NR326 CMS Proctored Exam 2024 Retake.

NR326 CMS Proctored Exam 2024 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. A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply.) - "Client was offered 8 oz of water every hr." - "Client shouted obscenities at assistive personnel." - "Client received chlorpromazine 15 mg by mouth at 1000." A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? Tell the nurse to stop discussing the behavior. A charge nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? Intonation A nurse in an acute mental health facility is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? Restating A nurse is communicating with a client who was admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? Offering advice A nurse caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? The nurse asks the client about personal body image perception. A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child's condition, which of the following responses should the nurse make? "I understand you're concerned. Let's discuss what concerns you specifically." A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? Denial A nurse is providing preoperative teaching for a client who was informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? Moderate 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? (Select all that apply.) - Discuss prior use of coping mechanisms with the client. - Demonstrate a calm manner while using simple and clear directions.