Rasmussen: Mental Health Exam 2 Latest Version
With Complete Verified Solution
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) 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) 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 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."
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."
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
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
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.
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?
With Complete Verified Solution
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) 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) 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 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."
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."
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
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
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.
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?
