NUR 221 EXAM 4

An older patient seeks emergency care for a sudden onset of severe abdominal pain. Which health problem should the nurse suspect be occurring in this patient? A. Rupture of the appendix B. Small bowel obstruction C. Passing of a kidney stone D. Rupture of an abdominal aneurysm

D. Rupture of an abdominal aneurysm

A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman's level of anxiety? A. Weak B. Mild C. Moderate D. Severe

D. Severe

A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? A. Bile acid resins B. Nicotinic acid C. Nitroglycerin D. Statins

D. Statins

Which trend is an effect of the nursing shortage on nursing education and ultimately a safety issue regarding client care? A. Only devoted qualified nurses are continuing to provide bedside nursing because of the complexity of care required, resulting in excellent client care. B. The number of applicants to nursing programs has risen, but enrollment is limited because of a decrease in the number of available scholarships and grants. C. With an increase in the number of nurses who are entering graduate school to escape bedside nursing, students will soon enjoy a lower faculty/student ratio. D. Students may be assigned to preceptors who have not yet developed expertise in the field of interest.

D. Students may be assigned to preceptors who have not yet developed expertise in the field of interest.

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider? A. Complaint of severe headache B. Large contusion behind left ear C. Bilateral periorbital ecchymosis D. Temperature of 101.4° F (38.6° C)

D. Temperature of 101.4° F (38.6° C)

The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient. A. The memory of the rape will be less vivid and less frightening. B. The patient is able to describe feelings of safety and relaxation. C. Symptoms of pain, discomfort, and anxiety are no longer present. D. The patient agrees to a follow-up appointment with a rape victim advocate.

D. The patient agrees to a follow-up appointment with a rape victim advocate.

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient's action? A. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. B. Crowding in skilled nursing facilities increases an individual's tendency toward violence. C. The patient learned violent behavior by watching other patients act out. D. The patient interpreted the UAP's behavior as potentially harmful.

D. The patient interpreted the UAP's behavior as potentially harmful.

The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include in the nursing diagnosis statement? A. The problem and the suggested patient goals or outcomes B. The problem with possible causes and the planned interventions C. The problem, its cause, and objective data that support the problem D. The problem with an etiology and the signs and symptoms of the problem

D. The problem with an etiology and the signs and symptoms of the problem

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? A. Cholesterol: 126 mg/dL B. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL C. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL D. Triglycerides: 198 mg/dL

D. Triglycerides: 198 mg/dL

When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor? A. Male gender B. Turner syndrome C. Abdominal trauma history D. Uncontrolled hypertension

D. Uncontrolled hypertension

Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n) A. hemoglobin count. B. additional antibiotic. C. decrease in IV infusion rate. D. blood urea nitrogen (BUN) level.

D. blood urea nitrogen (BUN) level.

A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will A. adhere willingly to unit norms. B. report decreased incidence of self-mutilative thoughts. C. demonstrate fewer attempts at splitting or manipulating staff. D. demonstrate ability to introduce self to a stranger in a social situation.

D. demonstrate ability to introduce self to a stranger in a social situation

A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is: A. demonstrating withdrawal. B. working though angry feelings. C. attempting to use relaxation strategies. D. exhibiting clues to potential aggression.

D. exhibiting clues to potential aggression.

A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to A. an inherited disorder that manifests itself as an incapacity to tolerate stress. B. use of projective identification and splitting to bring anxiety to manageable levels. C. a constitutional inability to regulate affect, predisposing to psychic disorganization. D. fear of abandonment associated with progress toward autonomy and independence.

D. fear of abandonment associated with progress toward autonomy and independence.

When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include A. preoccupation with minute details; perfectionist. B. charm, drama, seductiveness; seeking admiration. C. difficulty being alone; indecisive, submissiveness. D. grandiosity, self-importance, and a sense of entitlement.

D. grandiosity, self-importance, and a sense of entitlement.

A health care provider recently convicted of Medicare fraud says to a nurse, "Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I deserve the money." These statements show A. shame. B. suspiciousness. C. superficial remorse. D. lack of guilt feelings.

D. lack of guilt feelings.

An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient: A. was threatening to others. B. was experiencing psychosis. C. presented an undeniable escape risk. D. presented a clear and present danger to others.

