Rasmussen <Ans> 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 <Ans> - 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.) <Ans>
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 <Ans> <Ans> 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? <Ans> 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. <Ans> 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. <Ans> 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? <Ans> 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? <Ans> 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? <Ans>
hyper- tensive crisis
10. foods with tyramine in it <Ans> 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 <Ans> 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
<Ans> - cheese, sour cream, wine, beer, figs, anchovies, shrimp, bananas, and
chocolate, and avoid drugs (e.g., TCAs).
12. Risk for hypertensive crisis <Ans>
Avoid self-medication. WHY? <Ans> 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? <Ans> 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? <Ans> A <Ans> Affective flattening.
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 <Ans> - 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.) <Ans>
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 <Ans> <Ans> 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? <Ans> 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. <Ans> 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. <Ans> 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? <Ans> 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? <Ans> 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? <Ans>
hyper- tensive crisis
10. foods with tyramine in it <Ans> 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 <Ans> 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
<Ans> - cheese, sour cream, wine, beer, figs, anchovies, shrimp, bananas, and
chocolate, and avoid drugs (e.g., TCAs).
12. Risk for hypertensive crisis <Ans>
Avoid self-medication. WHY? <Ans> 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? <Ans> 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? <Ans> A <Ans> Affective flattening.
