Rasmussen: Mental Health Exam 2 Latest Version(2023)
1) 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." - 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.
2) 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 - 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
3) 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 - 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 characterized by recurrent, sudden onset panic attacks in which
the person feels intense fear, apprehension, or terror.
4) 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? - ANSWER>>>hypertensive crisis
foods with tyramine in it - ANSWER>>>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 -
ANSWER>>>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? - ANSWER>>>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.
, 5) 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." - ANSWER>>>ANS: A
Recurring doubt (obsessive thinking) and the need to check (compulsive
behavior) suggest obsessive-compulsive 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.
6) 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 - 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.
7) 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.
1) 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." - 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.
2) 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 - 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
3) 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 - 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 characterized by recurrent, sudden onset panic attacks in which
the person feels intense fear, apprehension, or terror.
4) 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? - ANSWER>>>hypertensive crisis
foods with tyramine in it - ANSWER>>>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 -
ANSWER>>>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? - ANSWER>>>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.
, 5) 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." - ANSWER>>>ANS: A
Recurring doubt (obsessive thinking) and the need to check (compulsive
behavior) suggest obsessive-compulsive 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.
6) 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 - 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.
7) 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.
