (Select all that
apply. One, some, or all options may be correct.) -
ANSWER-Unable to meet basic self-care needs.
Rationale: Involuntary treatment can be initiated if
the client is unable to meet basic self-care needs in
such a way that he or she is a danger to self.
States she has a plan to harm herself.
Rationale: Short-term involuntary care may be
initiated to protect the client if she has a plan to harm
herself. It can also be initiated if she presents an
intentional danger to others.
The client signs the treatment form and is admitted to
the mental health unit. During the first days of
,hospitalization, she begins antidepressant therapy
with fluoxetine 10 mg.
In what classification of drugs is the antidepressant
fluoxetine? - ANSWER-Selective serotonin reuptake
inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
What is the major action of SSRI antidepressants? -
ANSWER-Increase availability of serotonin.
Rationale: The major action of SSRIs is to selectively
inhibit the reuptake of serotonin and increase the
availability of serotonin.
The nurse understands that SSRIs are now more
widely prescribed than tricyclics for antidepressant
therapy. What is the rationale? - ANSWER-Tricyclics
have more dangerous side effects.
Rationale: SSRIs are more widely prescribed than
tricyclics because they have fewer side effects, and
tricyclics can be lethal in an overdose because they
are cardiotoxic.
When the client receives fluoxetine, the nurse must
explain the purpose and when to expect therapeutic
effectiveness. What should the nurse tell the client
regarding when she will begin to feel less depressed?
- ANSWER-Generally within 1 to 4 weeks.
Rationale: In general, it takes 2 to 4 weeks for
antidepressant effects to begin. However, it depends
on the individual, and some clients may feel effects
, start as soon as 1 week or as late as 4 weeks. It is
suggested that depression occurs when a depletion
of neurotransmitters in the synapse cause the
transmitter receptors to increase. As the
antidepressants make more transmitters available, it
takes the receptors several weeks to return their
numbers back to normal and allow normal synaptic
activity.
The nurse should be aware of common side effects of
SSRI antidepressants such as fluoxetine. Which side
effect should be communicated to the client that
commonly occur in clients who are taking SSRI
antidepressants? - ANSWER-Gastrointestinal
disturbances.
Rationale: GI disturbances such as nausea and
diarrhea, as well as genitourinary side effects such
as sexual dysfunction, are common with SSRIs. SSRIs
do not have significant anticholinergic,
cardiovascular, or sedative side effects.
The client also begins an atypical antipsychotic,
risperidone, because she reports hearing a "scary
voice" upon admission. Although the client remains
very withdrawn and noncommunicative, the nurse
must explain the purpose of risperidone. Which
explanation is best? - ANSWER-Risperidone will help
the think more clearly.
Rationale: Antipsychotic medications target
symptoms related to disorders of thinking such as
WRITTEN QUESTIONS
WITH(VERIFIEND ) ANSWERS GRADED
A+ FOR ALL STUDENTS
The nurse completes a physical assessment. When
asked what brought her to the hospital, the client
replies that things just aren't right and begins to cry.
After further conversation, the client describes her
mood as very sad now. She rarely goes out or invites
friends to visit. She admits that she feels like
strangers are saying bad things about her.
Sometimes she hears a man's voice that is a little bit
scary.
What is the priority focused nursing assessment? -
ANSWER-Determine how long the client has been
hearing the voice and what it is saying.
Rationale: Determining if voices are being heard and
the type of voices are priority. The nurse must assess
the content of the auditory hallucinations for the
presence of command hallucinations. Command
hallucinations may be telling the client to harm
herself or others.
,The client is assessed by the nurse, a social worker,
and the healthcare provider (HCP). Based on their
assessments, hospitalization is recommended for
psychotic depression.
Which behavior is inconsistent with depression? -
ANSWER-Hearing a man's voice.
Rationale: Auditory hallucinations are inconsistent
with depression and are more likely to occur with
psychoses. However, clients may experience a
psychotic depression in which there is evidence of
psychosis.
The nurse asks the client to sign the consent for
treatment.
If the client refuses treatment, which behaviors justify
short-term involuntary treatment? (Select all that
apply. One, some, or all options may be correct.) -
ANSWER-Unable to meet basic self-care needs.
Rationale: Involuntary treatment can be initiated if
the client is unable to meet basic self-care needs in
such a way that he or she is a danger to self.
States she has a plan to harm herself.
Rationale: Short-term involuntary care may be
initiated to protect the client if she has a plan to harm
herself. It can also be initiated if she presents an
intentional danger to others.
The client signs the treatment form and is admitted to
the mental health unit. During the first days of
,hospitalization, she begins antidepressant therapy
with fluoxetine 10 mg.
In what classification of drugs is the antidepressant
fluoxetine? - ANSWER-Selective serotonin reuptake
inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
What is the major action of SSRI antidepressants? -
ANSWER-Increase availability of serotonin.
Rationale: The major action of SSRIs is to selectively
inhibit the reuptake of serotonin and increase the
availability of serotonin.
The nurse understands that SSRIs are now more
widely prescribed than tricyclics for antidepressant
therapy. What is the rationale? - ANSWER-Tricyclics
have more dangerous side effects.
Rationale: SSRIs are more widely prescribed than
tricyclics because they have fewer side effects, and
tricyclics can be lethal in an overdose because they
are cardiotoxic.
When the client receives fluoxetine, the nurse must
explain the purpose and when to expect therapeutic
effectiveness. What should the nurse tell the client
regarding when she will begin to feel less depressed?
- ANSWER-Generally within 1 to 4 weeks.
Rationale: In general, it takes 2 to 4 weeks for
antidepressant effects to begin. However, it depends
on the individual, and some clients may feel effects
, start as soon as 1 week or as late as 4 weeks. It is
suggested that depression occurs when a depletion
of neurotransmitters in the synapse cause the
transmitter receptors to increase. As the
antidepressants make more transmitters available, it
takes the receptors several weeks to return their
numbers back to normal and allow normal synaptic
activity.
The nurse should be aware of common side effects of
SSRI antidepressants such as fluoxetine. Which side
effect should be communicated to the client that
commonly occur in clients who are taking SSRI
antidepressants? - ANSWER-Gastrointestinal
disturbances.
Rationale: GI disturbances such as nausea and
diarrhea, as well as genitourinary side effects such
as sexual dysfunction, are common with SSRIs. SSRIs
do not have significant anticholinergic,
cardiovascular, or sedative side effects.
The client also begins an atypical antipsychotic,
risperidone, because she reports hearing a "scary
voice" upon admission. Although the client remains
very withdrawn and noncommunicative, the nurse
must explain the purpose of risperidone. Which
explanation is best? - ANSWER-Risperidone will help
the think more clearly.
Rationale: Antipsychotic medications target
symptoms related to disorders of thinking such as
