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This document, "Mental Health Exam 2 Rasmussen," covers specific topics such as major depressive
disorder, psychoanalytic theory, ECT, suicidal ideations, serotonin syndrome, medication management,
grief, and psychosocial development. The document provides 77 questions with correct answers and
detailed explanations, serving as a comprehensive review of mental health nursing concepts for exam
preparation. Students can utilize this document to study, review, and understand key concepts,
ultimately enhancing their knowledge and retention of mental health nursing principles.
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EXAM QUESTIONS
QUESTION 1
Which nursing diagnosis supports the psychoanalytic theory of development of major depressive
disorder?
CORRECT ANSWER
Social isolation R/T self directed danger
RATIONALE: The psychoanalytic theory suggests that major depressive disorder develops as a result of the individual's
inability to reconcile unconscious conflicts and repressed emotions, which can lead to feelings of isolation and
disconnection from oneself and others. Therefore, "Social isolation R/T self-directed danger" accurately reflects this
concept by highlighting the individual's self-imposed separation from others and their inability to effectively cope with
internalized danger or threats, which contributes to the development of major depressive disorder.
QUESTION 2
Which patient is at the highest risk for the diagnosis of major depressive disorder?
CORRECT ANSWER
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, 24 yr old married woman
RATIONALE: The 24-year-old married woman is at the highest risk for the diagnosis of major depressive disorder
because individuals with established social relationships and family responsibilities may experience increased stress and
anxiety related to their roles, leading to a higher likelihood of developing depression. Additionally, societal expectations
and pressure to conform to traditional roles can also contribute to feelings of frustration, inadequacy, and low self-
esteem, further increasing her risk.
QUESTION 3
A patient diagnosed with MDD is being considered for ECT. Which patient teaching should the nurse
prioritize?
CORRECT ANSWER
Discuss with the patient and family expected short term memory loss
RATIONALE: A patient diagnosed with Major Depressive Disorder (MDD) undergoing Electroconvulsive Therapy (ECT) is
at risk for short-term memory loss due to the effects of ECT on the brain, specifically the hippocampus, which plays a
significant role in memory consolidation. By discussing expected short-term memory loss with the patient and family, the
nurse can prepare them for the potential treatment side effects and alleviate concerns, ultimately improving their
understanding and cooperation with the treatment plan.
QUESTION 4
Which nursing intervention takes priority when working with a newly admitted patient experiencing
suicidal ideations?
CORRECT ANSWER
Monitor the patient at a close, but irregular intervals.
RATIONALE: This answer prioritizes the patient's safety while still allowing for flexibility in monitoring their behavior, as
suicidal ideations can be unpredictable and may require sudden interventions. By monitoring the patient at close, but
irregular intervals, the nurse can be prepared to respond to any changes or escalations in the patient's condition without
being overly restrictive or intrusive.
QUESTION 5
A patient diagnosed with major depressive disorder is prescribed Nardil. Which teachings should the
nurse prioritize?
CORRECT ANSWER
Intruct the patient & family about the many food-drug & drug-drug interactions?
RATIONALE: Nardil is a monoamine oxidase inhibitor (MAOI), a class of medications that require careful management to
avoid potentially life-threatening food-drug and drug-drug interactions. By instructing the patient and family about these
interactions, the nurse prioritizes the patient's safety and minimizes the risk of adverse reactions, such as hypertensive
crises or serotonin syndrome.
QUESTION 6
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, What symptoms would the nurse expect to assess i a patient experiencing serotonin syndrome?
CORRECT ANSWER
Confusion, restlessness, Tachycardia, Labile BP, & diaphoresis
RATIONALE: Serotonin syndrome occurs when there is an excessive accumulation of serotonin in the body, typically due
to the interaction of certain medications, leading to overstimulation of serotonin receptors. The symptoms listed, such
as confusion, restlessness, tachycardia, labile blood pressure, and diaphoresis, are characteristic manifestations of this
overstimulation, which can cause a range of autonomic and neurological effects.
QUESTION 7
Which of the following meds would be classified as Tricyclic antidepressants?
CORRECT ANSWER
Nortriptyline (Pamelor)
RATIONALE: Nortriptyline (Pamelor) is correctly classified as a Tricyclic antidepressant because it belongs to a class of
medications that have a three-ring molecular structure, which is the characteristic chemical feature of Tricyclic
antidepressants. This classification is based on the specific chemical composition and pharmacological properties of the
medication, which distinguishes it from other types of antidepressants.
QUESTION 8
Which of the following are examples of anticholinergic side effects from tricyclic antidepressants?
CORRECT ANSWER
Urinary hesitancy, constipation, and blurred vision
RATIONALE: Tricyclic antidepressants (TCAs) work by inhibiting the action of acetylcholine, a neurotransmitter that
stimulates the parasympathetic nervous system, which is responsible for various involuntary functions such as muscle
contraction and glandular secretion. As a result, when TCAs block acetylcholine, it leads to anticholinergic side effects,
which include urinary hesitancy, constipation, and blurred vision due to decreased parasympathetic stimulation of the
bladder, intestines, and eyes.
QUESTION 9
A patient seen in the ED is experiencing irritability, pressured speech, and increased levels of anxiety.
The priority is?
CORRECT ANSWER
Assess vital signs and complete a physical assessment
RATIONALE: The patient's symptoms suggest a possible diagnosis of mania or a manic episode, which can be
associated with severe psychiatric conditions such as bipolar disorder. Therefore, assessing vital signs and completing a
physical assessment to rule out any underlying medical conditions that may be contributing to the patient's psychiatric
symptoms is crucial to ensure a comprehensive and accurate diagnosis.
QUESTION 10
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