D. presented a clear and present danger to others.

Before a victim of sexual assault is discharged from the emergency department, the nurse should: A. notify the victim's family to provide emotional support. B. offer to stay with the patient until stability is regained. C. advise the patient to try not to think about the assault. D. provide referral information verbally and in writing.

D. provide referral information verbally and in writing.

A nurse cares for a rape victim who was given a drink that contained flunitrazepam (Rohypnol) by an assailant. Which intervention has priority? Monitoring for: A. coma B. seizures C. hypotonia D. respiratory depression

D. respiratory depression

The priority nursing assessment for a 72-year-old patient being admitted with a brainstem infarction is A. reflex reaction time. B. pupil reaction to light. C. level of consciousness. D. respiratory rate and rhythm.

D. respiratory rate and rhythm.

The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include A. arrogant, grandiose, and a sense of self-importance. B. attention seeking, melodramatic, and flirtatious. C. impulsive, restless, socially aggressive behavior. D. socially anxious, rambling stories, peculiar ideas.

D. socially anxious, rambling stories, peculiar ideas.

Which information from a patient's record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of: A. academic problems. B. family involvement. C. childhood trauma. D. substance abuse.

D. substance abuse.

A 72-year-old patient is hospitalizedfor an aortic dissection of the abdomial aorta that stabilizes with treatment. The nurse develops a teaching plan for the patient's discharge that includes information about A. gradually increasing exercise to improve cardiac function and BP control. B. appropriate use of nonsteroidal antiinflammatory agents (NSAIDs) to control any abdominal pain. C. holding prescribed b-blockers if dizziness or weakness occur to avoid injury. D. the use of antihypertensive medications to lower the risk of further dissection or bleeding.

D. the use of antihypertensive medications to lower the risk of further dissection or bleeding.

For which behavior would limit setting be most essential? The patient who A. clings to the nurse and asks for advice about inconsequential matters. B. is flirtatious and provocative with staff members of the opposite sex. C. is hypervigilant and refuses to attend unit activities. D. urges a suspicious patient to hit anyone who stares.

D. urges a suspicious patient to hit anyone who stares.

A patient with neurogenic shock following a spinal cord injury is to receive lactated Ringer's solution 500 mL over 30 minutes. When setting the IV pump to deliver the IV fluid, the nurse will set the rate at how many mL/hour?

1000 To administer 500 mL in 30 minutes, the nurse will need to set the pump to run at 1000 mL/hour.

A patient has an intracranial pressure measurement of 22 mm Hg and blood pressure of 174/88 mm Hg. What is the patient's cerebral perfusion pressure?

95

A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response. A. "Are you thinking of harming yourself?" B. "It will take time, but you will feel the same as before the attack." C. "Your friends will understand when you explain it was not your fault." D. "You will be able to find meaning from this experience as time goes on."

A. "Are you thinking of harming yourself?"

The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? A. "I have an incredible headache!" B. "There is blood on my toothbrush!" C. "Look at the bruises on my arms!" D. "My arm is bleeding where my IV is!"

A. "I have an incredible headache!"

A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? A. "I know I can take care of all these needs by myself." B. "I need to seek counseling because I am very angry." C. "Hopefully things will improve gradually over time." D. "With respite care and support, I think I can do this."

A. "I know I can take care of all these needs by myself."

A patient says, "I get in trouble sometimes because I make quick decisions and act on them." Select the nurse's most therapeutic response. A. "Let's consider the advantages of being able to stop and think before acting." B. "It sounds as though you've developed some insight into your situation." C. "I bet you have some interesting stories to share about overreacting." D. "It's good that you're showing readiness for behavioral change."

A. "Let's consider the advantages of being able to stop and think before acting."

A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate an interview with these parents? Select all that apply. A. "Tell me how you discipline your children." B. "How do you stop your baby from crying?" C. "Caring for four small children must be difficult." D. "Do you or your husband ever spank your children?" E. "Calling children 'stupid' injures their self-esteem."

A. "Tell me how you discipline your children." B. "How do you stop your baby from crying?" C. "Caring for four small children must be difficult."

The family of a patient with a traumatic brain injury asks why the bed side rails are padded. What should the nurse explain to the family? A. "There is a risk for seizure activity after a head injury." B. "The padding prevents injury when turning the patient." C. "The padding prevents the patient from climbing out of bed." D. "The padding ensures the side rails are kept elevated at all times."

