NR 326 CMS Exam questions with accurate answers
Ans✓✓✓
A 65 years old client is in the first stage of Alzheimer's disease. Nurse
Patricia should plan to focus this client's care on:
A. Offering nourishing finger foods to help maintain the client's optimal
nutritional status.
B. Providing emotional support and individual counseling.
C. Monitoring the client to prevent minor illnesses from turning into
major problems.
D. Suggesting new activities for the client and family to do together.
Ans✓✓✓ CORRECT - Option B: Clients in the first stage of
Alzheimer's disease are aware that something is happening to them and
may become overwhelmed and frightened. Therefore, nursing care
typically focuses on providing emotional support and individual
counseling.
Options A, C, and D: The other options are appropriate during the
second stage of Alzheimer's disease when the client needs continuous
monitoring to prevent minor illnesses from progressing into major
problems and when maintaining adequate nutrition may become a
challenge. During this stage, offering nourishing finger foods helps
clients to feed themselves and maintain adequate nutrition.
A charge nurse is preparing an educational session for a group of newly
licensed nurses to review client rights under the law. Which of the
following statements should thee nurse make? Ans✓✓✓ "In the event a
client threatens harm to others, medications can be administered without
,consent." Primary commitment is to the client and their priority is
always to advocate for and protect their health and safety. During an
emergency situation, if the client is threatening harm to self or others,
meds can be administered without the client's consent and without a
court order
A client has alcohol toxicity and is unresponsive, what is an appropriate
nursing intrevention? Ans✓✓✓ Gather supplies for an endotracheal
intubation because an expected finding of an unresponsive client who
has alcohol toxicity is respiratory depression.
A client has anorexia nervosa, what finding requires hospitalization?
Ans✓✓✓ Total body fat 8.7%. The nurse should recognize that criteria
for hospitalization includes having a weight less than 75% of ideal body
weight, or less than 10% body fat.
A client has schizophrenia and reports auditory hallucinations. What
interventions should be included in their care plan? Ans✓✓✓ Promote
the use of music to compete with the client's auditory hallucinations.
This can assist in limiting the effect the hallucinations have on the
client's stress level.
A client is experiencing a headache and heart palpitations after having 1
glass of wine 1 hr ago. The client has a hx of depression and a BP of
210/105 mm Hg and a temp of 103.8 F. What action should the nurse
take first? Ans✓✓✓ Determine the client's prescribed medication
regimen. This way the nurse can determine the cause of thee
hypertension, such as the client taking mAOI to treat depression. These
,meds can precipitate a hypertensive crisis if consumed with tyramine-
containing foods, including wine.
A client is experiencing adverse effects of chlorpromazine. The nurse
should administer benztropine to relieve which of the following adverse
effects? Ans✓✓✓ Acute dystonia.
A client is taking buspirone for generalized anxiety disorder. What is an
adverse effects of this medication? Ans✓✓✓ Xerostomia (dry mouth)
Headache
Nausea
Insomnia
Myalgia
Blurry vision
Tachycardia
A client who has a recent diagnosis of bipolar disorder is placed in a
room with a client who has severe depression. The client who has
depression reports to the nurse, "My roommate never sleeps and keeps
me up, too." Which of the following actions should the nurse take?
Ans✓✓✓ Move the client who has bipolar disorder to a private room.
Clients who have bipolar disorder can disrupt the therapeutic milieu for
other clients. Therefore, the nurse should move this client to a private
room.
, A client with bipolar disorder stopped taking lithium 2 weeks ago. What
adverse effect could have caused the the client to stop taking this
medication? Ans✓✓✓ Hand tremors. Fine hand tremors are an
expected adverse effect of lithium and can interfere with performance of
ADLs, causing the client to stop taking the medication
A home health nurse is assessing an older adult client whose sibling is
the primary caregiver. Which of the following findings should the nurse
identify as a possible indicator of neglect? Ans✓✓✓ Inappropriate
dress. Clothing that is soiled or clothing that is not appropriate for
weather conditions is a possible indicator of neglect.
A nurse assigned to care for a patient scheduled for electroconvulsive
therapy (ECT) is aware of the following:
A.Patients are expected to be alert an hour following ECT, offer fluids
immediately upon awakening, monitor possible hypotension and
tachycardia after ECT procedure
B.Patients are expected to have short term memory loss, IV line is
maintained until full recovery, monitor for possible hypertension and
bradycardia after ECT procedure
C.Patients are expected to have permanent memory loss, maintain
indwelling catheter due to frequent urination, monitor for tonic-clonic
seizure activity associated after ECT procedure
D.Patients are expected to have relief of depressed moods two weeks
after ECT, oxygen via nasal cannula will be maintained for one day,
monitor for possible ECG changes and fever Ans✓✓✓ B. Patients are
expected to have short term memory loss, IV line is maintained until full
recovery, monitor for possible hypertension and bradycardia after ECT
procedure
Ans✓✓✓
A 65 years old client is in the first stage of Alzheimer's disease. Nurse
Patricia should plan to focus this client's care on:
A. Offering nourishing finger foods to help maintain the client's optimal
nutritional status.
