NUR 2459 / NUR2459 Mental and Behavioral Health Nursing Exam 2 | Already Graded A |Latest 2022 / 2023| Rasmussen

NUR 2459 / NUR2459 Mental and Behavioral Health Nursing Exam 2 | Already Graded A |Latest 2022 / 2023| Rasmussen 1. A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan? A. No risk B. Low level C. Moderate level D. High level  Answer: D  The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue. 2. A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient: A. monitors sodium intake and weight daily. B. wears support stockings and elevates the legs when sitting. C. consults the pharmacist when selecting over-the-counter medications. D. can identify foods with high selenium content, which should be avoided.  Answer: C  Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure. 3. 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  Answer: 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. 4. 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.  Answer: 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. 5. 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.  Answer: 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. 6. 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. 7. 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