NR326 CMS Proctored Exam
QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
ANSWERS)ALREADY GRADED
A+
Which of the following is a correct assumption regarding the concept of
crisis? - answer A crisis situation contains the potential for psychological
growth or deterioration
Crises occurs when an individual: - 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: - answer - ♥ Crisis resulting from
traumatic stress
- (Adventitious)
The most appropriate crisis intervention with Amanda (#3) would be to: -
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? - 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)
- answer - Paroxetine
- Lorazepam
Crisis medication - 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? - 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? - 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) - 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? - 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? - 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: - answer Survivor's guilt
Intervention with Andrew (12) would include: - 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: - 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? -
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? - 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? - 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? - 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? - 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? - answer Set limits and
boundaries, giving clear expectations
Which of the following is true about clients admitted for involuntary
admission? (SATA) - 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? - 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) - 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? -
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? -
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
statement by the nurse is the best response? - answer "I cannot promise
that. I must share this information with other members of the team who
are responsible for planning your care."
A nurse on a behavioral health unit is monitoring a client who was placed
in 4 point restraints. Nursing care for the client in restraint includes which
of the following? (SATA). - answer - Ensure that a face-to-face assessment
QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
ANSWERS)ALREADY GRADED
A+
Which of the following is a correct assumption regarding the concept of
crisis? - answer A crisis situation contains the potential for psychological
growth or deterioration
Crises occurs when an individual: - 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: - answer - ♥ Crisis resulting from
traumatic stress
- (Adventitious)
The most appropriate crisis intervention with Amanda (#3) would be to: -
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? - 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)
- answer - Paroxetine
- Lorazepam
Crisis medication - 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? - 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? - 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) - 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? - 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? - 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: - answer Survivor's guilt
Intervention with Andrew (12) would include: - 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: - 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? -
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? - 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? - 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? - 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? - 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? - answer Set limits and
boundaries, giving clear expectations
Which of the following is true about clients admitted for involuntary
admission? (SATA) - 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? - 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) - 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? -
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? -
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
statement by the nurse is the best response? - answer "I cannot promise
that. I must share this information with other members of the team who
are responsible for planning your care."
A nurse on a behavioral health unit is monitoring a client who was placed
in 4 point restraints. Nursing care for the client in restraint includes which
of the following? (SATA). - answer - Ensure that a face-to-face assessment
