NUR2488 / NUR 2488 EXAM 2 LATEST 2023 MENTAL HEALTH NURSING – RASMUSSEN|COMPLETE EXAM

NUR 2488 Mental Health Nursing Exam 2 Graded A • Question 1 1 out of 1 points You are the nurse responsible for assessing for extrapyramidal side effects in a patient who has been taking chlorpromazine. Which of the following may be side effects for this medication? (Select all that apply.) Akathisia Acute dystonia Tardive Dyskinesia Answer Amenorrhea s: Akathisia Acute dystonia Tardive Dyskinesia Response Extrapyramidal side effects of the central nervous system Feedback: include involuntary motor movements, resulting in possible dystonia, akathisia or dyskinesia. Amenorrhea is a possible side effect of chlorpromazine, but is not an extrapyramidal side effect. • Question 2 1 out of 1 points An adult with depression has been treated with medication and cognitive behavioral therapy. The patient now verbalizes that being passive and letting others make decisions for her contributed to the depression. What referrals could the nurse make to help this patient prevent recurrence of depression? Selected Answer: Social skills training Answers: Social skills training Use of complementary therapy Relaxation training classes Learning desensitization techniques Response Social skills training is helpful in treating and preventing the Feedback : recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others. Use of complementary therapy refers to adjunctive therapies such as herbals. Assertiveness would be of greater value than relaxation training because passivity has been identified as a concern. Desensitization is used in treatment of phobias • Question 3 1 out of 1 points 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? (Select all that apply.) Selected Answers: Maintain arm’s-length distance, institute one-on-one nursing observation around the clock Allow no glass or metal on meal trays Remove all potentially harmful objects from the patient’s possession Answers: Maintain arm’s-length distance, institute one-on-one nursing observation around the clock Allow no glass or metal on meal trays Keep patient within visual range while awake, but only check every 15 to 30 minutes while the patient is sleeping Only check the patient’s whereabouts every 15 minutes and make frequent verbal contacts. Remove all potentially harmful objects from the patient’s possession Response One-on-one observation is necessary for anyone who has Feedback 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. • Question 4 0 out of 1 points Which statement indicates a patient with major depression’s most likely outlook on life during the acute phase of the illness? Selected “If I ignore this, it will go away.” Answer: Answers: “It’s just a matter of time and I’ll be well.” “I deserve to be this way.” “I can fight this and get better.” “If I ignore this, it will go away.” Response Patients with depression feel worthless and often believe they Feedback: deserve to have “bad” things happen. Patients with depression are usually hopeless and would not respond optimistically. Patients with depression usually feel helpless and unable to fight. • Question 5 0 out of 1 points The nurse knows that sedation is a side effect of many antipsychotics. Which of the following medications should the nurse question if ordered for a patient taking antipsychotics? Selected Answer: hydrochlorothia zide Answers: hydrochlorothia zide diphenhydrami ne acetaminophen verapamil Response Diphenhydramine is an antihistamine that is likely to cause Feedback: drowsiness and enhance the sedative effect of an antipsychotic. Hydrochlorothiazide (diuretic), acetaminophen (antipyretic and pain reliever) and verapamil (antihypertensive) do not cause sedation. • Question 6 1 out of 1 points The nurse is caring for a patient who experiences orthostatic hypotension related to taking chlorpromazine. The nurse should suggest which of the following interventions for managing this side effect? Selected Answer: Sit on the side of the bed before standing up. Answers: Stay in bed for an hour after taking the medication. Sit on the side of the bed before standing up. Stand quickly, then wait a moment before walking. Take the medication with milk or food. Response Sudden position changes lead to dizziness associated with Feedback postural hypotension, so arising slowly from sitting or lying : down is a good suggestion. It’s not necessary to stay in bed for an hour after taking the medication. The patient should not stand quickly, as this can lead to a sudden drop in blood pressure. Taking the medication with milk or food will not affect blood pressure. • Question 7 1 out of 1 points 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? Selected flat affect Answer: Answers: illogical speech bizarre behavior delusions flat affect Response Muscle rigidity, hyperpyrexia, tachypnea, diaphoresis, and Feedback: drooling are all symptoms of neuromuscular malignant syndrome (NMS). The primary indications of serotonin syndrome, tardive dyskinesia (TD) and pseudo-Parkinsonism do not include these symptoms. • Question 8 1 out of 1 points During the maintenance phase of treatment a patient with bipolar disorder asks the nurse, “Do I have to keep taking this lithium even though my mood is stable now?” Which is the most appropriate response? Selected Answer: “Taking the medication every day helps prevent relapses and recurrences.” Answers: “You will be able to stop the medication in about 1 month.” “Usually patients take medication for approximately 6 months after discharge.” “Taking the medication every day helps prevent relapses and recurrences.” “It’s unusual that the health care provider hasn’t already stopped your medication.” Response Bipolar patients may be maintained on lithium indefinitely to Feedback: prevent recurrences. Helping the patient understand this need