Rasmussen: Mental Health Exam 2 questions
with correct answer
ANS: A f
- A neologism is a newly coined word having special meaning to the patient. "Volmer" is not
f f f f f f f f f f f f f f f f
a known common noun.
f f f f f
- Concrete thinking refers to the inability to think abstractly.
f f f f f f f f f
- Thought insertion refers to thoughts of others that are implanted in one's mind.
f f f f f f f f f f f f f f
- An idea of reference is a type of delusion in which trivial events are given personal
f f f f f f f f f f f f f f f f
significance. - answer-1) A patient with schizophrenia begins to talks about "volmers"
f f f f f f f f f f f f
hiding in the warehouse at work. The term "volmers" should be documented as:
f f f f f f f f f f f f f
a. neologismf f
b. concrete thinking
f f f
c. thought insertion
f f f
d. idea of reference
f f f
ANS: A, B, F f f f
One-on-one observation is necessary for anyone who has limited control over suicidal f f f f f f f f f f f
impulses.
f f
- Plastic dishes on trays and the removal of potentially harmful objects from the patient's
f f f f f f f f f f f f f f
possession are measures included in any-level suicide precautions.
f f f f f f f f f
The remaining options are used in less stringent levels of suicide precautions. - answer-2)
f f f f f f f f f f f f f
A patient with suicidal impulses is placed on the highest level of suicide precautions.
f f f f f f f f f f f f f f
Which measures should be incorporated into the plan of care by the nurse caring for the
f f f f f f f f f f f f f f f f
patient? (More than one answer is correct.)
f f f f f f f
a. Maintain arm's-length, one-on-one nursing observation around the clock.
f f f f f f f f
b. Allow no glass or metal on meal trays.
f f f f f f f f
c. Keep patient within visual range while awake. Check every 15 to 30 minutes while the
f f f f f f f f f f f f f f f
patient is sleeping.
f f f
d. Check the patient's whereabouts every 15 minutes and make frequent verbal contacts.
f f f f f f f f f f f f
e. Check whereabouts every hour. Make verbal contact at least three times each shift.
f f f f f f f f f f f f f
f. Remove all potentially harmful objects from the patient's possession.
f f f f f f f f f
,ANS: D f
The patient is describing phenomena that indicate personal boundary difficulties. The
f f f f f f f f f f
nurse should maintain an appropriate social distance and not touch the patient, because
f f f f f f f f f f f f f
the patient is anxious about the inability to maintain ego boundaries and merging with or
f f f f f f f f f f f f f f f
being swallowed by the environment. Physical closeness or touch could precipitate panic.
f f f f f f f f f f f f
- answer-3) A patient diagnosed with schizophrenia anxiously says, "I can see the left side
f f f f f f f f f f f f f f f
of my body merging with the wall, then my face appears and disappears in the mirror."
f f f f f f f f f f f f f f f f
While listening, the nurse should:
f f f f f
a. sit close to the patient.
f f f f f f
b. place an arm protectively around the patient's shoulders.
f f f f f f f f f
c. place a hand on the patient's arm and exert light pressure.
f f f f f f f f f f f f
d. maintain a normal social interaction distance from the patient.
f f f f f f f f f
During an acute phase of major depression, the client may feel worthless and deserve bad
f f f f f f f f f f f f f f
things to happen personally. - answer-4) Which statement indicates a patient with major
f f f f f f f f f f f f f
depression is most likely outlook on life during the acute phase of the illness?
f f f f f f f f f f f f f f
ANS: B f f
Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to
f f f f f f f f f f f
prevent recurrences. Helping the patient understand this need will promote medication
f f f f f f f f f f f
compliance. - answer-5) A patient diagnosed with bipolar disorder is in the maintenance
f f f f f f f f f f f f f
phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my
f f f f f f f f f f f f f f f f f
mood is stable now?" Select the nurse's appropriate response.
f f f f f f f f f f
a. "You will be able to stop the medication in about 1 month."
f f f f f f f f f f f f f
b. "Taking the medication every day helps reduce the risk of a relapse."
