RASMUSSEN: MENTAL HEALTH EXAM 2 QUESTIONS AND CORRECT ANSWERS VERIFIED LATEST 2024- 2025, Exams of Nursing

Download RASMUSSEN: MENTAL HEALTH EXAM 2 QUESTIONS AND CORRECT ANSWERS VERIFIED LATEST 2024- 2025 and more Exams Nursing in PDF only on Docsity!

RASMUSSEN: MENTAL HEALTH EXAM 2 QUESTIONS

AND CORRECT ANSWERS VERIFIED LATEST 2024-

2025 GUARANTEED PASS GRADE A + UPDATED!!

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 --ANSWER--- A neologism
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.) --ANSWER--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. 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: --ANSWER--maintain a normal social interaction distance from the patient.
4. Which statement indicates a patient with major depression is most likely outlook on life during the acute phase of the illness?

--ANSWER--During an acute phase of major depression, the client may feel worthless and deserve bad things to 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 stable now?" Select the nurse's appropriate response. --ANSWER--b. "Taking the medication every day helps reduce the risk of a relapse."
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. -- ANSWER--b. "Feeling that people want to destroy you must be very frightening."
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? --ANSWER--Denial
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 be the nurse's first priority? --ANSWER--Panic disorder and a nursing diagnosis of anxiety

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 be eaten while taking this medication. What is the potential problem if the patient is not compliant with these dietary restrictions? -- ANSWER--hypertensive crisis foods with tyramine in it --ANSWER--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 --ANSWER--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? --ANSWER--OTC preparations containing dextromethorphan, sympathomimetic agents, or antihistamines (e.g., cough, cold, and hay fever remedies, appetite suppressants) can precipitate severe hypertensive

reactions if taken during therapy or within 2-3 wk after discontinuation of an MAO inhibitor.

10. Which piece of subjective data obtained during the nurse's psychosocial assessment of a client experiencing severe anxiety would indicate the possibility of obsessive-compulsive disorder? --ANSWER--a. "I have to keep checking to see where my car keys are."
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? --ANSWER--A: Affective flattening.
12. The nurse is evaluating the effectiveness of an antipsychotic on negative symptoms of psychosis. Which of the following symptoms would be classified as negative symptoms of psychosis? --ANSWER--Blunted affect Poverty of thought Loss of motivation Inability to experience pleasure or joy
13. A 39-year-old woman is recently divorced and is learning to cope with additional stressors. Which of the following best demonstrate(s) that she is utilizing positive coping strategies to manage her stress? (Select all that apply). --ANSWER--3. control stress by increased physical activity.

4. change her reactions to stress with cognitive behavioral

therapy.

13. Which nursing diagnosis is likely to apply to an individual with severe and persistent mental illness who is homeless -- ANSWER--Chronic low self-esteem
14. A patient with depression is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this -- ANSWER--Urinary retention
15. Which individual in the emergency department should be considered at the highest risk for completing suicide? -- ANSWER--d. A 79-year-old single white man with cancer of the prostate gland.
16. 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? --ANSWER--Neuroleptic malignant syndrome
17. A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance --ANSWER-- Physiologic

18. 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? --ANSWER--Use of a long-acting antipsychotic preparation
19. Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? -- ANSWER--Converses with few interruptions; clothing matches; participates in activities."
20. A priority nursing intervention for a patient diagnosed with major depressive disorder is --ANSWER--carefully and inconspicuously observing the patient around the clock.
21. 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). --ANSWER--a. Caution in use of machinery c. The importance of caffeine restriction d. Avoidance of alcohol and other sedatives
22. A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention? --ANSWER--b. Concerns stated aloud become less overwhelming and help problem solving begin.

23. 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: --ANSWER--report increased suicidal thoughts.
24. 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? --ANSWER--ANS: Post-traumatic stress disorder (PTSD)
25. 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. -- ANSWER--. Distracting the patient can avoid power struggles.
26. 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: -- ANSWER--does not cause dependence.
27. A client with generalized anxiety disorder and depression comes to the anxiety disorders clinic displaying severe anxiety. Of the medications listed in the client's medical record, which

one, with an appropriate order, can be given as a prn anxiolytic? --ANSWER--Lorazepam( Ativan)

28. The nurse is caring for a female patient diagnosed with schizophrenia who believes that her thoughts are broadcast from her head. The nurse identifies which of the following as the most appropriate nursing diagnosis for this patient? -- ANSWER--Disturbed thought processes
29. What is the best intervention when a pt is responding to an auditory hallucination? --ANSWER--Can you tell me what you are hearing
30. A patient with depression is evaluated at the clinic and started on citalopram. The patient tells the nurse, "l have some pills I previously took for depression. They're called MAOIs. I think I should take them along with this new medication." What information is essential for the nurse to communicate regarding her statements? --ANSWER--Make sure to educate your patients about the expected side effects of MAOI inhibitors, which are:

