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NUR 2488 / NUR2488 / NU239 MENTAL HEALTH NURSING EXAM 3 RESPONDUS

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NUR 2488 / NUR2488 / NU239 MENTAL HEALTH NURSING EXAM 3 RESPONDUS • Question 1 A patient with a history of cocaine use reports a concurrent history of using other drugs in order to counteract the effects of cocaine. Which drug is this patient likely to have abused? • Question 2 A patient is admitted with a heart rate of 53 bpm, respirations 6/min, temp 96.8 and pinpoint pupils. Based on these clinical manifestations, what substance did this patient most likely overdose on? • Question 3 An elderly client with cognitive impairment is combative and pulled out a nasogastric tube, intravenous line, and indwelling urinary catheter. What can the nurse anticipate that the health care provider will most likely prescribe? • Question 4 A nursing care plan contains the intervention “monitor for complications of refeeding syndrome.” Which body system should a nurse most closely monitor for clinical manifestations of dysfunction? • Question 5 Which of the following is the best example of all-or-nothing thinking, a common cognitive distortion of patients with an eating disorder? • Question 6 A nurse reports to the interdisciplinary team that a patient with an antisocial personality disorder lies to other patients, verbally abuses a patient with Alzheimer’s disease, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting? • Question 7 Which of the following are primary characteristics of a person with borderline personality disorder? Selected • Question 8 A nurse is working with a patient with a histrionic personality disorder. Which of the following nursing interventions must be implemented throughout the inpatient stay? • Question 9 A patient has blindness related to conversion disorder. In order to assist the patient with eating, which of the following interventions should the nurse implement? • Question 10 A patient is admitted for psychiatric observation after being arrested for breaking windows in the home of a former girlfriend who had refused to see him. His history reveals childhood abuse by a punitive father, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority in the plan of care? • Question 11 A patient is referred to the mental health center by the family health care provider. Over the past year, the patient has cooked gourmet meals for family members, but eats only tiny portions of the food. The patient wears layers of loose clothing, saying, “It’s just my style.” The patient’s weight has dropped from 130 to 95 pounds. The patient has amenorrhea. Which medical diagnosis are the history and symptoms are most consistent with? • Question 12 A patient sat in silence for 20 minutes after a therapy appointment. The patient appeared tense and vigilant. The patient abruptly stood up and paced back and forth across the day room, clenching and unclenching his fists. Next, he stopped and stared intently into the face of a psychiatric technician. Which of the following best explains the nurse’s observations of this patient? • Question 13 A patient referred to the eating disorders clinic has lost 35 pounds during one summer. Which of the following questions would be best if the nurse wished to assess the patient’s eating patterns? • Question 14 When a victim of sexual assault is discharged from the emergency department, which of the following interventions should the nurse perform? • Question 15 A patient admitted for a heroin overdose received naloxone, which improved her breathing pattern. Two hours later the patient reports muscle aches, abdominal cramps, and gooseflesh, and says, “I feel terrible.” Which is the correct analysis of this assessment? • Question 16 A health care provider writes these new prescriptions for a nursing home resident: 2-g sodium diet; restraints as needed for behavioral problems; limit fluids to 2000 mL daily; continue antihypertensive medication; milk of magnesia 30 mL orally one time as needed if no bowel movement for 3 days. Which of the following is most appropriate for the nurse to do first? • Question 17 The son of an elderly client with dementia is talking to the nurse about discharge. He indicates that his father’s physician has given him 48 hours to decide on a living situation. The nurse discusses possible living arrangements and provides contact information. The nurse knows that the son requires further teaching when he says: • Question 18 A child with ADHD will begin medication therapy. Which of the following classifications of medications should the nurse prepare to teach the patient and family about? • Question 19 Which of the following nursing interventions is the highest priority while working with a patient who has a somatoform disorder for the first time? • Question 20 The nurse is assessing a patient who has been diagnosed with hypochondriasis. Which clinical manifestation would the nurse most likely assess in this patient? • Question 21 While providing health teaching for a patient with binge-purge bulimia, what information is most important for the nurse to prioritize? • Question 22 An 11-year-old is absent from school to stay at home and care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, “I don’t think my parents like me very much. They call me stupid and say I never do anything right.” Which type of abuse is most likely? • Question 24 A nurse in the emergency department tells the daughter of an older adult woman, “Your mother had a severe stroke.” The daughter tearfully says, “Who will take care of me now? My mother always tells me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious.” This behavior could best be assessed as: • Question 25 Which behavior best describes physical aggression? • Question 26 Which nursing intervention(s) would be most likely included in a plan of care for a patient with bulimia nervosa? Select all that apply. • Question 27 An older adult patient with Alzheimer’s disease lives with family and goes to day care on weekdays. The nurse at the center observed poor hygiene and discussed this observation with the caregiver, the patient’s adult child. The caregiver became defensive and said, “It takes all my time and energy to care for my mother. She’s awake all night. Last night she fell down the stairs.” Which nursing intervention takes highest priority in this case? • Question 28 Which patient statement would be best documented as a subjective assessment finding supporting a psychiatric diagnosis of dissociative fugue?

