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
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