• Dizziness
• Weakness/fainting resulting from an abrupt positional change
• Drowsiness
• Blurred vision (reversible)
• Nausea and vomiting
• Loss of appetite
• Emotional or mental changes
• Irritability/ nervousness

Patients should be informed about the warning signs that warrant immediate physician/nurse attention as well. They include:

• A headache
• Rashes
• Darkened urine
• Pale stools
• Eye/skin yellowing
• Chills and fever
• A sore throat

31. The nurse is caring for a patient who experiences orthostatic hypotension related to taking chlorpromazine (Thorazine). The nurse should suggest which of the following interventions for managing this side effect. --ANSWER--Rise slowly when getting out of bed.
32. An adult says, "When I was a child, I took medication because I couldn't follow my teachers' directions. I stopped taking it when I was about 13. I still have trouble getting organized, which causes difficulty doing my job." Which clinical disorder does this scenario suggest? a. Stress intolerance disorder b. Generalized anxiety disorder c. Borderline personality disorder d. Adult attention deficit hyperactivity disorder (AADHD) -- ANSWER--ANS: d.

Adult attention deficit hyperactivity disorder (AADHD)

33. lf a cruel and abusive person rationalizes the behavior, which comment would be most characteristic of rationalization as a defense mechanism?
34. If a cruel and abusive person rationalizes the behavior, which comment would be most characteristic? --ANSWER--That person shouldn't have provoked me."
35. At a unit meeting, staff discusses decor for a special bedroom for manic patients- Which is the best suggestion related to caring for an acutely manic patient? --ANSWER-- Neutral walls with pale, simple accessories
36. Two days ago, a client was admitted to the inpatient psychiatric unit with a diagnosis of PTSD and a history of violence. Currently, he continues to have sleep problems, trouble with concentration, and has been feeling increased anger toward another patient who reminds him of a former colleague. The priority nursing diagnosis would be: --ANSWER-- Risk for violence
37. A nurse is providing teaching for a client who has a new prescription for clozapine (Clozaril). Which of the following client statements indicates a need for further teaching? -- ANSWER--This medication will help prevent seizures."

37. You are the nurse responsible for assessing for extrapyramidal side effects in a patient who has been taking chlorpromazine. Which of the following may be side effects for this medication? (Select all that apply.) --ANSWER--A.acute dystonia B. akathisia E. Tardive dyskinesia F. Parkinsonism
38. A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan? --ANSWER--High level
39. A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient: --ANSWER--c. consults the pharmacist when selecting over-the-counter medications. A nurse is preparing administer clozapine 300 mg PO daily to a patient with schizophrenia. Available is clozapine 200 mg. How much administered per dose? --ANSWER--1.
40. When assessing a patient's plan for suicide, what aspect has priority? --ANSWER--Availability of means and lethality of method

43. A nurse receives this laboratory result: lithium level 1. mEq/L. How should the nurse interpret this lab value? A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is: -- ANSWER--within therapeutic limits
44. A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? --ANSWER--Milk
45. A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed going out with friends, but now I don't care if they even invite me." Which term best describes this patient's feelings? --ANSWER--anhedonia.
46. A patient receiving lithium should be assessed for which evidence of complications? --ANSWER--Diaphoresis, weakness, and nausea
47. The nurse knows that sedation is a side effect of many antipsychotics. Which of the following medications should the nurse question if ordered for a patient taking antipsychotics? -- ANSWER--Diphenhydramine (Benadryl)
48. A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Select the best initial

approach by the nurse. --ANSWER--Distraction: "Let's go to the dining room for a snack."

49. Which statement made by a client who has agoraphobia and does not leave her home identifies the thinking typical of a client with this disorder? --ANSWER--Being afraid to go out seems ridiculous, but I can't go out the door."
50. An adult with depression has been treated with medication and cognitive behavioral therapy. The patient now verbalizes that being passive and letting others make decisions for her contributed to the depression. What referrals could the nurse make to help this patient prevent recurrence of depression?Which intervention should the nurse suggest? -- ANSWER--Social skills training A nurse caring for a client diagnosed with schizophrenia recognizes the client is experiencing auditory hallucinations. Which of the following are ways to intervene with a client experiencing hallucinations? SATA --ANSWER---Validate that you do not hear any voices

