NR326 CMS Proctored Exam
Questions With Solved Solutions
Which of the following is a correct assumption regarding the concept of
crisis? - CORRECT ANSWER>>A crisis situation contains the potential
for psychological growth or deterioration
Crises occurs when an individual: - CORRECT
ANSWER>>Experiences a stressor and perceives coping strategies to
be ineffective
Amanda's mobile home was destroyed by a tornado. Amanda received
only minor injuries, but is experiencing disabling anxiety in the
aftermath of the event. This type of crisis is called: - CORRECT
ANSWER>>- ♥ Crisis resulting from traumatic stress
- (Adventitious)
The most appropriate crisis intervention with Amanda (#3) would be to:
- CORRECT ANSWER>>Discuss stages of grief and feelings
associated with each
A nurse is conducting chart reviews of multiple clients at a community
mental health facility. Which of the following events is an example of a
client experiencing a maturational crisis? - CORRECT
ANSWER>>Marriage
A nurse is caring for a client who is experiencing a crisis. Which of the
following medications might the provider prescribe? (select all that
apply) - CORRECT ANSWER>>- Paroxetine
- Lorazepam
Crisis medication - CORRECT ANSWER>>- Paroxetine
- Lorazepam
,A nurse is conducting a group therapy with a group of clients. Which of
the following statements made by a client is an example of aggressive-
communication? - CORRECT ANSWER>>"You'd better listen to me."
A nurse is caring for a client who is speaking in a loud voice with
clenched fists. Which of the following actions should the nurse take? -
CORRECT ANSWER>>Request that other staff members remain
close by
A nurse is assessing a client in an inpatient mental health unit. Which
of the following findings should the nurse expect if the client is in the
pre-assaultive stage of violence? (Select all that apply) - CORRECT
ANSWER>>- Hyperverbal
- Facial grimacing
- Agitation
A nurse is caring for a client in an inpatient mental health facility who
gets up from a chair and throws it across the day room. Which of the
following is the priority nursing action? - CORRECT ANSWER>>Move
the client away from others
A nurse is caring for a client who is screaming at staff members and
other clients. Which of the following is a therapeutic response by the
nurse to the client? - CORRECT ANSWER>>"Stop screaming and
walk with me down the hallway."
Andrew, a NYC Firefighter and his entire unit responded to the terrorist
attacks at the World Trade Center. He and his friend, Carlo, entered
the area together. Carlo was killed when the building collapsed.
Andrew was injured, but survived. Andrew has been having nightmares
and anxiety/panic attacks. He says to his nurse at the clinic, "I don't
know why Carlo didn't make it and I did!" This statement by Andrew
suggest that he is experiencing: - CORRECT ANSWER>>Survivor's
guilt
Intervention with Andrew (12) would include: - CORRECT
ANSWER>>- Encouraging expression of feelings
- Antianxiety medications
,Jenny reports to the high school nurse that her mom drinks too much.
She is drunk every afternoon when Jenny comes home from school
and her mom yells at Jenny and blames her for everything wrong.
Jenny is afraid to invite her friends over because of her mother's
behavior. Nursing interventions would include: - CORRECT
ANSWER>>Make arrangements for her to start attending Alateen
meetings.
You are asked to serve on a committee on which you do not wish to
serve. Which of the following is an example of your nonassertive
response? - CORRECT ANSWER>>"Okay, if I'm really needed, I'll
serve."
A nurse on a crisis hotline is speaking to a client who states, "I just
took an entire bottle of Xanax." Which of the following is the priority
nursing response? - CORRECT ANSWER>>"I'm glad you called, and I
want to send an ambulance to help you."
A nurse observes a client hitting another client. Which of the following
statements is the best response by the nurse? - CORRECT
ANSWER>>"Hitting others is unacceptable behavior."
A nurse is monitoring a client in restraints. Which of the following
findings should indicate to the nurse that the client is ready to
reintegrate into the unit? - CORRECT ANSWER>>The client follows
directions.
