RASMUSSEN MENTAL HEALTH EXAM 3{3 VERSIONS}
QUESTIONS AND ANSWERS VERIFIED 100% CORRECT
mental health exam 3
Which scenario best predicts the highest risk for a patient who may direct violent behavior toward
others?
Paranoid delusions of being followed by members of the mafia.
Which behavior best describes physical aggression?
Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a patient
standing at the pool table.
A nurse in the emergency department tells the daughter of an older adult woman. "Your mother had a
severe stroke." The daughter tearfully says. "Who will take care of me now? My mother always tells me
what to do, what to wear, and what to ear. I need someone to reassure me when I get anxious." This
behavior could best be assessed as:
Dependent.
The nurse is assessing a patient who has been diagnosed with hypochondriasis. Which clinical
manifestation would the nurse most likely assess in this patient?
Misinterpretation of physical sensation as evidence of serious illness
While providing health teaching for a patient with bine-purge bulimia, what information is most
important for the nurse to prioritise?
Symptoms of Hypokalemia.
A nurse is working with a patient with a histrionic personality disorder. Which of the following
nursing interventions must be implemented throughout the inpatient stay?
Setting appropriate limits on maladaptive behaviors.
Which patient statement would be best documented as a subjective assessment finding supporting a
psychiatric diagnosis of dissociative fugue?
"I can not recall why I'm living
in this town."
,A client with vascular dementia is experiencing agnosia. She sits at her dining table looking at her food,
but does not pick up a utensil and try to eat. Which intervention is most appropriate for the nurse to try
first?
Hand the fork to the client and say, "use this
fork to eat your meat loaf."
Nurses working in a family planning clinic for women routinely ask clients about whether they
have experienced domestic violence. The purpose of having this question in the assessment
tool is because:
A woman experiencing domestic violence may not seek
out help.
A patient admitted for a heroin overdose received naloxone, which improved her
breathing pattern. Two hours later the patient reports muscle aches, abdominal cramps, and gooseflesh,
and says, "I feel terrible." Which is the correct analysis of this assessment?
Symptoms of narcotic abstinence are present.
A 70-year-old client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day,
he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see
him every Wednesday. Let me out." The most therapeutic response by the nurse would be:
It's Monday and you're in the hospital. I'm your nurse.
A patient has blindness related to conversion disorder. In order to assist the patient with eating, which
of the following interventions should the nurse implement?
Expect the patient to feed himself after explaining arrangement of the food on the tray.
Which child shows behaviors that are most indicative of a potential mental illness?
A 3-year-old who is mute, passive toward adults, and twirls while walking.
A patient is admitted for psychiatric observation after being arrested for breaking windows in the home
of a former girlfriend who had refused to see him. His history reveals childhood abuse by a punitive
father, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority in
the plan of care?
Risk for other-directed
violence.
A patient with a history of cocaine use reports a concurrent history of using other drugs in order to
counteract the effects of cocaine. Which drug is this patient likely to have abused?
Alcohol
Which nursing intervention (s) would be most likely included in a plan of care for a patient
with bulimia nervosa?
, (1) Assist the patient to identify triggers to binge eating (2)
Assess for signs of impulsive eating
(3) Explore needs for health teaching.
An 11-year- old is absent from school to stay at home and care for siblings while the
parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly
says "I don't think my parents like me very much. They call me stupid and say I never do anything right.
"Which type of abuse is most likely?
Emotional
An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention
will be most helpful to the patient in managing these illusions?
Wearing glasses and hearing aids
A nursing care plan contains the intervention "monitor for complications of refeeding syndrome." Which
body system should a nurse most closely monitor for clinical manifestations of dysfunction?
Cardiovascular
Which intervention is most effective in managing excessive demands from a client with borderline
personality disorder?
Be consistent in responses to client demands.
A patient referred to the eating disorders clinic has lost 35 pounds during one summer. Which of the
following questions would be best if the nurse wishes to assess the patients' eating patterns?
"What do you eat in a typical day?"
Which of the following clinical manifestations should the nurse expect to assess in a 2-year -old with
suspected autistic disorder?
Failure to display affection toward others, such as hugging or touching a parent.
An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect withdrawal
symptoms to peak?
Between 0200 tomorrow and hospital day 2 (24 to
48 hours after drinking stopped).
Which of the following nursing interventions is the highest priority while working with a patient who has
a somatoform disorder for the first time?
Assess for objective data to support the patient's
report of each physical symptom.
What is the priority nursing diagnosis for a patient who is experiencing fluctuating levels of
consciousness, disturbed orientation, and visual and tactile hallucinations?
Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait
QUESTIONS AND ANSWERS VERIFIED 100% CORRECT
mental health exam 3
Which scenario best predicts the highest risk for a patient who may direct violent behavior toward
others?
Paranoid delusions of being followed by members of the mafia.
Which behavior best describes physical aggression?
Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a patient
standing at the pool table.
A nurse in the emergency department tells the daughter of an older adult woman. "Your mother had a
severe stroke." The daughter tearfully says. "Who will take care of me now? My mother always tells me
what to do, what to wear, and what to ear. I need someone to reassure me when I get anxious." This
behavior could best be assessed as:
Dependent.
The nurse is assessing a patient who has been diagnosed with hypochondriasis. Which clinical
manifestation would the nurse most likely assess in this patient?
Misinterpretation of physical sensation as evidence of serious illness
While providing health teaching for a patient with bine-purge bulimia, what information is most
important for the nurse to prioritise?
Symptoms of Hypokalemia.
A nurse is working with a patient with a histrionic personality disorder. Which of the following
nursing interventions must be implemented throughout the inpatient stay?
Setting appropriate limits on maladaptive behaviors.
Which patient statement would be best documented as a subjective assessment finding supporting a
psychiatric diagnosis of dissociative fugue?
"I can not recall why I'm living
in this town."
,A client with vascular dementia is experiencing agnosia. She sits at her dining table looking at her food,
but does not pick up a utensil and try to eat. Which intervention is most appropriate for the nurse to try
first?
Hand the fork to the client and say, "use this
fork to eat your meat loaf."
Nurses working in a family planning clinic for women routinely ask clients about whether they
have experienced domestic violence. The purpose of having this question in the assessment
tool is because:
A woman experiencing domestic violence may not seek
out help.
A patient admitted for a heroin overdose received naloxone, which improved her
breathing pattern. Two hours later the patient reports muscle aches, abdominal cramps, and gooseflesh,
and says, "I feel terrible." Which is the correct analysis of this assessment?
Symptoms of narcotic abstinence are present.
A 70-year-old client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day,
he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see
him every Wednesday. Let me out." The most therapeutic response by the nurse would be:
It's Monday and you're in the hospital. I'm your nurse.
A patient has blindness related to conversion disorder. In order to assist the patient with eating, which
of the following interventions should the nurse implement?
Expect the patient to feed himself after explaining arrangement of the food on the tray.
Which child shows behaviors that are most indicative of a potential mental illness?
A 3-year-old who is mute, passive toward adults, and twirls while walking.
A patient is admitted for psychiatric observation after being arrested for breaking windows in the home
of a former girlfriend who had refused to see him. His history reveals childhood abuse by a punitive
father, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority in
the plan of care?
Risk for other-directed
violence.
A patient with a history of cocaine use reports a concurrent history of using other drugs in order to
counteract the effects of cocaine. Which drug is this patient likely to have abused?
Alcohol
Which nursing intervention (s) would be most likely included in a plan of care for a patient
with bulimia nervosa?
, (1) Assist the patient to identify triggers to binge eating (2)
Assess for signs of impulsive eating
(3) Explore needs for health teaching.
An 11-year- old is absent from school to stay at home and care for siblings while the
parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly
says "I don't think my parents like me very much. They call me stupid and say I never do anything right.
"Which type of abuse is most likely?
Emotional
An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention
will be most helpful to the patient in managing these illusions?
Wearing glasses and hearing aids
A nursing care plan contains the intervention "monitor for complications of refeeding syndrome." Which
body system should a nurse most closely monitor for clinical manifestations of dysfunction?
Cardiovascular
Which intervention is most effective in managing excessive demands from a client with borderline
personality disorder?
Be consistent in responses to client demands.
A patient referred to the eating disorders clinic has lost 35 pounds during one summer. Which of the
following questions would be best if the nurse wishes to assess the patients' eating patterns?
"What do you eat in a typical day?"
Which of the following clinical manifestations should the nurse expect to assess in a 2-year -old with
suspected autistic disorder?
Failure to display affection toward others, such as hugging or touching a parent.
An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect withdrawal
symptoms to peak?
Between 0200 tomorrow and hospital day 2 (24 to
48 hours after drinking stopped).
Which of the following nursing interventions is the highest priority while working with a patient who has
a somatoform disorder for the first time?
Assess for objective data to support the patient's
report of each physical symptom.
What is the priority nursing diagnosis for a patient who is experiencing fluctuating levels of
consciousness, disturbed orientation, and visual and tactile hallucinations?
Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait
