Rasmussen: Mental Health Exam 2
1. 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: - A neologism
2. 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.): 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. 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:: maintain a normal social interaction distance from the patient.
4. 4) Which statement indicates a patient with major depression is most likely outlook on life
during the acute phase of the illness?: During an acute phase of major depression, the client may
feel worthless and deserve bad things to happen personally.
5. 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.: b. "Taking the medication every day helps reduce the
risk of a relapse."
6. 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.: b. "Feeling that people want to destroy you must be very frightening."
7. 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?: Denial
8. 8) A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoret- ic,
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?: Panic disorder and a nursing diagnosis of anxiety
9. 9) The nurse is providing health teaching for a patient who has been pre- scribed
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?: hyper- tensive crisis
10.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.
11.For depression that is refractory to TCAs. Avoid certain foods such as: - cheese, sour
cream, wine, beer, figs, anchovies, shrimp, bananas, and chocolate, and avoid drugs (e.g., TCAs).
12. Risk for hypertensive crisis:
Avoid self-medication. WHY?: OTC preparations containing dextromethorphan, sympathomimetic
agents, or antihistamines (e.g., cough, cold, and hay fever reme- dies, appetite suppressants) can
precipitate severe hypertensive reactions if taken during therapy or within 2-3 wk after
discontinuation of an MAO inhibitor.
13.10) Which piece of subjective data obtained during the nurse's psychoso- cial
assessment of a client experiencing severe anxiety would indicate the possibility of
obsessive-compulsive disorder?: a. "I have to keep checking to see where my car keys are."
14.11) 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?: A:
Affective flattening.
15.11) The nurse is evaluating the effectiveness of an antipsychotic on neg- ative
symptoms of psychosis. Which of the following symptoms would be classified as negative
symptoms of psychosis?: Blunted affect
Poverty of thought
Loss of motivation
Inability to experience pleasure or joy
16.12) 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
1. 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: - A neologism
2. 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.): 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. 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:: maintain a normal social interaction distance from the patient.
4. 4) Which statement indicates a patient with major depression is most likely outlook on life
during the acute phase of the illness?: During an acute phase of major depression, the client may
feel worthless and deserve bad things to happen personally.
5. 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.: b. "Taking the medication every day helps reduce the
risk of a relapse."
6. 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.: b. "Feeling that people want to destroy you must be very frightening."
7. 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?: Denial
8. 8) A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoret- ic,
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?: Panic disorder and a nursing diagnosis of anxiety
9. 9) The nurse is providing health teaching for a patient who has been pre- scribed
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?: hyper- tensive crisis
10.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.
11.For depression that is refractory to TCAs. Avoid certain foods such as: - cheese, sour
cream, wine, beer, figs, anchovies, shrimp, bananas, and chocolate, and avoid drugs (e.g., TCAs).
12. Risk for hypertensive crisis:
Avoid self-medication. WHY?: OTC preparations containing dextromethorphan, sympathomimetic
agents, or antihistamines (e.g., cough, cold, and hay fever reme- dies, appetite suppressants) can
precipitate severe hypertensive reactions if taken during therapy or within 2-3 wk after
discontinuation of an MAO inhibitor.
13.10) Which piece of subjective data obtained during the nurse's psychoso- cial
assessment of a client experiencing severe anxiety would indicate the possibility of
obsessive-compulsive disorder?: a. "I have to keep checking to see where my car keys are."
14.11) 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?: A:
Affective flattening.
15.11) The nurse is evaluating the effectiveness of an antipsychotic on neg- ative
symptoms of psychosis. Which of the following symptoms would be classified as negative
symptoms of psychosis?: Blunted affect
Poverty of thought
Loss of motivation
Inability to experience pleasure or joy
16.12) 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
