HESI RN- MENTAL HEALTH V1-V3 (2025) TEST
BANK Exam Elaborations Questions and
Complete Solutions
Course
NUR PSYCHIATRI (NURPSYCHIATRI)
1. A client with schizophrenia states, "I hear voices telling me to harm myself."
What is the nurse's priority action?
A. Distract the client with a board game
B. Ask the client to describe the voices
C. Initiate one-on-one observation
D. Document the hallucinations
✔ Correct Answer: C. Initiate one-on-one observation
Rationale: The client is experiencing command hallucinations, which pose an immediate safety
risk. One-on-one observation ensures the client's safety, which is the nurse's top priority.
Describing the voices can follow after safety is ensured.
2. A nurse is caring for a client experiencing a manic episode. Which intervention
is most appropriate?
A. Encourage group therapy participation
B. Provide a quiet, low-stimulation environment
C. Allow unlimited physical activity
D. Engage the client in detailed planning
✔ Correct Answer: B. Provide a quiet, low-stimulation environment
Rationale: Clients with mania are highly distractible and overstimulated. A calm setting
minimizes agitation and prevents escalation of symptoms.
3. A client with depression is prescribed sertraline. What side effect should the
nurse monitor for initially?
A. Hyperactivity
B. Suicidal ideation
C. Weight gain
D. Hypertension
,✔ Correct Answer: B. Suicidal ideation
Rationale: SSRIs like sertraline can increase suicidal thoughts in some clients, especially when
beginning treatment. Close monitoring is essential during the first few weeks.
4. What is the most therapeutic response for a nurse to make when a client says,
"I feel like a failure and want to die"?
A. "You should think positively."
B. "Why do you feel like that?"
C. "That must be very difficult. I'm here to listen."
D. "Everyone feels that way sometimes."
✔ Correct Answer: C. "That must be very difficult. I'm here to listen."
Rationale: This statement shows empathy and opens a space for the client to share feelings
without judgment or minimization.
5. Which finding indicates a positive outcome of electroconvulsive therapy (ECT)
in a severely depressed client?
A. Loss of short-term memory
B. Improved mood and energy
C. Elevated blood pressure
D. Increased anxiety
✔ Correct Answer: B. Improved mood and energy
Rationale: ECT is effective in treating severe depression. A key indicator of its success is the
client showing signs of improved mood and motivation.
6. A client with generalized anxiety disorder is prescribed lorazepam. What is the
nurse’s priority teaching?
A. Avoid aged cheeses
B. Rise slowly from a sitting position
C. Do not discontinue the drug abruptly
D. Take the medication with grapefruit juice
✔ Correct Answer: C. Do not discontinue the drug abruptly
Rationale: Abrupt withdrawal from benzodiazepines like lorazepam can cause severe
withdrawal symptoms, including seizures. Gradual tapering is necessary.
, 7. A nurse is teaching about defense mechanisms. Which example best illustrates
projection?
A. A client accuses their partner of being unfaithful when they themselves are having an
affair
B. A client forgets a traumatic event
C. A client returns to sucking their thumb during stress
D. A client jokes about their illness instead of discussing it
✔ Correct Answer: A. A client accuses their partner of being unfaithful when they
themselves are having an affair
Rationale: Projection involves attributing one's unacceptable thoughts or feelings to someone
else.
8. A client is pacing, has clenched fists, and speaks loudly. What is the nurse's
best initial intervention?
A. Call security immediately
B. Offer a PRN antipsychotic
C. Calmly ask the client to describe their feelings
D. Tell the client to calm down
✔ Correct Answer: C. Calmly ask the client to describe their feelings
Rationale: Early de-escalation is key in potential aggression. A calm, non-threatening approach
encourages verbal expression and reduces tension.
9. Which client behavior suggests improvement in a client with major depressive
disorder?
A. Sleeps for extended periods
B. Expresses feelings of guilt
C. Participates in group activities
D. Refuses meals
✔ Correct Answer: C. Participates in group activities
Rationale: Social engagement and increased activity are positive signs of recovery in depressive
clients.
