Rasmussen: Mental Health
Exam 2
1) A patient with schizophrenia begins to talks about "volmers" hiding in the warehouseat
work. The term "volmers" should be documented as:
a. neologism
b. concrete thinking
c. thought insertion
d. idea of reference - CORRECT ANSWERS ANS: A
- A neologism is a newly coined word having special meaning to the patient. "Volmer" isnot 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 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 thepatient? (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 thepatient
is sleeping.
d. Check the patient's whereabouts every 15 minutes and make frequent verbalcontacts.
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. - CORRECT
ANSWERS ANS: A, B, F
One-on-one observation is necessary for anyone who has limited control over suicidalimpulses.
- 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.
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:
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. - CORRECT
ANSWERS 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, becausethe patient is
anxious about the inability to maintain ego boundaries and merging with orbeing swallowed by
the environment. Physical closeness or touch could precipitate panic.
4) Which statement indicates a patient with major depression is most likely outlook on life
during the acute phase of the illness? - CORRECT ANSWERS During an
acute phase of major depression, the client may feel worthless and deserve bad thingsto 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 th
Exam 2
1) A patient with schizophrenia begins to talks about "volmers" hiding in the warehouseat
work. The term "volmers" should be documented as:
a. neologism
b. concrete thinking
c. thought insertion
d. idea of reference - CORRECT ANSWERS ANS: A
- A neologism is a newly coined word having special meaning to the patient. "Volmer" isnot 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 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 thepatient? (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 thepatient
is sleeping.
d. Check the patient's whereabouts every 15 minutes and make frequent verbalcontacts.
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. - CORRECT
ANSWERS ANS: A, B, F
One-on-one observation is necessary for anyone who has limited control over suicidalimpulses.
- 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.
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:
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. - CORRECT
ANSWERS 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, becausethe patient is
anxious about the inability to maintain ego boundaries and merging with orbeing swallowed by
the environment. Physical closeness or touch could precipitate panic.
4) Which statement indicates a patient with major depression is most likely outlook on life
during the acute phase of the illness? - CORRECT ANSWERS During an
acute phase of major depression, the client may feel worthless and deserve bad thingsto 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 th
