NR 326 CMS FINAL EXAM ACTUAL EXAM 100 QUESTIONS AND
CORRECT ANSWERS WITH RATIONALES
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
A nurse is caring for a client who is experiencing moderate anxiety. Which of the
following actions should the nurse take when trying to give necessary information to
the client? (SATA). - ANSWER: - Discuss prior use of coping mechanisms that have
helped with the client.
- Demonstrate a calm manner while using simple and clear directions.
Which of the following should the nurse include in the nursing assessment of a
client's
ability to cope during a crisis? - ANSWER: The client's suicidal or homicidal ideation,
present coping skills, problem solving
abilities.
A nurse working in an emergency department is caring for a client who has
benzodiazepine toxicity. Which of the following actions is the nurse's priority? -
ANSWER: Identify the client's level of orientation
Nursing considerations when giving a benzodiazepine medication to a client
exhibiting severe to panic anxiety include which of the following? - ANSWER:
Monitor for respiratory depression, seizures if abrupt cessation.
TMAPI - ANSWER: - Thoughts
- access to Means
- Ability
- Plan
- Intent
A charge nurse is discussing mental status examinations with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching? (Select all that apply.) - ANSWER: - "To assess
cognitive ability, I should ask the client to count backward by sevens."
- "To assess affect, I should observe the client's facial expression."
- "To assess language ability, I should instruct the client to write a sentence."
A nurse is planning care for a client who has a mental health disorder. Which of the
following actions should the nurse include as a psychobiological intervention? -
ANSWER: Monitor the client for adverse effects of medications
A nurse in an outpatient mental health clinic is preparing to conduct an initial client
interview. When conducting the interview, which of the following actions should the
CORRECT ANSWERS WITH RATIONALES
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
A nurse is caring for a client who is experiencing moderate anxiety. Which of the
following actions should the nurse take when trying to give necessary information to
the client? (SATA). - ANSWER: - Discuss prior use of coping mechanisms that have
helped with the client.
- Demonstrate a calm manner while using simple and clear directions.
Which of the following should the nurse include in the nursing assessment of a
client's
ability to cope during a crisis? - ANSWER: The client's suicidal or homicidal ideation,
present coping skills, problem solving
abilities.
A nurse working in an emergency department is caring for a client who has
benzodiazepine toxicity. Which of the following actions is the nurse's priority? -
ANSWER: Identify the client's level of orientation
Nursing considerations when giving a benzodiazepine medication to a client
exhibiting severe to panic anxiety include which of the following? - ANSWER:
Monitor for respiratory depression, seizures if abrupt cessation.
TMAPI - ANSWER: - Thoughts
- access to Means
- Ability
- Plan
- Intent
A charge nurse is discussing mental status examinations with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching? (Select all that apply.) - ANSWER: - "To assess
cognitive ability, I should ask the client to count backward by sevens."
- "To assess affect, I should observe the client's facial expression."
- "To assess language ability, I should instruct the client to write a sentence."
A nurse is planning care for a client who has a mental health disorder. Which of the
following actions should the nurse include as a psychobiological intervention? -
ANSWER: Monitor the client for adverse effects of medications
A nurse in an outpatient mental health clinic is preparing to conduct an initial client
interview. When conducting the interview, which of the following actions should the