A. "There is a risk for seizure activity after a head injury."

Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? A. "You are feeling violated because you thought you could trust your partner." B. "I'm here for you. I want you to tell me about the bad things that happened to you." C. "I was very worried about you. I knew you were living in a potentially violent situation." D. "Abusers often target people who are passive. I will refer you to an assertiveness class."

A. "You are feeling violated because you thought you could trust your partner."

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? A. A 45-year-old receiving IV antibiotics for meningococcal meningitis B. A 25-year-old admitted with a skull fracture and craniotomy the previous day C. A 55-year-old who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy D. A 35-year-old with ICP monitoring after a head injury last week

A. A 45-year-old receiving IV antibiotics for meningococcal meningitis

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders (Select all that apply.) A. A client with a moderate trauma may need hospitalization. B. A Glasgow Coma Scale score of 10 indicates a mild brain injury. C. Only open head injuries can cause a severe TBI. D. A client with a Glasgow Coma Scale score of 3 has severe TBI. E. The terms "mild TBI" and "concussion" have similar meanings

A. A client with a moderate trauma may need hospitalization. D. A client with a Glasgow Coma Scale score of 3 has severe TBI. E. The terms "mild TBI" and "concussion" have similar meanings

Which patient being cared for in the emergency department should the charge nurse evaluate first? A. A patient with a complete spinal injury at the C5 dermatome level B. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula C. An alert patient with a subdural bleed who is complaining of a headache D. An ischemic stroke patient with a blood pressure of 190/100 mm Hg

A. A patient with a complete spinal injury at the C5 dermatome level

A patient in a barbiturate coma for increased intracranial pressure (ICP) has audible gurgling through the endotracheal tube. What should the nurse do first before suctioning this patient? A. Administer 100% oxygen B. Elevate the head of the bed C. Interrupt sedative administration D. Place the head in a neutral position

A. Administer 100% oxygen

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? A. Administer IV 5% hypertonic saline. B. Draw blood for arterial blood gases (ABGs). C. Send patient for computed tomography (CT). D. Administer acetaminophen (Tylenol) 650 mg orally.

A. Administer IV 5% hypertonic saline

A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) A. Admission can overwhelm the coping mechanisms for older clients. B. Alcohol is typically involved in most traumatic brain injuries for this age group. C. These clients are more susceptible to systemic and wound infections. D. Other medical conditions can complicate treatment for these clients. E. Very few traumatic brain injuries occur in this age group

A. Admission can overwhelm the coping mechanisms for older clients C. These clients are more susceptible to systemic and wound infections. D. Other medical conditions can complicate treatment for these clients.

A nurse is completing the degree requirements for an advanced practice role as a nurse practitioner and is concerned about certification requirements. Which statement concerning certification for advanced practice is true? A. All states require certification for all specialty roles that are identified as advanced practice. B. Nurse anesthetists and nurse midwives are the only advanced practice role that require certification in the state nurse practice acts. C. Scope of practice remains unclear in state nurse practice acts due to the increasing number of new advanced practice roles. D. Certification is automatic when the nurse applies for an advanced practice license.

A. All states require certification for all specialty roles that are identified as advanced practice.

A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? Select all that apply. A. Allow the patient to talk at a comfortable pace. B. Place the patient in a private room with a caregiver. C. Pose questions in nonjudgmental, empathetic ways. D. Invite the patient's family members to the examination room. E. Put an arm around the patient to demonstrate support and compassion.

A. Allow the patient to talk at a comfortable pace. B. Place the patient in a private room with a caregiver. C. Pose questions in nonjudgmental, empathetic ways.

Which central nervous system structures are most associated with anger and aggression? (Select all that apply.) A. Amygdala B. Cerebellum C. Basal ganglia D. Temporal lobe E. Prefrontal cortex

A. Amygdala D. Temporal lobe E. Prefrontal cortex

Which technique should the nurse use to assess a patient's CN IX Glossopharyngeal? A. Apply a tongue depressor to the back of the throat B. Ask the patient to read from a book or a newspaper C. Ask the patient to smile, frown, puff cheeks, and raise eyebrows D. Ask the patient to follow the examiner's finger as it is moved toward the patient's nose

A. Apply a tongue depressor to the back of the throat

A nurse is concerned that the policy of using povidone-iodine to clean foot ulcers may lead to unwarranted allergic reactions and drying of surrounding tissue. A literature review is performed to determine the "best practice" related to care of foot ulcers. This nurse is engaging in what activities? (Select all that apply.) A. Applying evidence-based practice to the clinical setting B. Using critical thinking to change procedures performed in the care of foot ulcers C. Is participating in research to provide cost-effective care (soap is less expensive than povidone-iodine) D. Is demonstrating clinical competence in health assessment and in application of theory to the clinical setting E. Is using information to problem solve and ensure safe, competent care

A. Applying evidence-based practice to the clinical setting B. Using critical thinking to change procedures performed in the care of foot ulcers D. Is demonstrating clinical competence in health assessment and in application of theory to the clinical setting E. Is using information to problem solve and ensure safe, competent care

A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? Select all that apply. A. Appoint a person to clear a path and open, close, or lock doors. B. Quickly approach the patient and take the closest extremity. C. Select the person who will communicate with the patient. D. Move behind the patient when the patient is not looking. E. Remove jewelry, glasses, and harmful items.

A. Appoint a person to clear a path and open, close, or lock doors. C. Select the person who will communicate with the patient. E. Remove jewelry, glasses, and harmful items.

When admitting an acutely confused 20-year-old patient with a head injury, which action should the nurse take? A. Ask family members about the patient's health history. B. Ask leading questions to assist in obtaining health data. C. Wait until the patient is better oriented to ask questions. D. Obtain only the physiologic neurologic assessment data.

A. Ask family members about the patient's health history.

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? A. Assist the patient to the floor and provide soft head support. B. Insert a nasogastric tube and connect to continuous wall suction. C. Open the patient's mouth and insert a padded tongue blade. D. Restrain the patient's extremities until the seizure subsides.

A. Assist the patient to the floor and provide soft head support.

The nurse suspects that a patient with a brain tumor is developing increased intracranial pressure (ICP). What assessment findings caused the nurse to make this conclusion? Select all that apply. A. Ataxia B. Nausea C. Diarrhea D. Vomiting E. Headache

A. Ataxia B. Nausea C. Diarrhea E. Headache

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) A. Atherosclerosis B. Down syndrome C. Frequent heartburn D. History of hypertension E. History of smoking

A. Atherosclerosis D. History of hypertension E. History of smoking

A patient with neurogenic shock is demonstrating vagal stimulation. What should the nurse expect to be prescribed for this patient? A. Atropine B. Epinephrine C. Phenylephrine D. Norepinephrine

A. Atropine

Admission vital signs for a brain injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? A. Blood pressure 154/68, pulse 56, respirations 12 B. Blood pressure 134/72, pulse 90, respirations 32 C. Blood pressure 148/78, pulse 112, respirations 28 D. Blood pressure 110/70, pulse 120, respirations 30

A. Blood pressure 154/68, pulse 56, respirations 12

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? A. Call the provider or Rapid Response Team. B. Increase the rate of the IV fluid administration. C. Notify respiratory therapy for a breathing treatment. D. Prepare to give IV pain medication

A. Call the provider or Rapid Response Team.

An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? Select all that apply. A. Camera B. Body map C. DNA swabs D. Pulse oximeter E. Sphygmomanometer

A. Camera B. Body map C. DNA swabs

Following a cauda equina spinal cord injury, which action will the nurse include in the plan of care? A. Catheterize patient every 3 to 4 hours. B. Assist patient to ambulate several times daily. C. Administer medications to reduce bladder spasm. D. Stabilize the neck when repositioning the patient.

A. Catheterize patient every 3 to 4 hours.

A 68-year-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? A. Check oxygen saturation. B. Assess pupil reaction to light. C. Verify Glasgow Coma Scale (GCS) score. D. Palpate the head for hematoma or bony irregularities.

