Rasmussen: Mental Health Exam 2 Latest Version(2023)

Rasmussen: Mental Health Exam

2

1) A patient with schizophrenia begins to talks about "volmers" hiding in the

warehouse at work. The term "volmers" should be documented as:

a. neologism

b. concrete thinking

c. thought insertion

d. idea of reference Correct answer- ANS: A

- A neologism is a newly coined word having special meaning to the patient.

"Volmer" is not a known common noun.

- Concrete thinking refers to the inability to think abstractly.

- Thought insertion refers to thoughts of others that are implanted in one's

mind.

- An idea of reference is a type of delusion in which trivial events are given

personal significance.

2) A patient with suicidal impulses is placed on the highest level of suicide

precautions. Which measures should be incorporated into the plan of care by

the nurse caring for the patient? (More than one answer is correct.)

a. Maintain arm's-length, one-on-one nursing observation around the clock.

b. Allow no glass or metal on meal trays.

c. Keep patient within visual range while awake. Check every 15 to 30

minutes while the patient is sleeping.

d. Check the patient's whereabouts every 15 minutes and make frequent

verbal contacts.

e. Check whereabouts every hour. Make verbal contact at least three times

each shift.

f. Remove all potentially harmful objects from the patient's possession.

Correct answer- ANS: A, B, F

One-on-one observation is necessary for anyone who has limited control over

suicidal impulses.

- Plastic dishes on trays and the removal of potentially harmful objects from

the patient's possession are measures included in any-level suicide

precautions.

The remaining options are used in less stringent levels of suicide

precautions.

3) A patient diagnosed with schizophrenia anxiously says, "I can see the left

side of my body merging with the wall, then my face appears and disappears

in the mirror." While listening, the nurse should:

a. sit close to the patient.

b. place an arm protectively around the patient's shoulders.

c. place a hand on the patient's arm and exert light pressure.

d. maintain a normal social interaction distance from the patient. Correct

answer- ANS: D

The patient is describing phenomena that indicate personal boundary

difficulties. The nurse should maintain an appropriate social distance and not

touch the patient, because the patient is anxious about the inability to

maintain ego boundaries and merging with or being swallowed by the

environment. Physical closeness or touch could precipitate panic.

4) Which statement indicates a patient with major depression is most likely

outlook on life during the acute phase of the illness? Correct answer- During

an acute phase of major depression, the client may feel worthless and

deserve bad things to happen personally.

5) A patient diagnosed with bipolar disorder is in the maintenance phase of

treatment. The patient asks, "Do I have to keep taking this lithium even

though my mood is stable now?" Select the nurse's appropriate response.

a. "You will be able to stop the medication in about 1 month."

b. "Taking the medication every day helps reduce the risk of a relapse."

c. "Usually patients take medication for approximately 6 months after

discharge."

d. "It's unusual that the health care provider hasn't already stopped your

medication." Correct answer- ANS: B

Patients diagnosed with bipolar disorder may be maintained on lithium

indefinitely to prevent recurrences. Helping the patient understand this need

will promote medication compliance.

6) A person has had difficulty keeping a job because of arguing with coworkers and accusing them of conspiracy. Today the person shouts, "They're

all plotting to destroy me. Isn't that true?" Select the nurse's most

therapeutic response.

a."Everyone here is trying to help you. No one wants to harm you."

b. "Feeling that people want to destroy you must be very frightening."

c. "That is not true. People here are trying to help you if you will let them."

d. "Staff members are health care professionals who are qualified to help

you." Correct answer- ANS: B

Resist focusing on content; instead, focus on the feelings the patient is

expressing. This strategy prevents arguing about the reality of delusional

beliefs. Such arguments increase patient anxiety and the tenacity with which

the patient holds to the delusion. The other options focus on content and

provide opportunity for argument.

7) A patient is undergoing a series of diagnostic tests. The patient says,

"Nothing is wrong with me except a stubborn chest cold." The spouse reports

the patient smokes and coughs a lot, has lost 15 pounds, and is easily

fatigued. Which defense mechanism is the patient using?

a. Regression

b. Displacement

c. Denial

d. Projection Correct answer- ANS: C

Denial is an unconscious blocking of threatening or painful information or

feelings. Regression involves using behaviors appropriate at an earlier stage

of psychosexual development. Displacement shifts feelings to a more neutral

person or object. Projection attributes one's own unacceptable thoughts or

feelings to another

8) A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic,

tachycardia and dyspneic. A workup in an emergency department reveals no

pathology. Which medical diagnosis should a nurse suspect, and what

nursing diagnosis should be the nurse's first priority?

1. Generalized anxiety disorder and a nursing diagnosis of fear

2. Altered sensory perception and a nursing diagnosis of panic disorder

3. Pain disorder and a nursing diagnosis of altered role performance

4. Panic disorder and a nursing diagnosis of anxiety Correct answer- ANS: D

The nurse should suspect that the client has exhibited signs/symptoms of a

panic disorder. The priority nursing diagnosis should be anxiety. Panic

disorder is characterized by recurrent, sudden onset panic attacks in which

the person feels intense fear, apprehension, or terror.

9) The nurse is providing health teaching for a patient who has been

prescribed Phenelzine (Nardil) for depression and provides a written list of

foods that should not be eaten while taking this medication. What is the

potential problem if the patient is not compliant with these dietary

restrictions? Correct answer- hypertensive crisis