A client during a therapeutic group session led by the nurse suddenly
jumps up, screams, and runs out of the room. What is the nurse's
priority of action? - CORRECT ANSWER>>Follow the client to
determine the cause of the behavior
A nurse plans to develop a therapeutic relationship with a client. Which
of the following should be included in the care plan? - CORRECT
ANSWER>>Set limits and boundaries, giving clear expectations
, Which of the following is true about clients admitted for involuntary
admission? (SATA) - CORRECT ANSWER>>- The client admitted
involuntarily has a right to informed consent regarding prescribed
psychotropic medications.
- The client admitted involuntarily can request to defer a court hearing.
A mandatory educational session is conducted on an inpatient mental
health unit for all nurses about seclusion and restraints. Seclusion is
contraindicated in which of the following clients? - CORRECT
ANSWER>>An adult client following a suicide attempt.
A nurse is reviewing the protocol for restraints and seclusion (r/s).
Included in the protocol are which of the following? (SATA) -
CORRECT ANSWER>>- Documentation of all interventions that were
tried and response of patient, and the progression of nursing
care/interventions, leading up to necessary r/s.
- Documentation of offering fluids, food, comfort/pain assessment, V/S,
especially breathing/RR; toileting.
- Time limits for seclusion or restraints = 4 hours for adults; 2 hours 9-
17; 1 hour for 8 and under
A client is extremely suspicious of the nursing staff and other clients.
Which of the following nursing approaches is appropriate to include in
the plan of care when establishing a therapeutic relationship with this
client? - CORRECT ANSWER>>Adopt a neutral attitude when
providing care.
A nurse is caring for a client who has delusional behavior and states, "I
can't go to group therapy today. The mayor is coming any time now to
visit me!" The nurse responds, "I understand, but it is time for group
therapy and we expect everyone to attend. Let's walk over together."
For which of the following reasons is the nurse's response considered
therapeutic? - CORRECT ANSWER>>It clearly articulates what is
expected of the client.
A nurse is caring for an adolescent client with a history of violent
behavior. The client asked the nurse to keep information confidential
about the desire to kill several classmates and a school teacher. Which
Questions With Solved Solutions
Which of the following is a correct assumption regarding the concept of
crisis? - CORRECT ANSWER>>A crisis situation contains the potential
for psychological growth or deterioration
Crises occurs when an individual: - CORRECT
ANSWER>>Experiences a stressor and perceives coping strategies to
be ineffective
Amanda's mobile home was destroyed by a tornado. Amanda received
only minor injuries, but is experiencing disabling anxiety in the
aftermath of the event. This type of crisis is called: - CORRECT
ANSWER>>- ♥ Crisis resulting from traumatic stress
- (Adventitious)
The most appropriate crisis intervention with Amanda (#3) would be to:
- CORRECT ANSWER>>Discuss stages of grief and feelings
associated with each
A nurse is conducting chart reviews of multiple clients at a community
mental health facility. Which of the following events is an example of a
client experiencing a maturational crisis? - CORRECT
ANSWER>>Marriage
A nurse is caring for a client who is experiencing a crisis. Which of the
following medications might the provider prescribe? (select all that
apply) - CORRECT ANSWER>>- Paroxetine
- Lorazepam
Crisis medication - CORRECT ANSWER>>- Paroxetine
- Lorazepam
,A nurse is conducting a group therapy with a group of clients. Which of
the following statements made by a client is an example of aggressive-
communication? - CORRECT ANSWER>>"You'd better listen to me."
A nurse is caring for a client who is speaking in a loud voice with
clenched fists. Which of the following actions should the nurse take? -
CORRECT ANSWER>>Request that other staff members remain
close by
A nurse is assessing a client in an inpatient mental health unit. Which
of the following findings should the nurse expect if the client is in the
pre-assaultive stage of violence? (Select all that apply) - CORRECT
ANSWER>>- Hyperverbal
- Facial grimacing
- Agitation
A nurse is caring for a client in an inpatient mental health facility who
gets up from a chair and throws it across the day room. Which of the
following is the priority nursing action? - CORRECT ANSWER>>Move
the client away from others
A nurse is caring for a client who is screaming at staff members and
other clients. Which of the following is a therapeutic response by the
nurse to the client? - CORRECT ANSWER>>"Stop screaming and
walk with me down the hallway."
