HESI RN
RN Hesi Mental Health Questions
Extract:
Question 1 of 5
A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?
Correct Answer: A
Rationale: Ecchymotic blood accumulations (bruises) suggest trauma or physical manipulation, indicating non-disease-related hair loss. Patches of hair loss, pruritus, or erythema could be associated with medical conditions like alopecia or inflammation.
Question 2 of 5
Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)
Correct Answer: B,D,E
Rationale: Discussing suicide plans, encouraging expression of suicidal thoughts, and reinforcing hope are critical for safety and therapeutic support. Restricting visitors or limiting video games are less relevant.
Extract:
Nurse Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.
1100
The nurse reviews the physician's orders for clonazepam and gives the medication as ordered.
1115
Start clonazepam 0.25 mg PO every 12 hours
Question 3 of 5
What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.
Correct Answer: B,C,D
Rationale: Assessing mental status, providing oral care, and screening for orthostatic hypotension are appropriate for clonazepam's CNS effects and side effects like dry mouth. Bathroom assistance, calcium monitoring, and opioid agonists are irrelevant.
Extract:
Question 4 of 5
During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)
Correct Answer: A,B,E
Rationale: Measuring blood pressure assesses hypertension risk, screening for diabetes history addresses increased risk from obesity, and discussing exercise helps manage obesity-related risks. Immediate transport is not indicated, and fluid restriction/elevation is irrelevant without edema.
Question 5 of 5
Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?
Correct Answer: D
Rationale: Medication history is critical to identify potential drug interactions, especially with serotonergic drugs, to prevent serotonin syndrome. Heart disease history, familial mental illness, and weight are relevant but secondary. [Note: Document incorrectly lists A as correct; D is more appropriate per standard practice.]