2700 Mock Exam 2

While the nurse performs range of motion (ROM) on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. What should the nurse do first? a. Use restraints to protect the patient from injury. b. Perform the exercises less frequently because posturing can increase ICP. c. Administer central nervous system (CNS) depressants to lightly sedate the patient. d. Continue the exercises because they are necessary to maintain musculoskeletal function

B: While important, ROM is not a life saving intervention. Priority should be placed on minimizing worsening the ICP. Restraints are contraindicated unless the patients is a danger to themselves or the staff

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) A. Contact the nursing supervisor. B. Restrict the family's visiting privileges. C. Ask the family to stay with the patient if possible. D. Inform the family of the risks associated with side-rail use. E. Thank the family for being conscientious and put the four rails up. F. Discuss alternatives that are appropriate for this patient with the family.

C, D, F: All four side rails being up is a unapproved restraint. If the family persisted, the nursing supervisor may be called.

A healthy 2-month-old infant is being seen in the local clinic for a well-child checkup and initial immunizations. When analyzing the pediatric record, which immunizations would the nurse anticipate administering at this appointment? Select all that apply. A. IPV (inactivated polio vaccine) B. Hib (Haemophilus influenzae vaccine) C. Varicella (chickenpox) vaccine D. PCV (pneumococcal vaccine) E. DTaP (diphtheria, tetanus, and acellular pertussis) F. MMR (measles, mumps, and rubella)

A, B, D, and E: MMR and Varicella will be administered at 12-15 months of life.

A nurse is assessing a patient to determine educational needs. Which is most important for the nurse to consider? A. Make no assumptions about the patient. B. Teaching may be informal or formal in nature. C. The teaching plan should be documented on appropriate records. D. A copy of the teaching-learning contract should be given to the patient.

A: Make no assumptions about the patient. Many variables influence an individual's willingness and ability to learn (e.g., readiness, motivation, physical and emotional abilities, education, age, cultural and health beliefs, cognitive abilities).

When a patient is admitted to the ED following a head injury, what should be the nurse's first priority in management of the patient once a patent airway is confirmed? a. Maintain cervical spine precautions. b. Determine the presence of increased ICP. c. Monitor for changes in neurologic status. d. Establish IV access with a large-bore catheter

A: Monitoring for changes in neurological status is important, however maintaining cervical spine precautions must be maintained at all time to prevent death and risk of paralysis

Before assisting a patient with ambulation on the day after a total hip replacement, which action is most important for the nurse to take? A. Administer the ordered oral opioid pain medication. B. Instruct the patient about the benefits of ambulation. C. Ensure that the incisional drain has been discontinued. D. Change the hip dressing and document the wound appearance.

A: The patient would likely be in a lot of pain, which would put them at risk for falling. Administering the pain med would reduce this risk.

A nurse is designing a teaching-learning program for a patient who is to be discharged from the hospital. After developing a nurse-patient relationship, which should the nurse do next? A. Identify the patient's locus of control. B. Use a variety of teaching methods appropriate for the patient. C. Formulate an achievable, measurable, and realistic patient goal. D. Assess the patient's current understanding of the content to be taught.

D: Assess the patient's current understanding of the content to be taught. Learners bring their own lifetimes of learning to the learning situation. The nurse must customize each teaching plan, capitalize on the patient's previous experience and knowledge, and identify what the patient still needs to know before teaching can begin.

The nurse assesses that the client may need a restraint and recognizes that: A. An order for a restraint may be implemented indefinitely until it is no longer required by the client. B. Restraints may be ordered on a prn basis. C. No order or consent is necessary for restraints in long term care facilities. D. Restraints are to be periodically removed to have the client re-evaluated.

D: Restraints are used very infrequently in a clinical setting. If they are needed however, they must be periodically removed so the client can be reevaluated

During community lunch, a manic patient tells another patient, "Push yourself away from the table. You're too fat for your own good!" How should the nurse intervene? a. Say to the patient, "You may remain at lunch only if you apologize." b. Tell the patient, "You must leave lunch and go to your room now." c. Extinguish the behavior by ignoring it. d. Calmly tell the patient that insulting others is not permitted.

D: Setting boundaries is important, however it would not be appropriate to force a patient to apologize.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information? a: The vaccine prevents a future fetus from developing congenital anomalies. b: The client should avoid contact with children diagnosed with rubella. c: The injection will provide immunity against the chickenpox. d: Pregnancy should be avoided for 4 weeks after the immunization.

D: The rubella vaccine is considered a teratogen and should not be administered if the client is pregnant, or trying to become pregnant.

In regards to safety, which of the following statements in most accurate? A. Bacterial contamination of foods is uncontrollable. B. Fire is the greatest cause of unintentional death. C. Temperature extremes seldom affect the safety of clients in acute care facilities. D. Carbon dioxide levels should be monitored in home settings.

D: This is an accurate statement about home safety

A depressed patient tells the nurse, "The bad things that happen are always my fault." How should the nurse respond to assist the patient to reframe this overgeneralization? A. "I really doubt that one person can be blamed for all the bad things that happen." B. "You are being exceptionally hard on yourself when you imply you are a jinx." C. "It is not good for you to think that way. You will be better with treatment." D. "Let's look at one bad thing that happened to see if another explanation exists."

D: This response is the most therapeutic. It does not minimize or ignore the patient's feelings.