HESI EXIT MENTAL HEALTH NURSING EXAM 2025 | 170
QUESTIONS WITH ACCURATE SOLUTIONS
1. What is the appropriate medication to administer for a client exhibiting
signs of delirium tremens (DTs)?
Lorazepam (Ativan) 2 mg IM.
Prochlorperazine (Compazine) 5 mg IM.
Hydromorphone (Dialuadid) 2 mg IM.
Chlorpromazine (Thorazine) 50 mg IM.
2. What is the first action a nurse should take when a client threatens
physical harm with a broken chair leg?
Remove the other client from the room.
Administer the prescribed medication.
Call for security assistance.
Document the incident in the client's chart.
3. Why is it crucial for a client with liver damage to avoid over-the-counter
medications?
Over-the-counter medications can further harm the liver.
They are not effective for treating liver damage.
They can cause psychological distress.
They have no effect on liver health.
4. Why is it important for the RN to escort the client out of the bathroom in
this scenario?
To ensure the client's safety and maintain a hygienic
environment.
, To punish the client for inappropriate behavior.
To teach the client a lesson about cleanliness.
To allow the client to express himself freely.
5. In a scenario where a client with a history of alcohol use disorder is
admitted with severe agitation and confusion, what would be the most
appropriate nursing intervention based on the potential for delirium
tremens?
Administer Lorazepam as prescribed to manage agitation and
prevent progression to DTs.
Provide the client with opioid pain relief to address discomfort.
Encourage the client to engage in physical activity to reduce
agitation.
Monitor the client for signs of infection related to facial injuries.
6. A nurse working on a mental health unit receives a community call from a
person who is tearful and states, "I just feel so nervous all of the time. I
don't know what to do about my problems. I haven't been able to sleep
at night and have hardly eaten for the past 3 or 4 days." Which
assessment finding should the nurse reference when initiating a referral?
Altered thought processes.
Moderate levels of anxiety.
Inadequate social support.
Altered health maintenance.
7. Why is it important to take other clients to the lounge when a client is
agitated and refusing medication?
It helps to ensure the safety and comfort of all clients in the unit.
It allows the staff to focus solely on the agitated client.
, It prevents the agitated client from receiving any attention.
It minimizes the need for medication administration.
8. Why is it crucial for the nurse to include medication restrictions in the
discharge plan for a client with liver damage from an acetaminophen
overdose?
To prevent additional harm to the liver and ensure safe recovery
To encourage the client to self-medicate
To promote independence in medication management
To facilitate quicker discharge from the hospital
9. What is the first action the RN should take upon suspecting elder abuse
in a client?
Measure and document size, shape and color of the bruised
areas.
Ask the client specific questions about someone causing the
bruising.
Question the family members and caregiver how the bruising
occurred.
Report family conversations and anger towards the client when
visiting.
10. What are the symptoms that indicate a client on lithium carbonate may
be experiencing toxicity?
Diarrhea, vomiting, and drowsiness
Headache and insomnia
Increased appetite and weight gain
Anxiety and agitation
, 11. In a similar situation, if a client with severe agitation is found engaging in
self-harm behaviors, what should the RN prioritize in their intervention?
Ensure the client's safety by removing harmful objects and
providing a safe environment.
Encourage the client to talk about their feelings.
Provide medication to calm the client immediately.
Leave the client alone to avoid escalating the situation.
12. In a similar situation where a client exhibits aggressive behavior, what
intervention should the nurse prioritize to ensure safety?
Implement de-escalation techniques to manage the client's
behavior and ensure safety for all clients.
Encourage the client to engage in physical activities to expend
energy.
Provide the client with a quiet space to reflect on her actions.
Offer medication to calm the client immediately.
13. Mr. O, a manic depressive client, has been on Lithium 6 days. He tells the
nurse he feels drowsy, weak, shaky, and has diarrhea. Current Li level is
1.5 mEq/L. What is the nurse's initial action?
Administer Lomotil for his diarrhea
Encourage him to rest and drink extra fluids
Continue to observe and assess him for further symptoms
Withhold further Li and promptly call the physician
14. In view of Brenda's presenting problem, she is immediately placed on
suicide precautions. Several nursing diagnoses can apply to suicidal
persons. Which of the following takes highest priority for Brenda at this
time?
