Mental Health Exam 2 Rasmussen newest exam
with correct 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 - Answer- - 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.) - 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.
Which nursing diagnosis supports the psychoanalytic theory of development of major depressive
disorder? - Answer- Social isolation R/T self directed danger
Which patient is at the highest risk for the diagnosis of major depressive disorder? - Answer- 24
yr old married woman
A patient diagnosed with MDD is being considered for ECT. Which patient teaching should the
nurse prioritize? - Answer- Discuss with the patient and family expected short term memory loss
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.
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.
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."
Which nursing intervention takes priority when working with a newly admitted patient
experiencing suicidal ideations? - Answer- Monitor the patient at a close, but irregular intervals.
A patient diagnosed with major depressive disorder is prescribed Nardil. Which teachings should
the nurse prioritize? - Answer- Intruct the patient & family about the many food-drug & drug-
drug interactions?
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."
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
What symptoms would the nurse expect to assess i a patient experiencing serotonin syndrome? -
Answer- Confusion, restlessness, Tachycardia, Labile BP, & diaphoresis
Which of the following meds would be classified as Tricyclic antidepressants? - Answer-
Nortriptyline (Pamelor)
Which of the following are examples of anticholinergic side effects from tricyclic
antidepressants? - Answer- Urinary hesitancy, constipation, and blurred vision
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
, 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
A patient seen in the ED is experiencing irritability, pressured speech, and increased levels of
anxiety. The priority is? - Answer- Assess vital signs and complete a physical assessment
A patient diagnosed with bipolar 1 in the manic phase is yelling at another peer in the milieu.
The priority intervention is? - Answer- Calmly redirect and remove the patient from the milieu
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.
A patient diagnosed with bipolar 1 is experiencing auditory hallucinations and a flight of ideas.
Which meds would you expect to give? - Answer- Risperidone (Risperdal) & Lamotrigine
(Lamictal)
A patient prescribed Lithium is experiencing excessive output of dilute urine, tremors and
muscular irritability. The RN should? - Answer- Assess a serum Lithium level of 2.6mEq/L