A. Check oxygen saturation

An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." Which nursing diagnosis applies to this child? A. Chronic low self-esteem related to negative feedback from parents B. Deficient knowledge related to interpersonal skills with parents C. Disturbed personal identity related to negative self-evaluation D. Complicated grieving related to poor academic performance

A. Chronic low self-esteem related to negative feedback from parents

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? A. Client with a Glasgow Coma Scale score that was 10 and is now is 8 B. Client with a Glasgow Coma Scale score that was 9 and is now is 12 C. Client with a moderate brain injury who is amnesic for the event D. Client who is requesting pain medication for a headach

A. Client with a Glasgow Coma Scale score that was 10 and is now is 8

A patient with a traumatic brain injury is leaking clear fluid from the nose. What action should the nurse take? A. Collect the fluid with gauze B. Check the fluid for red blood cells C. Send a specimen for a protein level D. Insert a nasal plug in the nostril leaking the fluid

A. Collect the fluid with gauze

What action is considered a nursing responsibility when participating in a nurse licensure compact? A. Complying with the nursing practice laws in the state where practicing at the time care is rendered B. Purchasing a license in each state or retaking the licensure examination C. Determining residency based on the state where educated as registered nurse D. Practicing only in states or territories that recognizes the NCLEX as the source of licensure

A. Complying with the nursing practice laws in the state where practicing at the time care is rendered

Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? Select all that apply. A. Coping mechanisms the patient is using B. The patient's previous sexual experiences C. The patient's history of sexually transmitted diseases D. Signs and symptoms of emotional and physical trauma E. Adequacy and availability of the patient's support system

A. Coping mechanisms the patient is using D. Signs and symptoms of emotional and physical trauma E. Adequacy and availability of the patient's support system

A student nurse is preparing a presentation that requires identification of outcomes for the care of heart failure patients. Which statement represents an appropriately written outcome? A. Develop a teaching program to address physical activities that result in improved cardiac function. B. Discuss the clinical manifestations associated with Level 4 heart failure. C. List the most common pharmaceutical approaches to reduce preload in heart failure patients. D. Recognize the economic impact that recidivism has on the patient and health care facility.

A. Develop a teaching program to address physical activities that result in improved cardiac function.

When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase of reorganization, which symptoms should be included? Select all that apply. A. Development of fears and phobias B. Decreased motor activity C. Feelings of numbness D. Flashbacks, dreams E. Syncopal episodes

A. Development of fears and phobias C. Feelings of numbness D. Flashbacks, dreams

In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) A. Doll's eyes absent indicate a disruption in normal brainstem processing. B. Doll's eyes present indicate brainstem activity. C. Eye movement in the opposite direction as the head when turned indicates an intact reflex. D. Eye movement in the same direction as the head when turned indicates an intact reflex. E. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. F. Presence of cervical injuries is a contraindication to the assessment of this reflex.

A. Doll's eyes absent indicate a disruption in normal brainstem processing. B. Doll's eyes present indicate brainstem activity. C. Eye movement in the opposite direction as the head when turned indicates an intact reflex. E. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. F. Presence of cervical injuries is a contraindication to the assessment of this reflex.

An RN with a diploma preparation wants to participate in decisions about health care and decides the first step is to obtain a BSN. The nurse enrolls in a nursing program offering self-scheduling and a self-paced curriculum. This nurse is taking advantage of what characteristic of the nursing profession? A. Educational mobility B. Transitioning C. Creative scheduling D. Flexible progression

A. Educational mobility

A new trend in nursing education that is consistent with real-world practice is focused on what activity? A. Establishing appropriate outcomes B. Writing both cognitive and affective objectives C. Designing patient-centered clinical goals D. Deciding upon effective subjective appraisals

A. Establishing appropriate outcomes

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? A. Explain that personality changes are common following brain injuries. B. Ask the client why he or she is acting out and behaving differently. C. Refer the client and spouse to a head injury support group. D. Tell the spouse this is expected and he or she will have to learn to cop

A. Explain that personality changes are common following brain injuries

The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5° F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? A. Frequent neurological assessments B. Side to side position changes C. Range of motion to extremities D. Frequent oropharyngeal suctioning

A. Frequent neurological assessments

Although the use of technology and the Internet provide nursing faculty and students with unlimited resources and current information, what undesirable outcome has become associated with this trend? A. Getting distracted and spending a disproportionate amount of time looking for relevant content B. Additional time must be made available to study and revise curricula because special skills are needed to access information via the Internet. C. Immediate results and outcomes are expected from students and faculty, thus enhancing time management. D. Skills that require problem solving and reflective abilities are underdeveloped.