f f f f f f f f f f f f f
c. "Usually patients take medication for approximately 6 months after discharge."
f f f f f f f f f f f
d. "It's unusual that the health care provider hasn't already stopped your medication."
f f f f f f f f f f f f
ANS: B f
Resist focusing on content; instead, focus on the feelings the patient is expressing. This
f f f f f f f f f f f f f
strategy prevents arguing about the reality of delusional beliefs. Such arguments increase
f f f f f f f f f f f f
patient anxiety and the tenacity with which the patient holds to the delusion. The other
f f f f f f f f f f f f f f f
options focus on content and provide opportunity for argument. - answer-6) A person has
f f f f f f f f f f f f f f
had difficulty keeping a job because of arguing with co-workers and accusing them of
f f f f f f f f f f f f f f
conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?"
f f f f f f f f f f f f f f
Select the nurse's most therapeutic response.
f f f f f f
a."Everyone here is trying to help you. No one wants to harm you." f f f f f f f f f f f f
b. "Feeling that people want to destroy you must be very frightening."
f f f f f f f f f f f
c. "That is not true. People here are trying to help you if you will let them."
f f f f f f f f f f f f f f f f
, d. "Staff members are health care professionals who are qualified to help you."
f f f f f f f f f f f f
ANS: C f f
Denial is an unconscious blocking of threatening or painful information or feelings.
f f f f f f f f f f f
Regression involves using behaviors appropriate at an earlier stage of psychosexual
f f f f f f f f f f f
development. Displacement shifts feelings to a more neutral person or object. Projection
f f f f f f f f f f f f
attributes one's own unacceptable thoughts or feelings to another - answer-7) A patient is
f f f f f f f f f f f f f f
undergoing a series of diagnostic tests. The patient says, "Nothing is wrong with me
f f f f f f f f f f f f f f
except a stubborn chest cold." The spouse reports the patient smokes and coughs a lot,
f f f f f f f f f f f f f f f
has lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using?
f f f f f f f f f f f f f f f f
a. Regression
f f
b. Displacement
f f
c. Denial
f f
d. Projection
f
ANS: D f
The nurse should suspect that the client has exhibited signs/symptoms of a panic disorder.
f f f f f f f f f f f f f
The priority nursing diagnosis should be anxiety. Panic disorder is characterized by
f f f f f f f f f f f f
recurrent, sudden onset panic attacks in which the person feels intense fear,
f f f f f f f f f f f f
apprehension, or terror. - answer-8) A cab driver, stuck in traffic, becomes lightheaded,
f f f f f f f f f f f f f
tremulous, diaphoretic, tachycardia and dyspneic. A workup in an emergency department
f f f f f f f f f f f
reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing
f f f f f f f f f f f f f
diagnosis should be the nurse's first priority?
f f f f f f f f
1. Generalized anxiety disorder and a nursing diagnosis of fear
f f f f f f f f f
2. Altered sensory perception and a nursing diagnosis of panic disorder
f f f f f f f f f f
3. Pain disorder and a nursing diagnosis of altered role performance
f f f f f f f f f f
4. Panic disorder and a nursing diagnosis of anxiety
f f f f f f f f
hypertensive crisis - answer-9) The nurse is providing health teaching for a patient who has
f f f f f f f f f f f f f f
been prescribed Phenelzine (Nardil) for depression and provides a written list of foods that
f f f f f f f f f f f f f f
should not be eaten while taking this medication. What is the potential problem if the
f f f f f f f f f f f f f f f
patient is not compliant with these dietary restrictions?
f f f f f f f f
Aged meats or aged cheeses, protein extracts, sour cream, alcohol, anchovies, liver,
f f f f f f f f f f f
sausages, overripe figs, bananas, avocados, chocolate, soy sauce, bean curd, natural
f f f f f f f f f f f
yogurt, fava beans—tyramine-containing foods—may precipitate hypertensive crisis.
f f f f f f f
Avoid chocolate or caffeine.
