NR326 CMS Proctored Exam 2022 Retake.
Which of the following is a correct assumption regarding the concept of crisis?
A crisis situation contains the potential for psychological growth or deterioration
Crises occurs when an individual:
Experiences a stressor and perceives coping strategies to...
NR326 CMS Proctored Exam 2022 Retake.
Which of the following is a correct assumption regarding the concept of crisis?
A crisis situation contains the potential for psychological growth or deterioration
Crises occurs when an individual:
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:
- ♥ Crisis resulting from traumatic stress
- (Adventitious)
The most appropriate crisis intervention with Amanda (#3) would be to:
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?
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)
- Paroxetine
- Lorazepam
Crisis medication
- 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?
"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?
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)
- 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?
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?
"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:
Survivor's guilt
Intervention with Andrew (12) would include:
- 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:
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?
"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?
"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?
"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?
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?
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?
Set limits and boundaries, giving clear expectations
Which of the following is true about clients admitted for involuntary admission?
(SATA)
- 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?
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)
- 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?
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?
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?
"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).
- 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?
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?
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).
- 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?
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?
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?
Monitor for respiratory depression, seizures if abrupt cessation.
TMAPI
- 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.)
- "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?
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 nurse identify as the priority?
Identify the client's perception of their mental health status.
A nurse is planning a peer group discussion about the Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following
information is appropriate to include in the discussion? (Select all that apply.)
- The DSM-5 establishes diagnostic criteria for individual mental health disorders.
- The DSM-5 assists nurses in planning care for client's who have mental health
disorders.
- The DSM-5 indicates expected assessment findings of mental health disorders.
A nurse in an emergency mental health facility is caring for a group of clients.
The nurse should identify that which of the following clients requires a temporary
emergency admission?
A client who has borderline personality disorder and assaulted a homeless man with a
metal rod
A nurse decides to put a client who has a psychotic disorder in seclusion
overnight because the unit is very short-staffed, and the client frequently fights
with other clients. The nurse's actions are an example of which of the following
torts?
False imprisonment
A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress
in order to protect myself from my roommate, who is always threatening me."
Which of the following actions should the nurse take?
Tell the client that this must be reported to the health care team because it concerns the
health and safety of the client and others.
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