Rasmussen: Mental Health Exam 2
1. 1) 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: ANS: 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.
,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.
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.: ANS:
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.
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:
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.: ANS: D
The patient is describing phenomena that indicate personal boundary difficulties.
The nurse should maintain an appropriate social distance and not touch the pa-
tient, 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.
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.
1. 1) 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: ANS: 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.
,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.
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.: ANS:
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.
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:
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.: ANS: D
The patient is describing phenomena that indicate personal boundary difficulties.
The nurse should maintain an appropriate social distance and not touch the pa-
tient, 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.
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.
