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HESI Mental Health Practice Questions
1. For a female client with major depressive disorder reporting feelings of hopelessness and helplessness, what is the nurse's priority intervention?
- A. Encourage the client to join a support group.
- B. Refer the client for cognitive-behavioral therapy (CBT).
- C. Assess the client's risk for suicide.
- D. Suggest the client participate in daily exercise.
Correct answer: C
Rationale: The correct answer is to assess the client's risk for suicide. When a client expresses feelings of hopelessness and helplessness, it indicates a high risk of self-harm or suicide. Therefore, the priority intervention should be to assess the client's safety. Encouraging the client to join a support group (choice A) may be beneficial but not the priority at this time. Referring the client for cognitive-behavioral therapy (CBT) (choice B) and suggesting daily exercise (choice D) are important interventions in managing depression but assessing the risk for suicide takes precedence due to the immediate safety concern.
2. Which action should the nurse implement first for a client experiencing alcohol withdrawal?
- A. Apply vest or extremity restraints.
- B. Give an alpha-adrenergic blocker.
- C. Provide a diet high in protein and calories.
- D. Prepare the environment to prevent self-injury.
Correct answer: D
Rationale: The correct action for the nurse to implement first for a client experiencing alcohol withdrawal is to prepare the environment to prevent self-injury. Clients undergoing alcohol withdrawal are at risk of seizures and other symptoms that may lead to self-harm. By ensuring a safe environment, the nurse can mitigate the risk of injury. Applying restraints (Choice A) should only be considered if less restrictive measures fail, as restraints can agitate the client further. Giving an alpha-adrenergic blocker (Choice B) may be part of the treatment plan for alcohol withdrawal but is not the first action to take. Providing a diet high in protein and calories (Choice C) is important for overall health but is not the priority when addressing immediate safety concerns.
3. The RN is preparing to administer a prescribed dose of haloperidol (Haldol) to a client with schizophrenia. The client begins to exhibit muscle rigidity, fever, and altered mental status. What action should the RN take first?
- A. Administer the haloperidol as prescribed.
- B. Monitor the client's vital signs closely.
- C. Hold the medication and notify the healthcare provider.
- D. Give the client an antipyretic for the fever.
Correct answer: C
Rationale: Muscle rigidity, fever, and altered mental status are symptoms of neuroleptic malignant syndrome (NMS), a potentially life-threatening reaction to antipsychotic medications. The RN should hold the medication and notify the healthcare provider immediately. Option A is incorrect because administering more of the medication can worsen the symptoms. Option B is not the first priority when the client is experiencing symptoms of NMS. Option D is incorrect as addressing the fever alone does not address the underlying issue of NMS caused by haloperidol.
4. A client with major depressive disorder is being treated with cognitive-behavioral therapy (CBT). Which client statement indicates that CBT is having a positive effect?
- A. "I understand now that my negative thoughts are not always true."
- B. "I still feel down, but I am able to go to work."
- C. "I have stopped taking my antidepressant medication."
- D. "I avoid situations that make me feel anxious."
Correct answer: A
Rationale: The correct answer is A. Recognizing and challenging negative thoughts is a fundamental aspect of cognitive-behavioral therapy (CBT). In this statement, the client demonstrates insight into the fact that their negative thoughts may not always be accurate, showing progress in reframing their thoughts. Choice B indicates some improvement in functioning but does not directly relate to the core principles of CBT. Choice C is concerning as abruptly stopping antidepressant medication can be detrimental to the client's well-being. Choice D reflects avoidance behavior, which is typically a target for intervention in CBT rather than a sign of positive progress.
5. A teenaged client, a heroin addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?
- A. Assign the client to a teen support group.
- B. Assess intake and output.
- C. Monitor for wheezing and apnea.
- D. Limit visitors to family members only.
Correct answer: B
Rationale: Assessing intake and output is crucial during the first 24 hours after admission for detoxification. This helps the nurse monitor the client's hydration status and kidney function as the body goes through withdrawal from heroin. Option A is incorrect because joining a support group is beneficial but may not be the priority in the initial phase of detoxification. Option C, monitoring for wheezing and apnea, is important but not the most critical intervention during the first 24 hours. Option D, limiting visitors to family members only, is not directly related to the immediate needs of assessing intake and output.
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