BANK Exam Elaborations Questions and
Complete Solutions
Course
NUR PSYCHIATRI (NURPSYCHIATRI)
1. A client with schizophrenia states, "I hear voices telling me to harm myself."
What is the nurse's priority action?
A. Distract the client with a board game
B. Ask the client to describe the voices
C. Initiate one-on-one observation
D. Document the hallucinations
✔ Correct Answer: C. Initiate one-on-one observation
Rationale: The client is experiencing command hallucinations, which pose an immediate safety
risk. One-on-one observation ensures the client's safety, which is the nurse's top priority.
Describing the voices can follow after safety is ensured.
2. A nurse is caring for a client experiencing a manic episode. Which intervention
is most appropriate?
A. Encourage group therapy participation
B. Provide a quiet, low-stimulation environment
C. Allow unlimited physical activity
D. Engage the client in detailed planning
✔ Correct Answer: B. Provide a quiet, low-stimulation environment
Rationale: Clients with mania are highly distractible and overstimulated. A calm setting
minimizes agitation and prevents escalation of symptoms.
3. A client with depression is prescribed sertraline. What side effect should the
nurse monitor for initially?
A. Hyperactivity
B. Suicidal ideation
C. Weight gain
D. Hypertension
,✔ Correct Answer: B. Suicidal ideation
Rationale: SSRIs like sertraline can increase suicidal thoughts in some clients, especially when
beginning treatment. Close monitoring is essential during the first few weeks.
4. What is the most therapeutic response for a nurse to make when a client says,
"I feel like a failure and want to die"?
A. "You should think positively."
B. "Why do you feel like that?"
C. "That must be very difficult. I'm here to listen."
D. "Everyone feels that way sometimes."
✔ Correct Answer: C. "That must be very difficult. I'm here to listen."
Rationale: This statement shows empathy and opens a space for the client to share feelings
without judgment or minimization.
5. Which finding indicates a positive outcome of electroconvulsive therapy (ECT)
in a severely depressed client?
A. Loss of short-term memory
B. Improved mood and energy
C. Elevated blood pressure
D. Increased anxiety
✔ Correct Answer: B. Improved mood and energy
Rationale: ECT is effective in treating severe depression. A key indicator of its success is the
client showing signs of improved mood and motivation.
6. A client with generalized anxiety disorder is prescribed lorazepam. What is the
nurse’s priority teaching?
A. Avoid aged cheeses
B. Rise slowly from a sitting position
C. Do not discontinue the drug abruptly
D. Take the medication with grapefruit juice
✔ Correct Answer: C. Do not discontinue the drug abruptly
Rationale: Abrupt withdrawal from benzodiazepines like lorazepam can cause severe
withdrawal symptoms, including seizures. Gradual tapering is necessary.
, 7. A nurse is teaching about defense mechanisms. Which example best illustrates
projection?
A. A client accuses their partner of being unfaithful when they themselves are having an
affair
B. A client forgets a traumatic event
C. A client returns to sucking their thumb during stress
D. A client jokes about their illness instead of discussing it
✔ Correct Answer: A. A client accuses their partner of being unfaithful when they
themselves are having an affair
Rationale: Projection involves attributing one's unacceptable thoughts or feelings to someone
else.
8. A client is pacing, has clenched fists, and speaks loudly. What is the nurse's
best initial intervention?
A. Call security immediately
B. Offer a PRN antipsychotic
C. Calmly ask the client to describe their feelings
D. Tell the client to calm down
✔ Correct Answer: C. Calmly ask the client to describe their feelings
Rationale: Early de-escalation is key in potential aggression. A calm, non-threatening approach
encourages verbal expression and reduces tension.
9. Which client behavior suggests improvement in a client with major depressive
disorder?
A. Sleeps for extended periods
B. Expresses feelings of guilt
C. Participates in group activities
D. Refuses meals
✔ Correct Answer: C. Participates in group activities
Rationale: Social engagement and increased activity are positive signs of recovery in depressive
clients.
