Rasmussen: Mental Health Exam 2 Latest
Version(Updated 2025) with complete
solution
/. 1) A patient with schizophrenia begins to talks about "volmers" or about "frangularity"
hiding in the warehouse at work. The term "volmers" should be documented as -
Answer-✅- A neologism
/.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.) - Answer-✅A.Maintain arm's-length, one-
on-one nursing observation around the clock.
b. Allow no glass or metal on meal trays.
f. Remove all potentially harmful objects from the patient's possession.
/.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: - Answer-✅maintain a normal social interaction distance
from the patient.
/.4) Which statement indicates a patient 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 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. - Answer-✅. "Taking the medication
every day helps reduce the risk of a relapse."
/.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. - Answer-✅. "Feeling
that people want to destroy you must be very frightening."
/.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? - Answer-✅Denial
, /.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? - Answer-✅Panic disorder and a nursing diagnosis of anxiety
/.9) 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? - Answer-✅hypertensive crisis
/.foods with tyramine in it - Answer-✅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 - Answer-
✅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? - Answer-✅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.
/.10) 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? - Answer-✅. "I have to keep checking to see where my
car keys are."
/.11) The nurse is evaluating the effectiveness of psychotropic medication on negative
symptoms of psychosis. The nurse looks for a decrease in which of the following? -
Answer-✅: Affective flattening.
/.11) The nurse is evaluating the effectiveness of an antipsychotic on negative
symptoms of psychosis. Which of the following symptoms would be classified as
negative symptoms of psychosis? - Answer-✅Blunted affect
Poverty of thought
Loss of motivation
Inability to experience pleasure or joy
/.12) A 39-year-old woman is recently divorced and is learning to cope with additional
stressors. Which of the following best demonstrate(s) that she is utilizing positive coping
Version(Updated 2025) with complete
solution
/. 1) A patient with schizophrenia begins to talks about "volmers" or about "frangularity"
hiding in the warehouse at work. The term "volmers" should be documented as -
Answer-✅- A neologism
/.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.) - Answer-✅A.Maintain arm's-length, one-
on-one nursing observation around the clock.
b. Allow no glass or metal on meal trays.
f. Remove all potentially harmful objects from the patient's possession.
/.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: - Answer-✅maintain a normal social interaction distance
from the patient.
/.4) Which statement indicates a patient 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 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. - Answer-✅. "Taking the medication
every day helps reduce the risk of a relapse."
/.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. - Answer-✅. "Feeling
that people want to destroy you must be very frightening."
/.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? - Answer-✅Denial
, /.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? - Answer-✅Panic disorder and a nursing diagnosis of anxiety
/.9) 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? - Answer-✅hypertensive crisis
/.foods with tyramine in it - Answer-✅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 - Answer-
✅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? - Answer-✅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.
/.10) 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? - Answer-✅. "I have to keep checking to see where my
car keys are."
/.11) The nurse is evaluating the effectiveness of psychotropic medication on negative
symptoms of psychosis. The nurse looks for a decrease in which of the following? -
Answer-✅: Affective flattening.
/.11) The nurse is evaluating the effectiveness of an antipsychotic on negative
symptoms of psychosis. Which of the following symptoms would be classified as
negative symptoms of psychosis? - Answer-✅Blunted affect
Poverty of thought
Loss of motivation
Inability to experience pleasure or joy
/.12) A 39-year-old woman is recently divorced and is learning to cope with additional
stressors. Which of the following best demonstrate(s) that she is utilizing positive coping
