Mental Health Nursing Exam (50 Verified Answers, Already graded A) Rasmussen College

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? Answers Risk for injury : Post-trauma syndrome Disturbed thought processes Risk for other-directed violence Response The defining characteristics for Risk for other-directed violence include a Feedback: history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in the scenario Question 2 A patient is admitted with a heart rate of 53 bpm, respirations 6/min, temp 96.8 and pinpointpupils. Based on these clinical manifestations, what substance did this patient most likely overdose on? Answers Opioids : Alcohol Marijuana Amphetamine Response Opioids include prescribed medications such as oxycodone and morphine, Feedback: 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? Answers: A small dose of a selective serotonin reuptake inhibitor A large dose of a benzodiazepin A maintenance dose of buspirone A small dose of an atypical antipsychotic Response Aggressive behavior can be safely managed by antipsychotic medication. Feedback: 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? Answers Renal Central nervous Endocrine Cardiovascular Response Refeeding resulting in too-rapid weight gain can overwhelm the heart, Feedback: 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? 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 ground between Feedback: 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? Answers Lying to other patients Flattering the nurse Verbal abuse of another patient Detached superficiality during counseling Response Limits must be set in areas in which the patient's behavior affects the rights Feedback: 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? Answers Demonstrates flexibility and compromise : Demonstrates socially appropriate behaviors Demonstrates eagerness to learn new coping skills Demonstrated a self-defeating cycle of behavior Response A self-defeating cycle of behavior is a hallmark of borderline personality Feedback: disorder, creating difficulties is work, social and family relationships. Individuals with a borderline personality are inflexible and do not compromise easily. Socially inappropriate behavior is common in borderline personality, as is an unwillingness to change and learn new coping skills 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? Answers Setting appropriate limits on maladaptive behaviors : Offering relationship advice Providing multiple options when the patient makes frequent requests Having the patient approach different staff members for interpretation of unit rules Response Setting firm limits and maintaining consistency are essential elements in Feedback: working with people with personality disorders. Flexibility and providing too many choices does not help the individual with boundaries and limits. Offering relationship advice is not professional behavior and can have a negative effect on the nurse-client relationship. Encouraging the patient to attend daily activities may be a part of the care plan, but is not as high of a priority as setting limits 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? Answers Establish a "buddy" system with other patients who can feed this patient at each : meal. Expect the patient to feed himself after explaining arrangement of the food on the tray.