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NUR 2488 / NUR2488 / NU239 MENTAL HEALTH NURSING EXAM 3
RESPONDUS

 Question 1
A patient with a history of cocaine use reports a concurrent history of
using other drugs in order to counteract the effects of cocaine. Which
drug is this patient likely to have abused?
Selected
Answer: Alcohol
Answers: PCP
Alcohol
Methylpheni
date
Caffeine
Response
Feedback: Alcohol is a depressant which can neutralize the effects of
cocaine, which is a stimulant. Caffeine, methylphenidate (used
to treat ADHD) and the illegal drug PCP are also stimulating
and would only exacerbate the effects of cocaine.
 Question 2
A patient is admitted with a heart rate of 53 bpm, respirations 6/min, temp
96.8 and pinpoint pupils. Based on these clinical manifestations, what
substance did this patient most likely overdose on?
Selected
Answer: Marijuana
Answers: Opioids
Alcohol
Marijuana
Amphetam
ine
Response
Feedback: Opioids include prescribed medications such as oxycodone
and morphine, and the illegal substance heroin. The above
symptoms are typical of opioid overdose, but are not typically

, seen with marijuana, alcohol or amphetamines.
 Question 3
An elderly client with cognitive impairment is combative and pulled out a
nasogastric tube, intravenous line, and indwelling urinary catheter. What
can the nurse anticipate that the health care provider will most likely
prescribe?
Selected
Answer: A small dose of a selective serotonin
reuptake inhibitor
Answers: A small dose of a selective
serotonin reuptake inhibitor
A large dose of a
benzodiazepine A maintenance
dose of buspirone
A small dose of an atypical antipsychotic
Response
Feedback Aggressive behavior can be safely managed by antipsychotic
: medication. Initial dosing should be small and raised cautiously
until behavior is controlled. Selective serotonin reuptake
inhibitors are not indicated for aggressive behavior. If a
benzodiazepine is used, the initial dose should be low.
Buspirone is not effective if given on an as-needed basis. It is
administered in small divided doses daily to control agitation.
 Question 4
A nursing care plan contains the intervention “monitor for complications of
refeeding syndrome.” Which body system should a nurse most closely
monitor for clinical manifestations of dysfunction?
Selected
Answer: Central
nervous
Answers: Renal
Central
nervous
Endocrine
Cardiovascu
lar
Response
Feedback: Refeeding resulting in too-rapid weight gain can overwhelm the
heart, resulting in cardiovascular collapse; thus focused
assessment becomes a necessity to ensure patient
physiological integrity. The other body systems are not initially
involved in the refeeding syndrome.
 Question 5

, Which of the following is the best example of all-or-nothing thinking, a
common cognitive distortion of patients with an eating disorder?
Selected
Answer: “If I gain any weight, I’ll keep going until I’m huge.”
Answers: “If I gain any weight, I’ll keep going until I’m huge.”
“When people tell me I’m looking better, they really
mean I’m fatter.”
“No one likes me because I’m
fat.” “When I’m thin, I’m perfect.”
Response In all-or-nothing thinking, the person cannot see any middle
Feedback:
ground between extremes; a person with an eating disorder will
see themselves as either thin or immense. The other comments
are common in eating disorders but are not examples of all-or-
nothing thinking.
 Question 6
A nurse reports to the interdisciplinary team that a patient with an
antisocial personality disorder lies to other patients, verbally
abuses a patient with Alzheimer’s disease, and flatters the primary
nurse. This patient is detached and superficial during counseling
sessions. Which behavior most clearly warrants limit setting?
Selected
Answer: Flattering the nurse
Answers: Lying to other patients
Flattering the nurse
Verbal abuse of another patient
Detached superficiality during
counseling
Response
Feedback: Limits must be set in areas in which the patient’s behavior
affects the rights of others. Limiting verbal abuse of another
patient is a priority intervention. The other concerns should be
addressed during therapeutic encounters.
 Question 7
Which of the following are primary characteristics of a person with
borderline personality disorder?
Selected
Answer: Demonstrated a self-defeating cycle
of behavior
Answers: Demonstrates flexibility and
compromise

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