will promote medication compliance. • Question 9 0 out of 1 points A patient with bipolar disorder commands another patient to “Get me that book. Take this other stuff out of here,” and makes other similar demands. Which of the following actions could the nurse use to interrupt this behavior without entering into a power struggle with the patient? Select all that Apply Providing a distraction Setting clear limits Provide advice on how to correct behavior Answer Using humor s: Providing a distraction Setting clear limits Provide advice on how to correct behavior Response The distractibility characteristic of manic episodes can assist the Feedback : nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Limit setting is a main theme in treating a client with mania. Humor usually backfires by either encouraging the patient or inciting anger. Giving advice is considered a non-therapeutic communication technique, and should be avoided. • Question 10 1 out of 1 points A patient with depression is evaluated at the clinic and started on citalopram. The patient tells the nurse, “I have some pills I previously took for depression. They’re called MAOIs. I think I should take them along with this new medication.” What information is essential for the nurse to communicate regarding her statements? Selected The risk of a serious reaction if SSRIs and MAOIs are Answer: combined. Answers: The need to have blood pressure carefully monitored That SSRI antidepressant will be more effective in 3 weeks. The dietary restrictions required when taking MAOIs. The risk of a serious reaction if SSRIs and MAOIs are combined. Response The patient is at risk for a hypertensive crisis if he or she takes Feedback : MAOIs and citalopram, which is an SSRI, without an appropriate washout period. The duration of the washout period is determined by the half-life of the SSRI. The other options do not address the priority concern of the drug interaction. • Question 11 1 out of 1 points A patient with schizophrenia begins to talks about “volmers” hiding in the warehouse at work. Which of the following should the term “volmers” be assessed as? Selected A neologism Answer: Answers: A neologism Concrete thinking Thought insertion An idea of reference Response A neologism is a newly coined word having special meaning to Feedback : the patient. “Volmer” is not a known common noun. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to the idea that the thoughts of others are being planted in one’s mind. Ideas of reference are a type of delusion in which trivial events are given personal significance. • Question 12 1 out of 1 points The nurse is caring for a female patient diagnosed with schizophrenia who believes that her thoughts are broadcast to others. What is the most appropriate nursing diagnosis for this patient? Selected Answer: Disturbed Thought Processes Answers: Risk for Self-Directed Violence Impaired Communication Disturbed Thought Processes Disturbed Sensory Perception Response Thought broadcasting and thought withdrawal are disturbed Feedback : thought processes. There is no indicated that the patient is planning self-harm. Disturbed Sensory Perception would refer to the interpretation of sensory stimuli, such as sights and sounds. The patient does not have a problem with communication, but with her thought process. • Question 13 1 out of 1 points A nurse receives this laboratory result: lithium level 1.7 mEq/L. How should the nurse interpret this lab value? Selected Above therapeutic limits Answer: Answers: Within therapeutic limits Below therapeutic limits Above therapeutic limits Incorrect because of inaccurate testing Response Normal range for a blood sample taken 8 to 12 hours after the Feedback: last dose of lithium is 0.8 to 1.4 mEq/L for maintenance. This lab value represents likely lithium toxicity. • Question 14 1 out of 1 points Which of the following interventions should the nurse prioritize for a patient with severe depression? Selected Careful unobtrusive observation around the clock Answer: Answers: Allowing the patient to spend long periods alone in meditation. Careful unobtrusive observation around the clock Encouraging the patient to spend a major portion of each day in bed Provide opportunities for the patient to assume a leadership role on the unit Response Approximately two thirds of people with depression Feedback: contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the patient with depression may prevent a suicide attempt on the unit • Question 15 1 out of 1 points Which comment by a patient experiencing severe anxiety would indicate the possibility of obsessive-compulsive disorder? Selected “I have to keep checking to see where my Answer: car keys are.” Answers: “I have to keep checking to see where my car keys are.” “My legs feel weak most of the time.” “I’m afraid to go out in public.” “I keep reliving the car accident.” Response Recurring doubt (obsessive thinking) and the need to check Feedback : (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. Stating “My legs feel weak most of the time” is more in keeping with a somatoform disorder. Being afraid to go out in public is associated with agoraphobia and reliving a traumatic event is associated with posttraumatic stress disorder • Question 16 1 out of 1 points When educating a client and their family about taking a serotonin reuptake inhibitor (SSRI), which should the nurse prioritize for teaching purposes? Selected Answer: Report increased suicidal thoughts Answers: Avoid exposure to bright sunlight Report increased suicidal thoughts Restrict sodium intake to 1 g. daily Maintain a tyramine free diet Response Some evidence indicates that suicidal ideation may worsen at Feedback the beginning of antidepressant therapy; thus close monitoring : is necessary. Avoiding exposure to bright sunlight and restricting sodium