Mental Health Hesi Exam Version 4 Newest 2024-2025
Actual Exam Complete 84 Questions And Correct
Detailed Answers (Verified Answers).
The nurse completes a physical assessment. When asked what brought her to the hospital, the client replies
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that things just aren't right and begins to cry. After further conversation, the client describes her mood as
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very sad now. She rarely goes out or invites friends to visit. She admits that she feels like strangers are saying
j j j j j j j j j j j j j j j j j j j j j
bad things about her. Sometimes she hears a man's voice that is a little bit scary.
j j j j j j j j j j j j j j j j
What is the priority focused nursing assessment? - CORRECT ANSWER✔✔Determine how long the client
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has been hearing the voice and what it is saying.
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Rationale: Determining if voices are being heard and the type of voices are priority. The nurse must assess
j j j j j j j j j j j j j j j j j
the content of the auditory hallucinations for the presence of command hallucinations. Command
j j j j j j j j j j j j j
hallucinations may be telling the client to harm herself or others.
j j j j j j j j j j j
The client is assessed by the nurse, a social worker, and the healthcare provider (HCP). Based on their
j j j j j j j j j j j j j j j j j
assessments, hospitalization is recommended for psychotic depression.
j j j j j j j
Which behavior is inconsistent with depression? - CORRECT ANSWER✔✔Hearing a man's voice.
j j j j j j j j j j j
,Rationale: Auditory hallucinations are inconsistent with depression and are more likely to occur with
j j j j j j j j j j j j j
psychoses. However, clients may experience a psychotic depression in which there is evidence of psychosis.
j j j j j j j j j j j j j j j
The nurse asks the client to sign the consent for treatment.
j j j j j j j j j j
If the client refuses treatment, which behaviors justify short-term involuntary treatment? (Select all that
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apply. One, some, or all options may be correct.) - CORRECT ANSWER✔✔Unable to meet basic self-care
j j j j j j j j j j j j j j j j
needs.
j
Rationale: Involuntary treatment can be initiated if the client is unable to meet basic self-care needs in such
j j j j j j j j j j j j j j j j j
a way that he or she is a danger to self.
j j j j j j j j j j j
States she has a plan to harm herself.
j j j j j j j
Rationale: Short-term involuntary care may be initiated to protect the client if she has a plan to harm herself.
j j j j j j j j j j j j j j j j j j
It can also be initiated if she presents an intentional danger to others.
j j j j j j j j j j j j j
The client signs the treatment form and is admitted to the mental health unit. During the first days of
j j j j j j j j j j j j j j j j j j
hospitalization, she begins antidepressant therapy with fluoxetine 10 mg.
j j j j j j j j j
In what classification of drugs is the antidepressant fluoxetine? - CORRECT ANSWER✔✔Selective serotonin
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reuptake inhibitor (SSRI).
j j j
Rationale: Fluoxetine is an SSRI antidepressant. j j j j j
What is the major action of SSRI antidepressants? - CORRECT ANSWER✔✔Increase availability of
j j j j j j j j j j j j
serotonin.
j
Rationale: The major action of SSRIs is to selectively inhibit the reuptake of serotonin and increase the
j j j j j j j j j j j j j j j j
availability of serotonin.
j j j
The nurse understands that SSRIs are now more widely prescribed than tricyclics for antidepressant
j j j j j j j j j j j j j
therapy. What is the rationale? - CORRECT ANSWER✔✔Tricyclics have more dangerous side effects.
j j j j j j j j j j j j j
Rationale: SSRIs are more widely prescribed than tricyclics because they have fewer side effects, and
j j j j j j j j j j j j j j
tricyclics can be lethal in an overdose because they are cardiotoxic.
j j j j j j j j j j j
, When the client receives fluoxetine, the nurse must explain the purpose and when to expect therapeutic
j j j j j j j j j j j j j j j
effectiveness. What should the nurse tell the client regarding when she will begin to feel less depressed? -
j j j j j j j j j j j j j j j j j j
CORRECT ANSWER✔✔Generally within 1 to 4 weeks.
j j j j j j j
Rationale: In general, it takes 2 to 4 weeks for antidepressant effects to begin. However, it depends on the
j j j j j j j j j j j j j j j j j j
individual, and some clients may feel effects start as soon as 1 week or as late as 4 weeks. It is suggested that
j j j j j j j j j j j j j j j j j j j j j j j
depression occurs when a depletion of neurotransmitters in the synapse cause the transmitter receptors to
j j j j j j j j j j j j j j j
increase. As the antidepressants make more transmitters available, it takes the receptors several weeks to
j j j j j j j j j j j j j j j
return their numbers back to normal and allow normal synaptic activity.
