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 co-workers
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
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 co-workers
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
