Rasmussen: Mental Health Exam 2
1) A patient with schizophrenia begins to talks about "volmers" hiding in the warehouseat
work. The term "volmers" should be documented as:
a. neologism
b. concrete thinking
c. thought insertion
d. idea of reference - CORRECT ANSWERS ANS: A
- A neologism is a newly coined word having special meaning to the patient. "Volmer" isnot 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) 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 thepatient? (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 thepatient
is sleeping.
d. Check the patient's whereabouts every 15 minutes and make frequent verbalcontacts.
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. - CORRECT
ANSWERS ANS: A, B, F
One-on-one observation is necessary for anyone who has limited control over suicidalimpulses.
- 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) 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. - CORRECT
ANSWERS ANS: D
,Rasmussen: Mental Health Exam 2
The patient is describing phenomena that indicate personal boundary difficulties. The nurse
should maintain an appropriate social distance and not touch the patient, becausethe patient is
anxious about the inability to maintain ego boundaries and merging with orbeing swallowed by
the environment. Physical closeness or touch could precipitate panic.
4) Which statement indicates a patient with major depression is most likely outlook on life
during the acute phase of the illness? - CORRECT ANSWERS During an
acute phase of major depression, the client may feel worthless and deserve bad thingsto happen
personally.
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 stablenow?"
Select the nurse's appropriate response.
a. "You will be able to stop the medication in about 1 month."
b. "Taking the medication every day helps reduce the risk of a relapse."
c. "Usually patients take medication for approximately 6 months after discharge."
d. "It's unusual that the health care provider hasn't already stopped your medication." -
CORRECT ANSWERS ANS: B
Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent
recurrences. Helping the patient understand this need will promote medicationcompliance.
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 destroyme. Isn't that
true?" Select the nurse's most therapeutic response.
a."Everyone here is trying to help you. No one wants to harm you." b.
"Feeling that people want to destroy you must be very frightening."
c. "That is not true. People here are trying to help you if you will let them."
d. "Staff members are health care professionals who are qualified to help you." -
CORRECT ANSWERS ANS: B
Resist focusing on content; instead, focus on the feelings the patient is expressing. Thisstrategy
prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety
and the tenacity with which the patient holds to the delusion.
The other options focus on content and provide opportunity for argument.
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 mechanismis the patient using?
, Rasmussen: Mental Health Exam 2
a. Regression b.
Displacementc.
Denial
d. Projection - CORRECT ANSWERS ANS: C
Denial is an unconscious blocking of threatening or painful information or feelings. Regression
involves using behaviors appropriate at an earlier stage of psychosexual development.
Displacement shifts feelings to a more neutral person or object. Projectionattributes one's own
unacceptable thoughts or feelings to another
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 bethe nurse's first priority?
1. Generalized anxiety disorder and a nursing diagnosis of fear
2. Altered sensory perception and a nursing diagnosis of panic disorder3. Pain
disorder and a nursing diagnosis of altered role performance
4. Panic disorder and a nursing diagnosis of anxiety - CORRECT ANSWERSANS:
D
The nurse should suspect that the client has exhibited signs/symptoms of a panicdisorder. The
priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent,
sudden onset panic attacks in which the person feels intense fear, apprehension, or terror.
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 beeaten while taking
this medication. What is the potential problem if the patient is not compliant with these dietary
restrictions? - CORRECT ANSWERS hypertensive
crisis
foods with tyramine in it - CORRECT ANSWERS 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 - CORRECT
ANSWERS 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? - CORRECT ANSWERS OTC preparations
containing dextromethorphan, sympathomimetic agents, or antihistamines (e.g., cough,
1) A patient with schizophrenia begins to talks about "volmers" hiding in the warehouseat
work. The term "volmers" should be documented as:
a. neologism
b. concrete thinking
c. thought insertion
d. idea of reference - CORRECT ANSWERS ANS: A
- A neologism is a newly coined word having special meaning to the patient. "Volmer" isnot 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) 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 thepatient? (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 thepatient
is sleeping.
d. Check the patient's whereabouts every 15 minutes and make frequent verbalcontacts.
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. - CORRECT
ANSWERS ANS: A, B, F
One-on-one observation is necessary for anyone who has limited control over suicidalimpulses.
- 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) 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. - CORRECT
ANSWERS ANS: D
,Rasmussen: Mental Health Exam 2
The patient is describing phenomena that indicate personal boundary difficulties. The nurse
should maintain an appropriate social distance and not touch the patient, becausethe patient is
anxious about the inability to maintain ego boundaries and merging with orbeing swallowed by
the environment. Physical closeness or touch could precipitate panic.
4) Which statement indicates a patient with major depression is most likely outlook on life
during the acute phase of the illness? - CORRECT ANSWERS During an
acute phase of major depression, the client may feel worthless and deserve bad thingsto happen
personally.
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 stablenow?"
Select the nurse's appropriate response.
a. "You will be able to stop the medication in about 1 month."
b. "Taking the medication every day helps reduce the risk of a relapse."
c. "Usually patients take medication for approximately 6 months after discharge."
d. "It's unusual that the health care provider hasn't already stopped your medication." -
CORRECT ANSWERS ANS: B
Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent
recurrences. Helping the patient understand this need will promote medicationcompliance.
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 destroyme. Isn't that
true?" Select the nurse's most therapeutic response.
a."Everyone here is trying to help you. No one wants to harm you." b.
"Feeling that people want to destroy you must be very frightening."
c. "That is not true. People here are trying to help you if you will let them."
d. "Staff members are health care professionals who are qualified to help you." -
CORRECT ANSWERS ANS: B
Resist focusing on content; instead, focus on the feelings the patient is expressing. Thisstrategy
prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety
and the tenacity with which the patient holds to the delusion.
The other options focus on content and provide opportunity for argument.
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 mechanismis the patient using?
, Rasmussen: Mental Health Exam 2
a. Regression b.
Displacementc.
Denial
d. Projection - CORRECT ANSWERS ANS: C
Denial is an unconscious blocking of threatening or painful information or feelings. Regression
involves using behaviors appropriate at an earlier stage of psychosexual development.
Displacement shifts feelings to a more neutral person or object. Projectionattributes one's own
unacceptable thoughts or feelings to another
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 bethe nurse's first priority?
1. Generalized anxiety disorder and a nursing diagnosis of fear
2. Altered sensory perception and a nursing diagnosis of panic disorder3. Pain
disorder and a nursing diagnosis of altered role performance
4. Panic disorder and a nursing diagnosis of anxiety - CORRECT ANSWERSANS:
D
The nurse should suspect that the client has exhibited signs/symptoms of a panicdisorder. The
priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent,
sudden onset panic attacks in which the person feels intense fear, apprehension, or terror.
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 beeaten while taking
this medication. What is the potential problem if the patient is not compliant with these dietary
restrictions? - CORRECT ANSWERS hypertensive
crisis
foods with tyramine in it - CORRECT ANSWERS 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 - CORRECT
ANSWERS 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? - CORRECT ANSWERS OTC preparations
containing dextromethorphan, sympathomimetic agents, or antihistamines (e.g., cough,
