NR326 CMS Proctored Exam71
Which of the following is a correct assumption regarding the concept of crisis? - ANSWERS-A
crisis situation contains the potential for psychological growth or deterioration
Crises occurs when an individual: - ANSWERS-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: -
ANSWERS-- ♥ Crisis resulting from traumatic stress
- (Adventitious)
The most appropriate crisis intervention with Amanda (#3) would be to: - ANSWERS-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? -
ANSWERS-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) - ANSWERS-- Paroxetine
- Lorazepam
Crisis medication - ANSWERS-- 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? - ANSWERS-"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? - ANSWERS-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) - ANSWERS-- 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? - ANSWERS-
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? - ANSWERS-"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: - ANSWERS-Survivor's
guilt
Intervention with Andrew (12) would include: - ANSWERS-- 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: - ANSWERS-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? - ANSWERS-"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? - ANSWERS-"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? - ANSWERS-"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? - ANSWERS-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? - ANSWERS-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? - ANSWERS-Set limits and boundaries, giving clear expectations
, Which of the following is true about clients admitted for involuntary admission? (SATA) -
ANSWERS-- 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? -
ANSWERS-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) - ANSWERS-- 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? - ANSWERS-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? - ANSWERS-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? - ANSWERS-"I cannot promise that.
I must share this information with other members of the team who are responsible for planning
your care."
Which of the following is a correct assumption regarding the concept of crisis? - ANSWERS-A
crisis situation contains the potential for psychological growth or deterioration
Crises occurs when an individual: - ANSWERS-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: -
ANSWERS-- ♥ Crisis resulting from traumatic stress
- (Adventitious)
The most appropriate crisis intervention with Amanda (#3) would be to: - ANSWERS-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? -
ANSWERS-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) - ANSWERS-- Paroxetine
- Lorazepam
Crisis medication - ANSWERS-- 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? - ANSWERS-"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? - ANSWERS-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) - ANSWERS-- 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? - ANSWERS-
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? - ANSWERS-"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: - ANSWERS-Survivor's
guilt
Intervention with Andrew (12) would include: - ANSWERS-- 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: - ANSWERS-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? - ANSWERS-"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? - ANSWERS-"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? - ANSWERS-"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? - ANSWERS-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? - ANSWERS-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? - ANSWERS-Set limits and boundaries, giving clear expectations
, Which of the following is true about clients admitted for involuntary admission? (SATA) -
ANSWERS-- 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? -
ANSWERS-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) - ANSWERS-- 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? - ANSWERS-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? - ANSWERS-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? - ANSWERS-"I cannot promise that.
I must share this information with other members of the team who are responsible for planning
your care."
