MENTAL HEALTH COMPREHENSIVE EXAM
QUESTIONS & ANSWERS RAMUSSEN COLLEGE
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but
responsive.The mother states, "I think he took some of my pain pills." During initial
assessment of the teenager, what information is most important for the nurse to obtain from
the parents?
• If he has seemed depressed recently.
• If a drug overdose has ever occurred before.
• If he might have taken any other drugs.
• If he has a desire to quit taking drugs
The nurse should hold the next scheduled dose of a child's haldoperidol (Haldol) based on
which assessment findings?
• Dizziness when standing.
• Shuffling gait and hand tremors.
• Urinary retention.
• Fever of 102 F
A 65-year-old female complains to the nurse that recently she has been hearing voices. What
question should the nurse ask this patient first?
• "Do you have problems with hallucinations?"
• "Are you ever alone when you hear the voices?"
• "Has anyone in your family had hearing problems?"
• "Do you see things that others cannot see?"
The charge nurse is collaborating with the nursing staff about the plan of care for a patient
who is very depressed. What is the most important intervention to implement during the first
48 hoursafter the patient's admission to the unit?
• Monitor appetite and observe intake at meals.
• Maintain safety in the patient's milieu.
• Provide ongoing, supportive contact.
• Encourage participation in activities.
,Within several days of hospitalization, a patient is repeatedly washing the top of the same
table.Which intervention is best for the nurse to implement to help the patient cope with
anxiety related to this behavior?
• Administer a prescribed PRN antianxiety medication.
• Assist the patient to identify stimuli that precipitates the ritualistic activity.
• Allow time for the ritualistic behavior, then redirect the patient to other activities.
• Teach the patient relaxation and thought stopping techniques.
A female patient with depression attends groups and states that she sometimes misses her
medication appointment because she feels very anxious about riding the bus. Which
statementis the nurse's best response?
• "Can your case manager take to you to your appointment?"
• "Take your medication for anxiety before you ride the bus."
• "Let's talk about what happens when you feel very anxious."
• "What are some ways that you can cope with your anxiety?"
A nurse working on a mental health unit receives a community call from a person who is
tearfuland states, "I just feel so nervous all the time. I don't know what to do about my
problems. I haven't been able to sleep at night and hardly eaten for the past 3 to 4 days." The
nurse shouldinitiate a referral based on which assessment?
• Altered thought processes
• Moderate levels of anxiety.
• Inadequate social support.
• Altered health maintenance.
A female patient refuses to take an oral hypoglycemic agent because she believes the drug is
being administered as part of an elaborate plan by the Mafia to harm her. Which nursing
intervention is most important to include in this patient's plan of care?
• Reassure the patient that no one will harm her while she is in the hospital.
• Ask the healthcare provider to give the patient the medication.
• Explain that the diabetic medication is important to take.
• Reassess patient's mental status for thought processes and content.
, The nurse is planning discharge for a male patient with schizophrnia. The patient insists that
he isreturning to his apartment, although the healthcare provider informed him that he will
be
moving to a boarding home. What is the most important nursing diagnosis for discharge
planning?
• Ineffective denial related to situational anxiety.
• Ineffective coping related to inadequate support.
• Social isolation related to difficult interactions.
• Self-care deficit related to cognitive impairment.
A male patient is admitted to the mental health unit because he was feeling depressed about
theloss of his wife and job. The patient has a history of alcohol dependency and admits that
he was drinking alcohol 12 hours ago. Vitals are: temperature 100F, pulse 100, and BP
142/100. The nurse plans to give the patient lorazepam (Ativan) based on which priority
nursing diagnosis?
• Risk for injury related to suicidal ideation.
• Risk of injury related to alcohol detoxification.
• Knowledge deficit related to ineffective coping.
• Health seeking behaviors related to personal crisis.
An elderly patient with advanced dementia is admitted to the hospital with a fractured hip.
The patient repeatedly tells the staff, "take me home. I want my Mommy." Which response is
best forthe nurse to provide?
• Orient the patient to the tie, place, and person.
• Tell the patient that the nurse is there and will help her.
• Remind the patient that her mother is no longer living.
• Explain the seriousness of her injury and need for hospitalization.
When preparing a teaching plan for a patient who is to be discharged with a prescription for
lithium carbonate (Lithonate). It is most important for the nurse to include which
instructions.
• "It may take 3 to 4 weeks to achieve therapeutic effects."
• "Keep your dietary salt intake consistent."
• "Avoid eating aged cheese and chicken liver."
