RASMUSSEN MENTAL HEALTH NURSING EXAM 2 - Questions With 100% Verified Solutions Latest Update

RASMUSSEN MENTAL HEALTH NURSING EXAM 2 - Questions With 100% Verified Solutions Latest Update . 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 ANSWERS: 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. ANSWERS: 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. ANSWERS: 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? 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." ANSWERS: 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." ANSWERS: 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 ANSWERS: 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 ANSWERS: 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? hypertensive crisis foods with tyramine in it Aged meats or aged cheeses, protein extracts, sour cream, alcohol, anchovies, liver, sausages, overripe figs, bananas, avocados, chocolate, soy sauce, bean curd, natural yogurt, fava beans—tyramine-containing foods—may precipitate hypertensive crisis. Avoid chocolate or caffeine. Herbal: Ginseng, ephedra, ma huang, St. John's wort may cause hypertensive crisis. For depression that is refractory to TCAs. Avoid certain foods such as cheese, sour cream, wine, beer, figs, anchovies, shrimp, bananas, and chocolate, and avoid drugs (e.g., TCAs). Risk for hypertensive crisis: Avoid self-medication. WHY? OTC preparations containing dextromethorphan, sympathomimetic agents, or antihistamines (e.g., cough, cold, and hay fever remedies, appetite suppressants) can precipitate severe hypertensive reactions if taken during therapy or within 2-3 wk after discontinuation of an MAO inhibitor. 10) Which piece of subjective data obtained during the nurse's psychosocial assessment of a client experiencing severe anxiety would indicate the possibility of obsessive-compulsive disorder? a. "I have to keep checking to see where my car keys are." b. "My legs feel weak most of the time." c. "I'm afraid to go out in public." d. "I keep reliving the rape." ANSWERS: A Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessivecompulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. Option B is more in keeping with a somatoform disorder. Option C is associated with agoraphobia and option D with posttraumatic stress disorder. 11) The nurse is evaluating the effectiveness of psychotropic medication on negative symptoms of psychosis. The nurse looks for a decrease in which of the following? A: Affective flattening. B: Bizarre behavior. C: Illogicality. D: Somatic delusions. A: Affective flattening. Reason: Negative symptoms of psychosis involve a diminution or loss of normal functioning. They include affective flattening, alogia (restricted thought and speech), avolution/apathy (lack of behavior initiation), and anhedonia/asociality (inability to experience pleasure or maintain social contacts). Positive symptoms of psychosis involve an excess or distortion of normal functioning. These include psychotic disorders of thinking (delusions) and disorganization of speech (illogicality) and behavior. 11) The nurse is evaluating the effectiveness of an antipsychotic on negative symptoms of psychosis. Which of the following symptoms would be classified as negative symptoms of psychosis? Blunted affect Poverty of thought Loss of motivation Inability to experience pleasure or joy 12) A 39-year-old woman is recently divorced and is learning to cope with additional stressors. Which of the following best demonstrate(s) that she is utilizing positive coping strategies to manage her stress? (Select all that apply). 1. alter her general lifestyle by moving to another area. 2. arrange to increase her job hours, to avoid home life. 3. control stress by increased physical activity. 4. change her reactions to stress with cognitive behavioral therapy. ANSWERS: 3, 4 3. control stress by increased physical activity. 4. change her reactions to stress with cognitive behavioral therapy. 13) Which nursing diagnosis is likely to apply to an individual with severe and persistent mental illness who is homeless? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome ANSWERS: C Many individuals with severe mental illness do not live with their families and are homeless. Life on the street or in a shelter has a negative influence on the individual's self-esteem, making this nursing diagnosis one that should be considered. Insomnia may be noted in some patients but is not a universal problem. Substance abuse is not an approved North American Nursing Diagnosis Association (NANDA) International diagnosis. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not observed in a majority of the homeless. 14) A patient with depression is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth c. Nasal congestion b. Blurred vision d. Urinary retention ANSWERS: D. Urinary retention All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues. 15) Which individual in the emergency department should be considered at the highest risk for completing suicide? a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma b. A 38-year-old single African-American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate gland ANSWERS: D High-risk factors include being an older adult, single, and male and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African-American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age. 16) The nurse is caring for a patient who takes antipsychotic medications and has developed muscle rigidity, hyperpyrexia, diaphoresis, and drooling. Which of the following adverse effects of antipsychotic educations is most likely causing these symptoms? Neuroleptic malignant syndrome 17) A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a. Self-esteem. c. Physiological b. Psychosocial. d. Self-actualization ANSWERS: C. Physiologic Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher level needs are of lesser concern. 18) A nurse works with a patient with paranoid schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Family members say they feel helpless to foster compliance. Which treatment strategy should the nurse discuss with the health care provider? a. Use of a long-acting antipsychotic preparation b. Addition of a benzodiazepine, such as lorazepam (Ativan) c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil) d. Prolonged hospitalization; this patient is not ready for discharge ANSWERS: A. Use of a long-acting antipsychotic preparation Medications such as fluphenazine decanoate and haloperidol decanoate are long-acting forms of antipsychotic medications. They are administered by depot injection every 2 to 4 weeks, thus reducing daily opportunities for noncompliance. The other options do not address the patient's dislike of taking pills. 19) Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech." ANSWERS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.