f f f f f
Herbal: Ginseng, ephedra, ma huang, St. John's wort may cause hypertensive crisis. -
f f f f f f f f f f f f
answer-foods with tyramine in it
f f f f f
with correct answer
ANS: A f
- A neologism is a newly coined word having special meaning to the patient. "Volmer" is not
f f f f f f f f f f f f f f f f
a known common noun.
f f f f f
- Concrete thinking refers to the inability to think abstractly.
f f f f f f f f f
- Thought insertion refers to thoughts of others that are implanted in one's mind.
f f f f f f f f f f f f f f
- An idea of reference is a type of delusion in which trivial events are given personal
f f f f f f f f f f f f f f f f
significance. - answer-1) A patient with schizophrenia begins to talks about "volmers"
f f f f f f f f f f f f
hiding in the warehouse at work. The term "volmers" should be documented as:
f f f f f f f f f f f f f
a. neologismf f
b. concrete thinking
f f f
c. thought insertion
f f f
d. idea of reference
f f f
ANS: A, B, F f f f
One-on-one observation is necessary for anyone who has limited control over suicidal f f f f f f f f f f f
impulses.
f f
- Plastic dishes on trays and the removal of potentially harmful objects from the patient's
f f f f f f f f f f f f f f
possession are measures included in any-level suicide precautions.
f f f f f f f f f
The remaining options are used in less stringent levels of suicide precautions. - answer-2)
f f f f f f f f f f f f f
A patient with suicidal impulses is placed on the highest level of suicide precautions.
f f f f f f f f f f f f f f
Which measures should be incorporated into the plan of care by the nurse caring for the
f f f f f f f f f f f f f f f f
patient? (More than one answer is correct.)
f f f f f f f
a. Maintain arm's-length, one-on-one nursing observation around the clock.
f f f f f f f f
b. Allow no glass or metal on meal trays.
f f f f f f f f
c. Keep patient within visual range while awake. Check every 15 to 30 minutes while the
f f f f f f f f f f f f f f f
patient is sleeping.
f f f
d. Check the patient's whereabouts every 15 minutes and make frequent verbal contacts.
f f f f f f f f f f f f
e. Check whereabouts every hour. Make verbal contact at least three times each shift.
f f f f f f f f f f f f f
f. Remove all potentially harmful objects from the patient's possession.
f f f f f f f f f
,ANS: D f
The patient is describing phenomena that indicate personal boundary difficulties. The
f f f f f f f f f f
nurse should maintain an appropriate social distance and not touch the patient, because
f f f f f f f f f f f f f
the patient is anxious about the inability to maintain ego boundaries and merging with or
f f f f f f f f f f f f f f f
being swallowed by the environment. Physical closeness or touch could precipitate panic.
f f f f f f f f f f f f
- answer-3) A patient diagnosed with schizophrenia anxiously says, "I can see the left side
f f f f f f f f f f f f f f f
of my body merging with the wall, then my face appears and disappears in the mirror."
f f f f f f f f f f f f f f f f
While listening, the nurse should:
f f f f f
a. sit close to the patient.
f f f f f f
b. place an arm protectively around the patient's shoulders.
f f f f f f f f f
c. place a hand on the patient's arm and exert light pressure.
f f f f f f f f f f f f
d. maintain a normal social interaction distance from the patient.
f f f f f f f f f
During an acute phase of major depression, the client may feel worthless and deserve bad
f f f f f f f f f f f f f f
things to happen personally. - answer-4) Which statement indicates a patient with major
f f f f f f f f f f f f f
depression is most likely outlook on life during the acute phase of the illness?
f f f f f f f f f f f f f f
ANS: B f f
Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to
f f f f f f f f f f f
prevent recurrences. Helping the patient understand this need will promote medication
f f f f f f f f f f f
compliance. - answer-5) A patient diagnosed with bipolar disorder is in the maintenance
f f f f f f f f f f f f f
phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my
f f f f f f f f f f f f f f f f f
mood is stable now?" Select the nurse's appropriate response.
f f f f f f f f f f
a. "You will be able to stop the medication in about 1 month."
f f f f f f f f f f f f f
b. "Taking the medication every day helps reduce the risk of a relapse."
f f f f f f f f f f f f f
c. "Usually patients take medication for approximately 6 months after discharge."