Andrew, a NYC Firefighter and his entire unit responded to the terrorist
attacks at the World Trade Center. He and his friend, Carlo, entered
the area together. Carlo was killed when the building collapsed.
Andrew was injured, but survived. Andrew has been having nightmares
and anxiety/panic attacks. He says to his nurse at the clinic, "I don't
know why Carlo didn't make it and I did!" This statement by Andrew
suggest that he is experiencing: - CORRECT ANSWER>>Survivor's
guilt
Intervention with Andrew (12) would include: - CORRECT
ANSWER>>- Encouraging expression of feelings
- Antianxiety medications
,Jenny reports to the high school nurse that her mom drinks too much.
She is drunk every afternoon when Jenny comes home from school
and her mom yells at Jenny and blames her for everything wrong.
Jenny is afraid to invite her friends over because of her mother's
behavior. Nursing interventions would include: - CORRECT
ANSWER>>Make arrangements for her to start attending Alateen
meetings.
You are asked to serve on a committee on which you do not wish to
serve. Which of the following is an example of your nonassertive
response? - CORRECT ANSWER>>"Okay, if I'm really needed, I'll
serve."
A nurse on a crisis hotline is speaking to a client who states, "I just
took an entire bottle of Xanax." Which of the following is the priority
nursing response? - CORRECT ANSWER>>"I'm glad you called, and I
want to send an ambulance to help you."
A nurse observes a client hitting another client. Which of the following
statements is the best response by the nurse? - CORRECT
ANSWER>>"Hitting others is unacceptable behavior."
A nurse is monitoring a client in restraints. Which of the following
findings should indicate to the nurse that the client is ready to
reintegrate into the unit? - CORRECT ANSWER>>The client follows
directions.
A client during a therapeutic group session led by the nurse suddenly
jumps up, screams, and runs out of the room. What is the nurse's
priority of action? - CORRECT ANSWER>>Follow the client to
determine the cause of the behavior
A nurse plans to develop a therapeutic relationship with a client. Which
of the following should be included in the care plan? - CORRECT
ANSWER>>Set limits and boundaries, giving clear expectations
, Which of the following is true about clients admitted for involuntary
admission? (SATA) - CORRECT ANSWER>>- The client admitted
involuntarily has a right to informed consent regarding prescribed
psychotropic medications.
- The client admitted involuntarily can request to defer a court hearing.
A mandatory educational session is conducted on an inpatient mental
health unit for all nurses about seclusion and restraints. Seclusion is
contraindicated in which of the following clients? - CORRECT
ANSWER>>An adult client following a suicide attempt.
A nurse is reviewing the protocol for restraints and seclusion (r/s).
Included in the protocol are which of the following? (SATA) -
CORRECT ANSWER>>- Documentation of all interventions that were
tried and response of patient, and the progression of nursing
care/interventions, leading up to necessary r/s.
- Documentation of offering fluids, food, comfort/pain assessment, V/S,
especially breathing/RR; toileting.
- Time limits for seclusion or restraints = 4 hours for adults; 2 hours 9-
17; 1 hour for 8 and under
A client is extremely suspicious of the nursing staff and other clients.
Which of the following nursing approaches is appropriate to include in
the plan of care when establishing a therapeutic relationship with this
client? - CORRECT ANSWER>>Adopt a neutral attitude when
providing care.
A nurse is caring for a client who has delusional behavior and states, "I
can't go to group therapy today. The mayor is coming any time now to
visit me!" The nurse responds, "I understand, but it is time for group
therapy and we expect everyone to attend. Let's walk over together."
For which of the following reasons is the nurse's response considered
therapeutic? - CORRECT ANSWER>>It clearly articulates what is
expected of the client.
A nurse is caring for an adolescent client with a history of violent
behavior. The client asked the nurse to keep information confidential
about the desire to kill several classmates and a school teacher. Which
