NR 326 CMS Proctored Exam Graded A+
The nurse planning on discharge of the client with Neurocognitive Disorder who was
admitted for an acute exacerbation will include which of the following caregiver
education? - ANSWER-Educate the caregivers on installing locks that cannot be easily
opened and mark step edges with colored tape.
A nurse is caring for a client who has early stage Alzheimer's disease with a new
prescription for Donepezil. The nurse should include which of the following statements
when teaching the client about this medication? - ANSWER-"You should take this
medication before going to bed and avoid antihistamines while on Donepezil."
Nursing care of clients who have potential for complications of Delirium include which of
the following? - ANSWER-Manage potential for complications by using the CAM-ICU
tool and provide a well-lit room with low auditory stimuli
A nurse is caring for a client diagnosed with an eating disorder. Which of the following
medications are contraindicated in clients with an eating disorder? - ANSWER-
Bupropion
A nurse is caring for a client admitted for complications related to an eating disorder.
Which of the following nursing actions need to be included during complications such as
re-feeding syndrome when caring for a client with an eating disorder? - ANSWER-
Monitor electrolytes, cardiac dysrhythmias, consult with nutritional support services.
A nurse is caring for an older adult client who is recovering from total hip surgery. The
client has a history of Depression and Dementia. Which of the following symptom
manifestation is the highest priority for nursing action? - ANSWER-Onset of sudden
hypoactive consciousness with apathy and inattentiveness
A nurse is assessing a client's withdrawal symptoms using the clinical institute
withdrawal assessment of alcohol scale (CIWA). Which of the following scores would
indicate a mild to moderate level of withdrawal? - ANSWER-10-19
A nurse is discharging a client with bipolar personality disorder. Plan includes: -
ANSWER-Crisis intervention safety plan
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 has been completed by a
physician within 1 hour of placing the client in restraint.
- Ensure and document offering fluids and toileting to the client.
- Ensure to maintain the client's dignity and respect.
The nurse initiating therapeutic relationship with clients knows which of the following
defense mechanisms are always adaptive and never maladaptive? - ANSWER-Altruism
and Sublimation
A client tells a nurse that the nurse is the only one who cares about them, yet the
following day, the client refuses to talk to that nurse. This is an example of which of the
following defense mechanisms? - ANSWER-Splitting
The nurse planning on discharge of the client with Neurocognitive Disorder who was
admitted for an acute exacerbation will include which of the following caregiver
education? - ANSWER-Educate the caregivers on installing locks that cannot be easily
opened and mark step edges with colored tape.
A nurse is caring for a client who has early stage Alzheimer's disease with a new
prescription for Donepezil. The nurse should include which of the following statements
when teaching the client about this medication? - ANSWER-"You should take this
medication before going to bed and avoid antihistamines while on Donepezil."
Nursing care of clients who have potential for complications of Delirium include which of
the following? - ANSWER-Manage potential for complications by using the CAM-ICU
tool and provide a well-lit room with low auditory stimuli
A nurse is caring for a client diagnosed with an eating disorder. Which of the following
medications are contraindicated in clients with an eating disorder? - ANSWER-
Bupropion
A nurse is caring for a client admitted for complications related to an eating disorder.
Which of the following nursing actions need to be included during complications such as
re-feeding syndrome when caring for a client with an eating disorder? - ANSWER-
Monitor electrolytes, cardiac dysrhythmias, consult with nutritional support services.
A nurse is caring for an older adult client who is recovering from total hip surgery. The
client has a history of Depression and Dementia. Which of the following symptom
manifestation is the highest priority for nursing action? - ANSWER-Onset of sudden
hypoactive consciousness with apathy and inattentiveness
A nurse is assessing a client's withdrawal symptoms using the clinical institute
withdrawal assessment of alcohol scale (CIWA). Which of the following scores would
indicate a mild to moderate level of withdrawal? - ANSWER-10-19
A nurse is discharging a client with bipolar personality disorder. Plan includes: -
ANSWER-Crisis intervention safety plan
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 has been completed by a
physician within 1 hour of placing the client in restraint.
- Ensure and document offering fluids and toileting to the client.
- Ensure to maintain the client's dignity and respect.
The nurse initiating therapeutic relationship with clients knows which of the following
defense mechanisms are always adaptive and never maladaptive? - ANSWER-Altruism
and Sublimation
A client tells a nurse that the nurse is the only one who cares about them, yet the
following day, the client refuses to talk to that nurse. This is an example of which of the
following defense mechanisms? - ANSWER-Splitting
