RASMUSSEN MENTAL HEALTH EXAM 2 TEST BANK ACTUAL LATEST 200
QUESTIONS & DETAILED ANSWERS GRADED A
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
- A neologism
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.)
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.
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:
maintain a normal social interaction distance from the patient.
Which statement indicates a patient with major depression is most likely outlook on life during
the acute phase of the illness?
During an acute phase of major depression, the client may feel worthless and deserve bad things
to happen personally.
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.
b. "Taking the medication every day helps reduce the risk of a relapse."
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.
b. "Feeling that people want to destroy you must be very frightening."
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?
Denial
The nurse is caring for a patient who takes antipsychotic medications and has developed muscle
rigidity, hyperpyrexia, diaphoresis, and drooling. Which of the following adverse effects of
antipsychotic educations is most likely causing these symptoms?
Neuroleptic malignant syndrome
A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates
waxy flexibility. Which patient needs are of priority importance
, Physiologic
A nurse works with a patient with paranoid schizophrenia regarding the importance of
medication management. The patient repeatedly says, "I don't like taking pills." Family members
say they feel helpless to foster compliance. Which treatment strategy should the nurse discuss
with the health care provider?
Use of a long-acting antipsychotic preparation
Which documentation indicates that the treatment plan for a patient diagnosed with acute mania
has been effective?
Converses with few interruptions; clothing matches; participates in activities."
A priority nursing intervention for a patient diagnosed with major depressive disorder is
carefully and inconspicuously observing the patient around the clock.
A nurse plans health teaching for a patient with generalized anxiety disorder who begins a new
prescription for lorazepam (Ativan). What information should be included? (Select all that
apply).
a. Caution in use of machinery
c. The importance of caffeine restriction
d. Avoidance of alcohol and other sedatives
A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about
feelings and concerns. What is the rationale for this intervention?
b. Concerns stated aloud become less overwhelming and help problem solving begin.
A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor
(SSRI) antidepressant therapy. Priority information given to the patient and family should
include a directive to:
report increased suicidal thoughts.
A veteran of the lraq War describes that he is having intrusive thoughts of missiles, screaming,
explosions, and the same feelings of terror first experienced in combat. Which of the following
clinical disorders would this patient most likely be describing symptoms of?
ANS: Post-traumatic stress disorder (PTSD)
A patient with acute mania approaches the nurse, waves a newspaper, and says, "I want the
phone right now. I need to call this store while their sale is going on. I need ten dresses and four
pairs of shoes." Select the nurse's best intervention.
Distracting the patient can avoid power struggles.
A patient tells the nurse, "I wanted my health care provider to prescribe diazepam (Valium) for
my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why?" The nurse's reply
should be based on the knowledge that buspirone:
does not cause dependence.
QUESTIONS & DETAILED ANSWERS GRADED A
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
- A neologism
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.)
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.
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:
maintain a normal social interaction distance from the patient.
Which statement indicates a patient with major depression is most likely outlook on life during
the acute phase of the illness?
During an acute phase of major depression, the client may feel worthless and deserve bad things
to happen personally.
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.
b. "Taking the medication every day helps reduce the risk of a relapse."
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.
b. "Feeling that people want to destroy you must be very frightening."
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?
Denial
The nurse is caring for a patient who takes antipsychotic medications and has developed muscle
rigidity, hyperpyrexia, diaphoresis, and drooling. Which of the following adverse effects of
antipsychotic educations is most likely causing these symptoms?
Neuroleptic malignant syndrome
A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates
waxy flexibility. Which patient needs are of priority importance
, Physiologic
A nurse works with a patient with paranoid schizophrenia regarding the importance of
medication management. The patient repeatedly says, "I don't like taking pills." Family members
say they feel helpless to foster compliance. Which treatment strategy should the nurse discuss
with the health care provider?
Use of a long-acting antipsychotic preparation
Which documentation indicates that the treatment plan for a patient diagnosed with acute mania
has been effective?
Converses with few interruptions; clothing matches; participates in activities."
A priority nursing intervention for a patient diagnosed with major depressive disorder is
carefully and inconspicuously observing the patient around the clock.
A nurse plans health teaching for a patient with generalized anxiety disorder who begins a new
prescription for lorazepam (Ativan). What information should be included? (Select all that
apply).
a. Caution in use of machinery
c. The importance of caffeine restriction
d. Avoidance of alcohol and other sedatives
A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about
feelings and concerns. What is the rationale for this intervention?
b. Concerns stated aloud become less overwhelming and help problem solving begin.
A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor
(SSRI) antidepressant therapy. Priority information given to the patient and family should
include a directive to:
report increased suicidal thoughts.
A veteran of the lraq War describes that he is having intrusive thoughts of missiles, screaming,
explosions, and the same feelings of terror first experienced in combat. Which of the following
clinical disorders would this patient most likely be describing symptoms of?
ANS: Post-traumatic stress disorder (PTSD)
A patient with acute mania approaches the nurse, waves a newspaper, and says, "I want the
phone right now. I need to call this store while their sale is going on. I need ten dresses and four
pairs of shoes." Select the nurse's best intervention.
Distracting the patient can avoid power struggles.
A patient tells the nurse, "I wanted my health care provider to prescribe diazepam (Valium) for
my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why?" The nurse's reply
should be based on the knowledge that buspirone:
does not cause dependence.
