NUR 2459 / NUR2459 Exam 2: Mental and
Behavioral Health Nursing Exam 2 Questions and
Answers 100% Correct with Rationales
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.
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.
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.
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.
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.
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.
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
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.
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?
OTC .preparations .containing .dextromethorphan, .sympathomimetic .agents, .or
.antihistamines .(e.g., .cough, .cold, .and .hay .fever .remedies, .appetite .suppressants) .can
.precipitate .severe .hypertensive .reactions .if .taken .during .therapy .or .within .2-3 .wk .after
.discontinuation .of .an .MAO .inhibitor.
Which .piece .of .subjective .data .obtained .during .the .nurse's .psychosocial
.assessment .of .a .client .experiencing .severe .anxiety .would .indicate .the
.possibility .of .obsessive-compulsive .disorder?
Behavioral Health Nursing Exam 2 Questions and
Answers 100% Correct with Rationales
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.
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.
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.
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.
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.
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.
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
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.
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?
OTC .preparations .containing .dextromethorphan, .sympathomimetic .agents, .or
.antihistamines .(e.g., .cough, .cold, .and .hay .fever .remedies, .appetite .suppressants) .can
.precipitate .severe .hypertensive .reactions .if .taken .during .therapy .or .within .2-3 .wk .after
.discontinuation .of .an .MAO .inhibitor.
Which .piece .of .subjective .data .obtained .during .the .nurse's .psychosocial
.assessment .of .a .client .experiencing .severe .anxiety .would .indicate .the
.possibility .of .obsessive-compulsive .disorder?
