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Rasmussen: Mental Health Exam 2 || Latest Version

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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) 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) 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) 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) A patient diagnosed with bipolar disorder is in the maintenance phase of treatment.
The patient asks, I have to keep taking this lithium even though my mood is stable


b. the medication every day helps reduce the risk of a

6) A person has had difficulty keeping a job because of arguing with co-workers and

,b. that people want to destroy you must be very



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) 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?

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?

hypertensive crisis 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 foods such as

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?

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?

a. "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?

A: 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?

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
strategies to manage her stress? (Select all that apply).

3. control stress by increased physical activity.


4. change her reactions to stress with cognitive behavioral
therapy.



13) Which nursing diagnosis is likely to apply to an individual with severe and
persistent mental illness who is homeless

Chronic low self-esteem

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