• "Eat foods high in fiber such as whole grain breads."
QUESTIONS & ANSWERS RAMUSSEN COLLEGE
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but
responsive.The mother states, "I think he took some of my pain pills." During initial
assessment of the teenager, what information is most important for the nurse to obtain from
the parents?
• If he has seemed depressed recently.
• If a drug overdose has ever occurred before.
• If he might have taken any other drugs.
• If he has a desire to quit taking drugs
The nurse should hold the next scheduled dose of a child's haldoperidol (Haldol) based on
which assessment findings?
• Dizziness when standing.
• Shuffling gait and hand tremors.
• Urinary retention.
• Fever of 102 F
A 65-year-old female complains to the nurse that recently she has been hearing voices. What
question should the nurse ask this patient first?
• "Do you have problems with hallucinations?"
• "Are you ever alone when you hear the voices?"
• "Has anyone in your family had hearing problems?"
• "Do you see things that others cannot see?"
The charge nurse is collaborating with the nursing staff about the plan of care for a patient
who is very depressed. What is the most important intervention to implement during the first
48 hoursafter the patient's admission to the unit?
• Monitor appetite and observe intake at meals.
• Maintain safety in the patient's milieu.
• Provide ongoing, supportive contact.
• Encourage participation in activities.
,Within several days of hospitalization, a patient is repeatedly washing the top of the same
table.Which intervention is best for the nurse to implement to help the patient cope with
anxiety related to this behavior?
• Administer a prescribed PRN antianxiety medication.
• Assist the patient to identify stimuli that precipitates the ritualistic activity.
• Allow time for the ritualistic behavior, then redirect the patient to other activities.
• Teach the patient relaxation and thought stopping techniques.
A female patient with depression attends groups and states that she sometimes misses her
medication appointment because she feels very anxious about riding the bus. Which
statementis the nurse's best response?
• "Can your case manager take to you to your appointment?"
• "Take your medication for anxiety before you ride the bus."
• "Let's talk about what happens when you feel very anxious."
• "What are some ways that you can cope with your anxiety?"
A nurse working on a mental health unit receives a community call from a person who is
tearfuland states, "I just feel so nervous all the time. I don't know what to do about my
problems. I haven't been able to sleep at night and hardly eaten for the past 3 to 4 days." The
nurse shouldinitiate a referral based on which assessment?
• Altered thought processes
• Moderate levels of anxiety.
• Inadequate social support.
• Altered health maintenance.
A female patient refuses to take an oral hypoglycemic agent because she believes the drug is
being administered as part of an elaborate plan by the Mafia to harm her. Which nursing
intervention is most important to include in this patient's plan of care?
• Reassure the patient that no one will harm her while she is in the hospital.
• Ask the healthcare provider to give the patient the medication.
• Explain that the diabetic medication is important to take.
• Reassess patient's mental status for thought processes and content.
, The nurse is planning discharge for a male patient with schizophrnia. The patient insists that
he isreturning to his apartment, although the healthcare provider informed him that he will
be
moving to a boarding home. What is the most important nursing diagnosis for discharge
planning?
• Ineffective denial related to situational anxiety.
• Ineffective coping related to inadequate support.
• Social isolation related to difficult interactions.
• Self-care deficit related to cognitive impairment.
A male patient is admitted to the mental health unit because he was feeling depressed about
theloss of his wife and job. The patient has a history of alcohol dependency and admits that
he was drinking alcohol 12 hours ago. Vitals are: temperature 100F, pulse 100, and BP
142/100. The nurse plans to give the patient lorazepam (Ativan) based on which priority
nursing diagnosis?
• Risk for injury related to suicidal ideation.
• Risk of injury related to alcohol detoxification.
• Knowledge deficit related to ineffective coping.
• Health seeking behaviors related to personal crisis.
An elderly patient with advanced dementia is admitted to the hospital with a fractured hip.
The patient repeatedly tells the staff, "take me home. I want my Mommy." Which response is
best forthe nurse to provide?
• Orient the patient to the tie, place, and person.
• Tell the patient that the nurse is there and will help her.
• Remind the patient that her mother is no longer living.
• Explain the seriousness of her injury and need for hospitalization.
When preparing a teaching plan for a patient who is to be discharged with a prescription for
lithium carbonate (Lithonate). It is most important for the nurse to include which
instructions.
• "It may take 3 to 4 weeks to achieve therapeutic effects."
• "Keep your dietary salt intake consistent."
• "Avoid eating aged cheese and chicken liver."
• "Eat foods high in fiber such as whole grain breads."
