Rasmussen: Mental Health Exam 2
1. 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: 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. 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.:
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. 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.: ANS: D
The patient is describing phenomena that indicate personal boundary
difficulties. The nurse should maintain an appropriate social distance
and not touch the pa- tient, 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.
4.4) Which statement indicates a patient with major depression is most
likely outlook on life during the acute phase of the illness?: During an
acute phase of major depression, the client may feel worthless and
deserve bad things to happen personally.
5. 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
, dis- charge."
d. "It's unusual that the health care provider hasn't already stopped
your medication.": 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. 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."
1. 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: 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. 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.:
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. 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.: ANS: D
The patient is describing phenomena that indicate personal boundary
difficulties. The nurse should maintain an appropriate social distance
and not touch the pa- tient, 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.
4.4) Which statement indicates a patient with major depression is most
likely outlook on life during the acute phase of the illness?: During an
acute phase of major depression, the client may feel worthless and
deserve bad things to happen personally.
5. 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
, dis- charge."
d. "It's unusual that the health care provider hasn't already stopped
your medication.": 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. 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."