j j j j j j j j j j j
The nurse should be aware of common side effects of SSRI antidepressants such as fluoxetine. Which side
j j j j j j j j j j j j j j j j
effect should be communicated to the client that commonly occur in clients who are taking SSRI
j j j j j j j j j j j j j j j j
antidepressants? - CORRECT ANSWER✔✔Gastrointestinal disturbances.
j j j j j
Rationale: GI disturbances such as nausea and diarrhea, as well as genitourinary side effects such as sexual
j j j j j j j j j j j j j j j j
dysfunction, are common with SSRIs. SSRIs do not have significant anticholinergic, cardiovascular, or
j j j j j j j j j j j j j
sedative side effects.
j j j
The client also begins an atypical antipsychotic, risperidone, because she reports hearing a "scary voice"
j j j j j j j j j j j j j j
upon admission. Although the client remains very withdrawn and noncommunicative, the nurse must
j j j j j j j j j j j j j
explain the purpose of risperidone. Which explanation is best? - CORRECT ANSWER✔✔Risperidone will
j j j j j j j j j j j j j
help the think more clearly.
j j j j j
Rationale: Antipsychotic medications target symptoms related to disorders of thinking such as psychosis
j j j j j j j j j j j j
and behaviors associated with agitation and disorganization or speech and behavior.
j j j j j j j j j j j
The nurse is reviewing the client's admission lab work on the third day of hospitalization. Admission labs
j j j j j j j j j j j j j j j j
include thyroid profile, urinalysis, chemistry panel, pregnancy test, urine drug screen, and VDRL (RPR) which
j j j j j j j j j j j j j j j
tests for venereal disease.
j j j j
A thyroid profile is important for several reasons. What role do thyroid levels play in depression? - CORRECT
j j j j j j j j j j j j j j j j j
ANSWER✔✔Hypothyroidism can lead to feeling sluggish and depressed.
j j j j j j j j
Rationale: Thyroid levels can help detect hypothyroidism, which can lead to depression.
j j j j j j j j j j j
Actual Exam Complete 84 Questions And Correct
Detailed Answers (Verified Answers).
The nurse completes a physical assessment. When asked what brought her to the hospital, the client replies
j j j j j j j j j j j j j j j j
that things just aren't right and begins to cry. After further conversation, the client describes her mood as
j j j j j j j j j j j j j j j j j j
very sad now. She rarely goes out or invites friends to visit. She admits that she feels like strangers are saying
j j j j j j j j j j j j j j j j j j j j j
bad things about her. Sometimes she hears a man's voice that is a little bit scary.
j j j j j j j j j j j j j j j j
What is the priority focused nursing assessment? - CORRECT ANSWER✔✔Determine how long the client
j j j j j j j j j j j j j
has been hearing the voice and what it is saying.
j j j j j j j j j j
Rationale: Determining if voices are being heard and the type of voices are priority. The nurse must assess
j j j j j j j j j j j j j j j j j
the content of the auditory hallucinations for the presence of command hallucinations. Command
j j j j j j j j j j j j j
hallucinations may be telling the client to harm herself or others.
j j j j j j j j j j j
The client is assessed by the nurse, a social worker, and the healthcare provider (HCP). Based on their
j j j j j j j j j j j j j j j j j
assessments, hospitalization is recommended for psychotic depression.
j j j j j j j
Which behavior is inconsistent with depression? - CORRECT ANSWER✔✔Hearing a man's voice.
j j j j j j j j j j j
,Rationale: Auditory hallucinations are inconsistent with depression and are more likely to occur with
j j j j j j j j j j j j j
psychoses. However, clients may experience a psychotic depression in which there is evidence of psychosis.
j j j j j j j j j j j j j j j
The nurse asks the client to sign the consent for treatment.
j j j j j j j j j j
If the client refuses treatment, which behaviors justify short-term involuntary treatment? (Select all that
j j j j j j j j j j j j j
apply. One, some, or all options may be correct.) - CORRECT ANSWER✔✔Unable to meet basic self-care
j j j j j j j j j j j j j j j j
needs.
j
Rationale: Involuntary treatment can be initiated if the client is unable to meet basic self-care needs in such
j j j j j j j j j j j j j j j j j
a way that he or she is a danger to self.
j j j j j j j j j j j
States she has a plan to harm herself.