• Avoid asking the client if they are experiencing hallucinations
• Keep the client safe by implementing hospital protocol Since learning that he will receive a trial pass to a new group home tomorrow, a client has been having behavioral changes. The nurse recognizes that symptoms of severe anxiety. Which initial response is the most appropriate by the nurse? --

ANSWER--Slow down. Listen to me. You are in a safe place. Take a deep breath and lets go to a quieter place. Which of the following is a therapeutic communication strategy to use when working with a client with auditory hallucinations? --ANSWER---Asking the client to describe the hallucinations A client with schizophrenia is about to start medication therapy with clozapine. Which of the following would be a priority for the nurse to evaluate? --ANSWER--Obtain a baseline white blood cell count A nurse is preparing to administer fluoxetine 40 mg PO daily. Available to 20mg/5mL. How many mL should be administered? --ANSWER--10 ml When educating a client and his family about taking selective serotonin reuptake inhibitor, which statement from the family shows an understanding of priority for the client? --ANSWER--If he talks about wanting to hurt himself, we will call the doctor A patient being triaged in the emergency department admits her spouse punched her. Which statement from the client reflects rationalization? --ANSWER--Its hard for him to control his reactions A client asks the nurse "What is the difference between post traumatic stress disorder and acute stress disorder?" Which

response by the nurse is accurate? --ANSWER--hypervigilance and flashbacks are less frequent in acute stress disorder A nurse working an outpatient clinic believes the client has been non-compliant with the prescription medication regimen. When addressing the clients mood, the response is "better but letter, post office, doctors office, shrink and sink, pink. The nurse recognizes which of the following symptoms? --ANSWER-

• Clanging The client is experiencing a manic episode. Which of the following activities will be included in the plan of care? SATA -- ANSWER--Coloring activity and assist as needed A client diagnosed with nyctophobia has recently started systematic desensitization therapy. The nurse understands the therapy will help the client through with of the following techniques. --ANSWER--The client will gradually be exposed to the situation until they do not experience panic level anxiety. What are the nursing interventions that are most effective when caring for a client who is very suspicious and experiencing delusions of persecution? --ANSWER--Use the same staff as much as possible.
• Avoid laughing or whispering were the client can see but not hear you
• Encourage the client to elaborate on the plot against them

What condition suggests that caution is necessary for prescribing benzodiazepine to an anxious client? --ANSWER--- Alcohol Dependance A client has received a new prescription for quetiapine. Which statement by the client reflects an understanding of the teaching? --ANSWER--My weight will be closely monitored while taking this medication. Which documentation indicates that the treatment plan for a client with acute mania has een effective. --ANSWER--Talking without interrupting, clothing matched, participates in activities A nurse is planning care for a client who has OCD. Which of the following actions should the nurse plan to take? --ANSWER-- explore situations that precipitate anxiety A client diagnosed with major depressive disorder takes propranolol for hypertension and imipramine for depression. Given the side effects of these drugs, what would be the essential teaching by the nurse? --ANSWER--Rise slowly when you change from lying to sitting to standing. A nurse is preparing to administer imipramine 200 mg PO daily divided equally every 12 hr. The amount available is imipramine 25 mg tablets. How many tablets should the nurse administer with each dose? --ANSWER-- 4

The nurse is providing health teaching for a client that has been prescribed phenelzine for depression and provided education about the types of food to avoid. Which statement by the client indicates a need for further teaching? --ANSWER---I can have a glass of wine as long as it is before my next dose A nurse is preparing to administer fluoxetine 30 mg PO daily to a client. Available is fluoxetine 10 mg. How many tablets per dose? --ANSWER-- 3 The nurse is evaluating effectiveness of an antipsychotic for positive symptoms of psychosis. Which statement by the client would show an improvement of positive symptoms? -- ANSWER--I believe the FBI has stopped monitoring my calls. I've been visiting with my friends lately The nurse is caring for a client who experiences orthostatic hypotension related to taking chlorpromazine. The nurse should suggest which of the following interventions for managing this side effect? --ANSWER--Sit on the side of the bed before getting up A client diagnosed with obsessive-compulsive disorder (OCD) has recently started thought stopping as part of therapy. The nurse understands this therapy will help the client through which of the following techniques? --ANSWER--The client will snap a rubber band on their wrist to stop the obsessive thought from occurring.