QUESTIONS WITH ACCURATE SOLUTIONS
1. What is the appropriate medication to administer for a client exhibiting
signs of delirium tremens (DTs)?
Lorazepam (Ativan) 2 mg IM.
Prochlorperazine (Compazine) 5 mg IM.
Hydromorphone (Dialuadid) 2 mg IM.
Chlorpromazine (Thorazine) 50 mg IM.
2. What is the first action a nurse should take when a client threatens
physical harm with a broken chair leg?
Remove the other client from the room.
Administer the prescribed medication.
Call for security assistance.
Document the incident in the client's chart.
3. Why is it crucial for a client with liver damage to avoid over-the-counter
medications?
Over-the-counter medications can further harm the liver.
They are not effective for treating liver damage.
They can cause psychological distress.
They have no effect on liver health.
4. Why is it important for the RN to escort the client out of the bathroom in
this scenario?
To ensure the client's safety and maintain a hygienic
environment.
, To punish the client for inappropriate behavior.
To teach the client a lesson about cleanliness.
To allow the client to express himself freely.
5. In a scenario where a client with a history of alcohol use disorder is
admitted with severe agitation and confusion, what would be the most
appropriate nursing intervention based on the potential for delirium
tremens?
Administer Lorazepam as prescribed to manage agitation and
prevent progression to DTs.
Provide the client with opioid pain relief to address discomfort.
Encourage the client to engage in physical activity to reduce
agitation.
Monitor the client for signs of infection related to facial injuries.
6. A nurse working on a mental health unit receives a community call from a
person who is tearful and states, "I just feel so nervous all of the time. I
don't know what to do about my problems. I haven't been able to sleep
at night and have hardly eaten for the past 3 or 4 days." Which
assessment finding should the nurse reference when initiating a referral?
Altered thought processes.
Moderate levels of anxiety.
Inadequate social support.
Altered health maintenance.
7. Why is it important to take other clients to the lounge when a client is
agitated and refusing medication?
It helps to ensure the safety and comfort of all clients in the unit.
It allows the staff to focus solely on the agitated client.
, It prevents the agitated client from receiving any attention.
It minimizes the need for medication administration.
8. Why is it crucial for the nurse to include medication restrictions in the
discharge plan for a client with liver damage from an acetaminophen
overdose?
To prevent additional harm to the liver and ensure safe recovery
To encourage the client to self-medicate
To promote independence in medication management
To facilitate quicker discharge from the hospital
9. What is the first action the RN should take upon suspecting elder abuse
in a client?
Measure and document size, shape and color of the bruised
areas.
Ask the client specific questions about someone causing the
bruising.
Question the family members and caregiver how the bruising
occurred.
Report family conversations and anger towards the client when
visiting.
10. What are the symptoms that indicate a client on lithium carbonate may
be experiencing toxicity?
Diarrhea, vomiting, and drowsiness
Headache and insomnia
Increased appetite and weight gain
Anxiety and agitation
, 11. In a similar situation, if a client with severe agitation is found engaging in
self-harm behaviors, what should the RN prioritize in their intervention?
Ensure the client's safety by removing harmful objects and
providing a safe environment.
Encourage the client to talk about their feelings.
Provide medication to calm the client immediately.
Leave the client alone to avoid escalating the situation.
12. In a similar situation where a client exhibits aggressive behavior, what
intervention should the nurse prioritize to ensure safety?
Implement de-escalation techniques to manage the client's
behavior and ensure safety for all clients.
Encourage the client to engage in physical activities to expend
energy.
Provide the client with a quiet space to reflect on her actions.
Offer medication to calm the client immediately.
13. Mr. O, a manic depressive client, has been on Lithium 6 days. He tells the
nurse he feels drowsy, weak, shaky, and has diarrhea. Current Li level is
1.5 mEq/L. What is the nurse's initial action?
Administer Lomotil for his diarrhea
Encourage him to rest and drink extra fluids
Continue to observe and assess him for further symptoms
Withhold further Li and promptly call the physician
14. In view of Brenda's presenting problem, she is immediately placed on
suicide precautions. Several nursing diagnoses can apply to suicidal
persons. Which of the following takes highest priority for Brenda at this
time?
