Rasmussen: Mental Health Exam 2 ,./ ,./ ,./ ,./
ANS: A ,./
-
A neologism is a newly coined word having special meaning t
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
o 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 implante
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
d in one's mind.
,./ ,./ ,./ ,./
-
An idea of reference is a type of delusion in which trivial even
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ts are given personal significance. - correct answer ✔ ✔
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
1) A patient with schizophrenia begins to talks about "volmer
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
s" 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, B, F ,./ ,./ ,./
One-on-
one observation is necessary for anyone who has limited contro
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
l over suicidal impulses.
,./ ,./ ,./ ,./
-
Plastic dishes on trays and the removal of potentially harmful
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
objects from the patient's possession are measures included in a
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ny-level suicide precautions. ,./ ,./ ,./
The remaining options are used in less stringent levels of suicid
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
e precautions. - correct answer ✔ ✔
,./ ,./ ,./ ,./ ,./
2) A patient with suicidal impulses is placed on the highest le
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
vel of suicide precautions. Which measures should be incorpora
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
,ted into the plan of care by the nurse caring for the patient? (M
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ore 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 pos
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
session.
ANS: D ,./
The patient is describing phenomena that indicate personal bou
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ndary difficulties. The nurse should maintain an appropriate soc
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ial distance and not touch the patient, because the patient is anx
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ious about the inability to maintain ego boundaries and mergin
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
g with or being swallowed by the environment. Physical closen
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
, ess or touch could precipitate panic. - correct answer ✔ ✔
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
3) A patient diagnosed with schizophrenia anxiously says, "I
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
can see the left side of my body merging with the wall, then m
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
y face appears and disappears in the mirror." While listening, t
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
he 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 patien
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
t.
During an acute phase of major depression, the client may feel
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
worthless and deserve bad things to happen personally. - ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
correct answer ✔ ✔
,./ ,./ ,./
4) Which statement indicates a patient with major depression
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
is most likely outlook on life during the acute phase of the illne
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ss?
ANS: B ,./ ,./
ANS: A ,./
-
A neologism is a newly coined word having special meaning t
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
o 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 implante
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
d in one's mind.
,./ ,./ ,./ ,./
-
An idea of reference is a type of delusion in which trivial even
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ts are given personal significance. - correct answer ✔ ✔
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
1) A patient with schizophrenia begins to talks about "volmer
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
s" 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, B, F ,./ ,./ ,./
One-on-
one observation is necessary for anyone who has limited contro
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
l over suicidal impulses.
,./ ,./ ,./ ,./
-
Plastic dishes on trays and the removal of potentially harmful
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
objects from the patient's possession are measures included in a
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ny-level suicide precautions. ,./ ,./ ,./
The remaining options are used in less stringent levels of suicid
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
e precautions. - correct answer ✔ ✔
,./ ,./ ,./ ,./ ,./
2) A patient with suicidal impulses is placed on the highest le
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
vel of suicide precautions. Which measures should be incorpora
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
,ted into the plan of care by the nurse caring for the patient? (M
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ore 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 pos
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
session.
ANS: D ,./
The patient is describing phenomena that indicate personal bou
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ndary difficulties. The nurse should maintain an appropriate soc
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ial distance and not touch the patient, because the patient is anx
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ious about the inability to maintain ego boundaries and mergin
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
g with or being swallowed by the environment. Physical closen
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
, ess or touch could precipitate panic. - correct answer ✔ ✔
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
3) A patient diagnosed with schizophrenia anxiously says, "I
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
can see the left side of my body merging with the wall, then m
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
y face appears and disappears in the mirror." While listening, t
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
he 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 patien
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
t.
During an acute phase of major depression, the client may feel
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
worthless and deserve bad things to happen personally. - ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
correct answer ✔ ✔
,./ ,./ ,./
4) Which statement indicates a patient with major depression
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
is most likely outlook on life during the acute phase of the illne
,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./ ,./
ss?
ANS: B ,./ ,./