A 39-year-old woman is recently divorced and is learning to cope with additional stressors. Which of the following best demonstrate(s) that she utilizes positive coping strategies to manage her stress? (Select all that apply.) --ANSWER---Starting an exercise program

• Using Cognitive Behavioral techniques
• States that she has been feeling less stressed at work A nurse is reviewing a client's chart before medication administration. The client is scheduled for lithium with the morning med pass. The nurse recognizes which of the following medications would require further clarification from the provider? --ANSWER--Furosemide The nurse is caring for a client in the prodromal phase of schizophrenia. What behaviors should the nurse expect to observe? --ANSWER---Depression and social withdrawal In the acute phase of major depression, which statement by the client most likely expresses their outlook on life? --ANSWER--I deserve to be this way A client admitted with general anxiety disorder (GAD) becomes increasingly confused and agitated over 3 hours. What is the priority action by the nurse? --ANSWER---Assess the client to determine the possible cause After being called into the boss's office to be reprimanded, the employee slams the door on the way out of the meeting. This is

an example of which defense mechanism? --ANSWER-- Displacement A client with past traumatic experiences uses sublimation. Which of the following would demonstrate sublimation? -- ANSWER---The client speaks at a high-school about her story A nurse working at a primary physician's office. The nurse enters the room of a 67-year-old male client who is there for a routine checkup. Which statement by the client alerts the nurse that this client is at risk for suicide? --ANSWER--I recently found that I find very little pleasure in the activities I partake in. A client is very stressed about work and has started taking yoga classes. Which comment would indicate this physical activity has been successful? --ANSWER---I haven't needed to take my anxiety medication as often A client has a mass in the left upper lobe, and a biopsy is scheduled today. As the nurse explains the procedure, the client does not respond when asked a direct question and cannot focus on the current situation. The client is shaking and appears immobile. The nurse recognizes the client is experiencing which level of anxiety? --ANSWER--Panic A nurse is assessing a client who has schizophrenia and has been treated with a first-generation antipsychotic. Which of the following findings should the nurse document as a

manifestation of akathisia? --ANSWER--Constant tapping of feet when sitting A nurse is preparing to administer buspirone 7.5 mg PO every 12 hr to a client. Available is buspirone 15 mg/tablet. How many tablets should the nurse administer per dose? --ANSWER-

The nurse is evaluating the effectiveness of an antipsychotic on negative symptoms of psychosis. Which statement by the client would show improvement of negative symptoms? --ANSWER---I noticed I have a lot more energy lately A client has been observed having minimal interaction, constantly remains in their room, and the physician documented the client is experiencing anergia. Which statement by the client would reflect these findings? -- ANSWER---I'm just too tired to get up A client is diagnosed with obsessive-compulsive disorder (OCD). Which action by the nurse would be more likely to increase the client's anxiety? --ANSWER--Changing the schedule throughout the day A client tells the nurse that psychotropic medicines are dangerous and refuses to take them. Which intervention should the nurse use next? --ANSWER--Ask the client about any previous problems with psychotropic medications

The client is prescribed phenelzine and is on a tyramine-free diet. Which food selections should the client avoid? (Select all that apply.) --ANSWER---A pepperoni and cheese pizza

• Smoked turkey and beans
• A banana and iced coffee A nurse is providing education to a client recently prescribed buspirone. Which of the following statements by the client indicates further education is needed? --ANSWER--This medication won't cause severe drowsiness A client diagnosed with major depressive disorder is considering cognitive behavioral therapy. The client asks the nurse how this therapy would help alleviate depressive thoughts. What is the best response by the nurse? --ANSWER--
• "This therapy helps you learn to think more positively, and thereby reduce depressive thoughts and symptoms. A nurse caring for a client, who has been neglecting personal hygiene, observes the client coming to breakfast freshly bathed, wearing clean clothes, and combed and styled hair. Which of the following is the most therapeutic response by the nurse? --ANSWER--I see you have done some grooming today Which of the following would be the best therapeutic response by the nurse when a client states, "I no longer need my medication since I do not hear voices."? --ANSWER---"What happened the last time you stopped taking your medication?"

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective -- ANSWER--"Converses with few interruptions; clothing matches; participates in activities." A nurse is providing education to a client recently prescribed buspirone. Which of the following statement by the client indicates further education is needed --ANSWER--This medication will be effective by next week When educating a client and his family about taking a selective serotonin reuptake inhibitor (SSRI). Which statement from the family shows an understanding of a priority for client education? --ANSWER--. If he talks about wanting to hurt himself, we will call the doctor

. A client diagnosed with nyctophobia has recently started systematic desensitization therapy. The nurse understands this therapy will help the client through which of the following techniques? --ANSWER--The client will gradually be exposed to the situation until they do not experience panic level anxiety A nurse is assessing a client who has schizophrenia and has been treated with a first-generation antipsychotic. Which of the following findings should the nursedocument as manifestation of tardive dyskinesia --ANSWER--b. Twisting tongue movement