RASMUSSEN: MENTAL HEALTH EXAM 2 2024 100%
CORRECT GUARANTEED GRADE A+
1) A client 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
- A neologism is a newly coined word having special meaning to the client.
"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 client 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 client? (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 client within visual range while awake. Check every 15 to 30 minutes
while the client is sleeping.
D. Check the client'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 client'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
client's possession are measures included in any-level suicide precautions.
,The remaining options are used in less stringent levels of suicide precautions.
3) A client 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. sits close to the client.
B. place an arm protectively around the client's shoulders.
C. places a hand on the client's arm and exert light pressure.
D. maintains a normal social interaction distance from the client. - ANS: D
The client is describing phenomena that indicate personal boundary difficulties.
The nurse should maintain an appropriate social distance and not touch the
client, because the client 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 client with major depression is most likely outlook
on life during the acute phase of the illness? - ANSWER During an acute phase of
major depression, the client may feel worthless and deserve bad things to happen
personally.
5) A client diagnosed with bipolar disorder is in the maintenance phase of
treatment. The client 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 clients take medication for approximately 6 months after discharge.
D. It's unusual that the health care provider hasn't already stopped your
medication.- ANSWER: B
clients diagnosed with bipolar disorder may be maintained on lithium indefinitely
to prevent recurrences. Helping the client 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. -
ANSWER B
Resist focusing on content; instead, focus on the feelings the client is expressing.
This strategy prevents arguing about the reality of delusional beliefs. Such
arguments increase client anxiety and the tenacity with which the client holds to
the delusion. The other options focus on content and provide opportunity for
argument.
7) A client is undergoing a series of diagnostic tests. The client says, "Nothing is
wrong with me except a stubborn chest cold." The spouse reports the client
smokes and coughs a lot, has lost 15 pounds, and is easily fatigued. Which
defense mechanism is the client using?
A. Regression
B. Displacement
C Denial
D. Projection – ANSWER: 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?
CORRECT GUARANTEED GRADE A+
1) A client 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
- A neologism is a newly coined word having special meaning to the client.
"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 client 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 client? (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 client within visual range while awake. Check every 15 to 30 minutes
while the client is sleeping.
D. Check the client'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 client'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
client's possession are measures included in any-level suicide precautions.
,The remaining options are used in less stringent levels of suicide precautions.
3) A client 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. sits close to the client.
B. place an arm protectively around the client's shoulders.
C. places a hand on the client's arm and exert light pressure.
D. maintains a normal social interaction distance from the client. - ANS: D
The client is describing phenomena that indicate personal boundary difficulties.
The nurse should maintain an appropriate social distance and not touch the
client, because the client 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 client with major depression is most likely outlook
on life during the acute phase of the illness? - ANSWER During an acute phase of
major depression, the client may feel worthless and deserve bad things to happen
personally.
5) A client diagnosed with bipolar disorder is in the maintenance phase of
treatment. The client 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 clients take medication for approximately 6 months after discharge.
D. It's unusual that the health care provider hasn't already stopped your
medication.- ANSWER: B
clients diagnosed with bipolar disorder may be maintained on lithium indefinitely
to prevent recurrences. Helping the client 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. -
ANSWER B
Resist focusing on content; instead, focus on the feelings the client is expressing.
This strategy prevents arguing about the reality of delusional beliefs. Such
arguments increase client anxiety and the tenacity with which the client holds to
the delusion. The other options focus on content and provide opportunity for
argument.
7) A client is undergoing a series of diagnostic tests. The client says, "Nothing is
wrong with me except a stubborn chest cold." The spouse reports the client
smokes and coughs a lot, has lost 15 pounds, and is easily fatigued. Which
defense mechanism is the client using?
A. Regression
B. Displacement
C Denial
D. Projection – ANSWER: 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?