j j j j j j j
Rationale: Short-term involuntary care may be initiated to protect the client if she has a plan to harm herself.
j j j j j j j j j j j j j j j j j j
It can also be initiated if she presents an intentional danger to others.
j j j j j j j j j j j j j
The client signs the treatment form and is admitted to the mental health unit. During the first days of
j j j j j j j j j j j j j j j j j j
hospitalization, she begins antidepressant therapy with fluoxetine 10 mg.
j j j j j j j j j
In what classification of drugs is the antidepressant fluoxetine? - CORRECT ANSWER✔✔Selective serotonin
j j j j j j j j j j j j
reuptake inhibitor (SSRI).
j j j
Rationale: Fluoxetine is an SSRI antidepressant. j j j j j
What is the major action of SSRI antidepressants? - CORRECT ANSWER✔✔Increase availability of
j j j j j j j j j j j j
serotonin.
j
Rationale: The major action of SSRIs is to selectively inhibit the reuptake of serotonin and increase the
j j j j j j j j j j j j j j j j
availability of serotonin.
j j j
The nurse understands that SSRIs are now more widely prescribed than tricyclics for antidepressant
j j j j j j j j j j j j j
therapy. What is the rationale? - CORRECT ANSWER✔✔Tricyclics have more dangerous side effects.
j j j j j j j j j j j j j
Rationale: SSRIs are more widely prescribed than tricyclics because they have fewer side effects, and
j j j j j j j j j j j j j j
tricyclics can be lethal in an overdose because they are cardiotoxic.
j j j j j j j j j j j
, When the client receives fluoxetine, the nurse must explain the purpose and when to expect therapeutic
j j j j j j j j j j j j j j j
effectiveness. What should the nurse tell the client regarding when she will begin to feel less depressed? -
j j j j j j j j j j j j j j j j j j
CORRECT ANSWER✔✔Generally within 1 to 4 weeks.
j j j j j j j
Rationale: In general, it takes 2 to 4 weeks for antidepressant effects to begin. However, it depends on the
j j j j j j j j j j j j j j j j j j
individual, and some clients may feel effects start as soon as 1 week or as late as 4 weeks. It is suggested that
j j j j j j j j j j j j j j j j j j j j j j j
depression occurs when a depletion of neurotransmitters in the synapse cause the transmitter receptors to
j j j j j j j j j j j j j j j
increase. As the antidepressants make more transmitters available, it takes the receptors several weeks to
j j j j j j j j j j j j j j j
return their numbers back to normal and allow normal synaptic activity.
j j j j j j j j j j j
The nurse should be aware of common side effects of SSRI antidepressants such as fluoxetine. Which side
j j j j j j j j j j j j j j j j
effect should be communicated to the client that commonly occur in clients who are taking SSRI
j j j j j j j j j j j j j j j j
antidepressants? - CORRECT ANSWER✔✔Gastrointestinal disturbances.
j j j j j
Rationale: GI disturbances such as nausea and diarrhea, as well as genitourinary side effects such as sexual
j j j j j j j j j j j j j j j j
dysfunction, are common with SSRIs. SSRIs do not have significant anticholinergic, cardiovascular, or
j j j j j j j j j j j j j
sedative side effects.
j j j
The client also begins an atypical antipsychotic, risperidone, because she reports hearing a "scary voice"
j j j j j j j j j j j j j j
upon admission. Although the client remains very withdrawn and noncommunicative, the nurse must
j j j j j j j j j j j j j
explain the purpose of risperidone. Which explanation is best? - CORRECT ANSWER✔✔Risperidone will
j j j j j j j j j j j j j
help the think more clearly.
j j j j j
Rationale: Antipsychotic medications target symptoms related to disorders of thinking such as psychosis
j j j j j j j j j j j j
and behaviors associated with agitation and disorganization or speech and behavior.
j j j j j j j j j j j
The nurse is reviewing the client's admission lab work on the third day of hospitalization. Admission labs
j j j j j j j j j j j j j j j j
include thyroid profile, urinalysis, chemistry panel, pregnancy test, urine drug screen, and VDRL (RPR) which
j j j j j j j j j j j j j j j
tests for venereal disease.
j j j j
A thyroid profile is important for several reasons. What role do thyroid levels play in depression? - CORRECT
j j j j j j j j j j j j j j j j j
ANSWER✔✔Hypothyroidism can lead to feeling sluggish and depressed.
j j j j j j j j
Rationale: Thyroid levels can help detect hypothyroidism, which can lead to depression.
j j j j j j j j j j j
