Rasmussen- Mental Health Exam 2
4) Which statement indicates a patient with major During an acute phase of major depression, the client may feel worthless and
depression is most likely outlook on life during the deserve bad things to happen personally.
acute phase of the illness?
5) A patient diagnosed with bipolar disorder is in the b. "Taking the medication every day helps reduce the risk of a relapse."
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.
6) A person has had difficulty keeping a job because of b. "Feeling that people want to destroy you must be very frightening."
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.
7) A patient is undergoing a series of diagnostic tests. Denial
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?
8) A cab driver, stuck in traffic, becomes lightheaded, Panic disorder and a nursing diagnosis of anxiety
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?
9) The nurse is providing health teaching for a patient hypertensive crisis
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?
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 cheese, sour cream, wine, beer, figs, anchovies, shrimp, bananas, and
foods such as chocolate, and avoid drugs (e.g., TCAs).
Risk for hypertensive crisis: OTC preparations containing dextromethorphan, sympathomimetic agents, or
Avoid self-medication. WHY? 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.
, Rasmussen- Mental Health Exam 2
10) Which piece of subjective data obtained during the a. "I have to keep checking to see where my car keys are."
nurse's psychosocial assessment of a client
experiencing severe anxiety would indicate the
possibility of obsessive-compulsive disorder?
11) The nurse is evaluating the effectiveness of A: Affective flattening.
psychotropic medication on negative symptoms of
psychosis. The nurse looks for a decrease in which of
the following?
11) The nurse is evaluating the effectiveness of an Blunted affect
antipsychotic on negative symptoms of psychosis. Poverty of thought
Which of the following symptoms would be classified Loss of motivation
as negative symptoms of psychosis? Inability to experience pleasure or joy
12) A 39-year-old woman is recently divorced and is 3. control stress by increased physical activity.
learning to cope with additional stressors. Which of the
following best demonstrate(s) that she is utilizing 4. change her reactions to stress with cognitive behavioral
positive coping strategies to manage her stress? (Select therapy.
all that apply).
13) Which nursing diagnosis is likely to apply to an Chronic low self-esteem
individual with severe and persistent mental illness who
is homeless
14) A patient with depression is receiving imipramine Urinary retention
(Tofranil) 200 mg every night at bedtime. Which
assessment finding would prompt the nurse to
collaborate with the health care provider regarding
potentially hazardous side effects of this
15) Which individual in the emergency department d. A 79-year-old single white man with cancer of the prostate gland.
should be considered at the highest risk for completing
suicide?
16) The nurse is caring for a patient who takes Neuroleptic malignant syndrome
antipsychotic medications and has developed muscle
rigidity, hyperpyrexia, diaphoresis, and drooling. Which
of the following adverse effects of antipsychotic
educations is most likely causing these symptoms?
17) A patient with catatonic schizophrenia exhibits little Physiologic
spontaneous movement and demonstrates waxy
flexibility. Which patient needs are of priority
importance
4) Which statement indicates a patient with major During an acute phase of major depression, the client may feel worthless and
depression is most likely outlook on life during the deserve bad things to happen personally.
acute phase of the illness?
5) A patient diagnosed with bipolar disorder is in the b. "Taking the medication every day helps reduce the risk of a relapse."
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.
6) A person has had difficulty keeping a job because of b. "Feeling that people want to destroy you must be very frightening."
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.
7) A patient is undergoing a series of diagnostic tests. Denial
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?
8) A cab driver, stuck in traffic, becomes lightheaded, Panic disorder and a nursing diagnosis of anxiety
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?
9) The nurse is providing health teaching for a patient hypertensive crisis
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?
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 cheese, sour cream, wine, beer, figs, anchovies, shrimp, bananas, and
foods such as chocolate, and avoid drugs (e.g., TCAs).
Risk for hypertensive crisis: OTC preparations containing dextromethorphan, sympathomimetic agents, or
Avoid self-medication. WHY? 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.
, Rasmussen- Mental Health Exam 2
10) Which piece of subjective data obtained during the a. "I have to keep checking to see where my car keys are."
nurse's psychosocial assessment of a client
experiencing severe anxiety would indicate the
possibility of obsessive-compulsive disorder?
11) The nurse is evaluating the effectiveness of A: Affective flattening.
psychotropic medication on negative symptoms of
psychosis. The nurse looks for a decrease in which of
the following?
11) The nurse is evaluating the effectiveness of an Blunted affect
antipsychotic on negative symptoms of psychosis. Poverty of thought
Which of the following symptoms would be classified Loss of motivation
as negative symptoms of psychosis? Inability to experience pleasure or joy
12) A 39-year-old woman is recently divorced and is 3. control stress by increased physical activity.
learning to cope with additional stressors. Which of the
following best demonstrate(s) that she is utilizing 4. change her reactions to stress with cognitive behavioral
positive coping strategies to manage her stress? (Select therapy.
all that apply).
13) Which nursing diagnosis is likely to apply to an Chronic low self-esteem
individual with severe and persistent mental illness who
is homeless
14) A patient with depression is receiving imipramine Urinary retention
(Tofranil) 200 mg every night at bedtime. Which
assessment finding would prompt the nurse to
collaborate with the health care provider regarding
potentially hazardous side effects of this
15) Which individual in the emergency department d. A 79-year-old single white man with cancer of the prostate gland.
should be considered at the highest risk for completing
suicide?
16) The nurse is caring for a patient who takes Neuroleptic malignant syndrome
antipsychotic medications and has developed muscle
rigidity, hyperpyrexia, diaphoresis, and drooling. Which
of the following adverse effects of antipsychotic
educations is most likely causing these symptoms?
17) A patient with catatonic schizophrenia exhibits little Physiologic
spontaneous movement and demonstrates waxy
flexibility. Which patient needs are of priority
importance