f f f f f f f f f f f
d. "It's unusual that the health care provider hasn't already stopped your medication."
f f f f f f f f f f f f
ANS: B f
Resist focusing on content; instead, focus on the feelings the patient is expressing. This
f f f f f f f f f f f f f
strategy prevents arguing about the reality of delusional beliefs. Such arguments increase
f f f f f f f f f f f f
patient anxiety and the tenacity with which the patient holds to the delusion. The other
f f f f f f f f f f f f f f f
options focus on content and provide opportunity for argument. - answer-6) A person has
f f f f f f f f f f f f f f
had difficulty keeping a job because of arguing with co-workers and accusing them of
f f f f f f f f f f f f f f
conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?"
f f f f f f f f f f f f f f
Select the nurse's most therapeutic response.
f f f f f f
a."Everyone here is trying to help you. No one wants to harm you." f f f f f f f f f f f f
b. "Feeling that people want to destroy you must be very frightening."
f f f f f f f f f f f
c. "That is not true. People here are trying to help you if you will let them."
f f f f f f f f f f f f f f f f
, d. "Staff members are health care professionals who are qualified to help you."
f f f f f f f f f f f f
ANS: C f f
Denial is an unconscious blocking of threatening or painful information or feelings.
f f f f f f f f f f f
Regression involves using behaviors appropriate at an earlier stage of psychosexual
f f f f f f f f f f f
development. Displacement shifts feelings to a more neutral person or object. Projection
f f f f f f f f f f f f
attributes one's own unacceptable thoughts or feelings to another - answer-7) A patient is
f f f f f f f f f f f f f f
undergoing a series of diagnostic tests. The patient says, "Nothing is wrong with me
f f f f f f f f f f f f f f
except a stubborn chest cold." The spouse reports the patient smokes and coughs a lot,
f f f f f f f f f f f f f f f
has lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using?
f f f f f f f f f f f f f f f f
a. Regression
f f
b. Displacement
f f
c. Denial
f f
d. Projection
f
ANS: D f
The nurse should suspect that the client has exhibited signs/symptoms of a panic disorder.
f f f f f f f f f f f f f
The priority nursing diagnosis should be anxiety. Panic disorder is characterized by
f f f f f f f f f f f f
recurrent, sudden onset panic attacks in which the person feels intense fear,
f f f f f f f f f f f f
apprehension, or terror. - answer-8) A cab driver, stuck in traffic, becomes lightheaded,
f f f f f f f f f f f f f
tremulous, diaphoretic, tachycardia and dyspneic. A workup in an emergency department
f f f f f f f f f f f
reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing
f f f f f f f f f f f f f
diagnosis should be the nurse's first priority?
f f f f f f f f
1. Generalized anxiety disorder and a nursing diagnosis of fear
f f f f f f f f f
2. Altered sensory perception and a nursing diagnosis of panic disorder
f f f f f f f f f f
3. Pain disorder and a nursing diagnosis of altered role performance
f f f f f f f f f f
4. Panic disorder and a nursing diagnosis of anxiety
f f f f f f f f
hypertensive crisis - answer-9) The nurse is providing health teaching for a patient who has
f f f f f f f f f f f f f f
been prescribed Phenelzine (Nardil) for depression and provides a written list of foods that
f f f f f f f f f f f f f f
should not be eaten while taking this medication. What is the potential problem if the
f f f f f f f f f f f f f f f
patient is not compliant with these dietary restrictions?
f f f f f f f f
Aged meats or aged cheeses, protein extracts, sour cream, alcohol, anchovies, liver,
f f f f f f f f f f f
sausages, overripe figs, bananas, avocados, chocolate, soy sauce, bean curd, natural
f f f f f f f f f f f
yogurt, fava beans—tyramine-containing foods—may precipitate hypertensive crisis.
f f f f f f f
Avoid chocolate or caffeine.
f f f f f
Herbal: Ginseng, ephedra, ma huang, St. John's wort may cause hypertensive crisis. -
f f f f f f f f f f f f
answer-foods with tyramine in it
f f f f f