B. Providing emotional support and individual counseling.
C. Monitoring the client to prevent minor illnesses from turning into
major problems.
D. Suggesting new activities for the client and family to do together.
Ans✓✓✓ CORRECT - Option B: Clients in the first stage of
Alzheimer's disease are aware that something is happening to them and
may become overwhelmed and frightened. Therefore, nursing care
typically focuses on providing emotional support and individual
counseling.
Options A, C, and D: The other options are appropriate during the
second stage of Alzheimer's disease when the client needs continuous
monitoring to prevent minor illnesses from progressing into major
problems and when maintaining adequate nutrition may become a
challenge. During this stage, offering nourishing finger foods helps
clients to feed themselves and maintain adequate nutrition.
A charge nurse is preparing an educational session for a group of newly
licensed nurses to review client rights under the law. Which of the
following statements should thee nurse make? Ans✓✓✓ "In the event a
client threatens harm to others, medications can be administered without
,consent." Primary commitment is to the client and their priority is
always to advocate for and protect their health and safety. During an
emergency situation, if the client is threatening harm to self or others,
meds can be administered without the client's consent and without a
court order
A client has alcohol toxicity and is unresponsive, what is an appropriate
nursing intrevention? Ans✓✓✓ Gather supplies for an endotracheal
intubation because an expected finding of an unresponsive client who
has alcohol toxicity is respiratory depression.
A client has anorexia nervosa, what finding requires hospitalization?
Ans✓✓✓ Total body fat 8.7%. The nurse should recognize that criteria
for hospitalization includes having a weight less than 75% of ideal body
weight, or less than 10% body fat.
A client has schizophrenia and reports auditory hallucinations. What
interventions should be included in their care plan? Ans✓✓✓ Promote
the use of music to compete with the client's auditory hallucinations.
This can assist in limiting the effect the hallucinations have on the
client's stress level.
A client is experiencing a headache and heart palpitations after having 1
glass of wine 1 hr ago. The client has a hx of depression and a BP of
210/105 mm Hg and a temp of 103.8 F. What action should the nurse
take first? Ans✓✓✓ Determine the client's prescribed medication
regimen. This way the nurse can determine the cause of thee
hypertension, such as the client taking mAOI to treat depression. These
,meds can precipitate a hypertensive crisis if consumed with tyramine-
containing foods, including wine.
A client is experiencing adverse effects of chlorpromazine. The nurse
should administer benztropine to relieve which of the following adverse
effects? Ans✓✓✓ Acute dystonia.
A client is taking buspirone for generalized anxiety disorder. What is an
adverse effects of this medication? Ans✓✓✓ Xerostomia (dry mouth)
Headache
Nausea
Insomnia
Myalgia
Blurry vision
Tachycardia
A client who has a recent diagnosis of bipolar disorder is placed in a
room with a client who has severe depression. The client who has
depression reports to the nurse, "My roommate never sleeps and keeps
me up, too." Which of the following actions should the nurse take?
Ans✓✓✓ Move the client who has bipolar disorder to a private room.
Clients who have bipolar disorder can disrupt the therapeutic milieu for
other clients. Therefore, the nurse should move this client to a private
room.
, A client with bipolar disorder stopped taking lithium 2 weeks ago. What
adverse effect could have caused the the client to stop taking this
medication? Ans✓✓✓ Hand tremors. Fine hand tremors are an
expected adverse effect of lithium and can interfere with performance of
ADLs, causing the client to stop taking the medication
A home health nurse is assessing an older adult client whose sibling is
the primary caregiver. Which of the following findings should the nurse
identify as a possible indicator of neglect? Ans✓✓✓ Inappropriate
dress. Clothing that is soiled or clothing that is not appropriate for
weather conditions is a possible indicator of neglect.
A nurse assigned to care for a patient scheduled for electroconvulsive
therapy (ECT) is aware of the following:
A.Patients are expected to be alert an hour following ECT, offer fluids
immediately upon awakening, monitor possible hypotension and
tachycardia after ECT procedure
B.Patients are expected to have short term memory loss, IV line is
maintained until full recovery, monitor for possible hypertension and
bradycardia after ECT procedure
C.Patients are expected to have permanent memory loss, maintain
indwelling catheter due to frequent urination, monitor for tonic-clonic
seizure activity associated after ECT procedure
D.Patients are expected to have relief of depressed moods two weeks
after ECT, oxygen via nasal cannula will be maintained for one day,
monitor for possible ECG changes and fever Ans✓✓✓ B. Patients are
expected to have short term memory loss, IV line is maintained until full
recovery, monitor for possible hypertension and bradycardia after ECT
procedure
