NR 326 CMS Exam 1 Correctly Solved!!

A suicidal patient is found by the nurse as he tries to hang himself from the shower in the bathroom. What nursing intervention would address the patient's need for safety while maintaining his self-esteem? a. Assign a staff member to remain with him at all times. b. Place him in the seclusion room with 15 minute checks c. Request that he remain with the patient group at all times. d. Tell him he may use the bathroom only with staff supervision. -ANSWER a The nursing student learned of a high school classmate who recently committed suicide. The classmate's death surprised the student, because the classmate had always seemed very confident and popular. The student knows, however, that suicide is usually: a. An act with a message and purpose b. An impulsive act without meaning c. A random act of selfishness d. A random act without meaning or purpose -ANSWER a A voluntary patient mutilates herself whenever she leaves the unit. The nurse suggests use of four-point restraint to prevent the patient from further harming herself. What question should be considered before this measure is undertaken? a. Is this the least restrictive measure possible? b. Can four-point restraint be used for voluntary patients? c. What litigation is likely to follow from this action? d. What documentation will be necessary after restraint application? -ANSWER a A patient, who has recently lost a spouse, calls the crisis line stating the occurrence of suicidal ideations that involve jumping off a bridge over the river when no one is around. What level of lethality would a nurse assess for this plan? a. Low b. Moderate c. High d. Lethality cannot be determined from this data -ANSWER c Which of the following symptoms indicates Neuroleptic Malignant Syndrome (NMS), a potentially fatal side effect of an antipsychotic medication such as Haldol (haloperidol)? a. Photosensitivity and an itchy rash on face, neck, chest and extremities b. Hyperthermia and muscle rigidity c. Blurred vision, constipation, and urinary retention d. Tongue protrusion, lip smacking, and grimacing -ANSWER b The nurse using cognitive behavior techniques when working with patients knows that attributions are meanings the patient gives to events or circumstances that: a. may or may not be objectively accurate b. support a sense of autonomy c. promote rigidity and chaos d. isolate family members from each other -ANSWER a A patient was the driver of a car that struck and killed a child. The patient tells a nurse, "I killed a child! I'm haunted by the sight of the body being thrown into the air. If I hadn't been drinking I might have been able to stop. I don't know how I can go on living with myself!" The crisis nurse should give prior