A. Getting distracted and spending a disproportionate amount of time looking for relevant content

A nursing student is in the final term of an Associate Science of Nursing (ASN) program and is preparing for licensure. Prior to licensure the candidate must provide evidence that they have fulfilled what requirements? (Select all that apply.) A. Graduation from a nursing program B. Graduation from high school or high school equivalency C. Possess current malpractice insurance D. A plan to continue study to obtain a minimum of a BSN within 2 years E. Validation of skills competence provided by a certifying agency

A. Graduation from a nursing program B. Graduation from high school or high school equivalency

What duties are assumed by a state's board of nursing? (Select all that apply.) A. Grants nursing licensure. B. Constructs the licensure examination. C. Assigns disciplinary action when the nurse acts in a manner that results in harm to a patient. D. Assures qualified members are appointed to the board. E. Conducts certification examinations for advanced practice nurses.

A. Grants nursing licensure. C. Assigns disciplinary action when the nurse acts in a manner that results in harm to a patient. D. Assures qualified members are appointed to the board.

Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence? A. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking. B. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. C. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. D. Administer an antipsychotic or anti anxiety medication.

A. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.

A patient with a cerebral vasospasm is receiving triple H therapy. What parameter should the nurse use to determine adequacy of hemodilution? A. Hemoglobin level = 30 g/dL B. Blood pressure 154/80 mm Hg C. Serum sodium level less than 160 mg/dL D. Serum potassium level between 4.0 and 4.5 mEq/L

A. Hemoglobin level = 30 g/dL

A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? A. History of family violence B. Loss of employment C. Abuse of alcohol D. Poverty

A. History of family violence

The nurse is conducting patient teaching about cholesterol levels. When discussing the patients elevated LDL and lowered HDL levels, the patient shows an understanding of the significance of these levels by stating what? A. Increased LDL and decreased HDL increase my risk of coronary artery disease. B. Increased LDL has the potential to decrease my risk of heart disease. C. The decreased HDL level will increase the amount of cholesterol moved away from the artery walls. D. The increased LDL will decrease the amount of cholesterol deposited on the artery walls.

A. Increased LDL and decreased HDL increase my risk of coronary artery disease.

What entity establishes the "rules" for nursing practice? A. Individual state boards of nursing B. Employer, based on area of practice C. United States Department of Health and Human Services D. Local health officials

A. Individual state boards of nursing

Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/LVN) who is working on a medical-surgical unit (select all that apply)? A. Institutional policies B. Stability of the patient C. State nurse practice act D. LPN/LVN teaching abilities E. Experience of the LPN/LVN

A. Institutional policies B. Stability of the patient C. State nurse practice act E. Experience of the LPN/LVN

A patient has been diagnosed with Marfan syndrome. What information does the nurse plan to teach the patient about this condition? A. It is an autosomal dominant inherited disorder of connective tissue. B. It is caused by a random genetic mutation and is not familial. C. There are no drugs that help control the cardiac symptoms of the disease. D. Contact sports are permitted if precautions against concussion are taken.

A. It is an autosomal dominant inherited disorder of connective tissue.

A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? Select all that apply. A. Keep a cell phone fully charged. B. Hide money with which to buy new clothes. C. Have the phone number for the nearest shelter. D. Take enough toys to amuse the children for 2 days. E. Secure a supply of current medications for self and children. F. Assemble birth certificates, Social Security cards, and licenses. G. Determine a code word to signal children when it is time to leave.

A. Keep a cell phone fully charged. C. Have the phone number for the nearest shelter. E. Secure a supply of current medications for self and children. F. Assemble birth certificates, Social Security cards, and licenses. G. Determine a code word to signal children when it is time to leave.

A patient is diagnosed with a 7 cm abdominal aortic aneurysm. What should the nurse include in this patient's plan of care? A. Keep the bed flat B. Elevate the lower extremities C. Raise the head of the bed 30 degrees D. Assist to sit out of bed in a chair twice a day

A. Keep the bed flat

A nurse holds a license in one state but wishes to practice in a second state that is not participating in a nurse licensure compact agreement. The nurse is granted licensure on payment of a fee but does not retake the licensure examination. The nurse has obtained licensure in the second state by what process? A. Licensure by endorsement B. Certification C. Statutory process known as being grandfathered D. Sunset legislation

A. Licensure by endorsement

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) A. Make frequent neurological assessments. B. Maintain CO 2 level at 50 mm Hg. C. Maintain MAP less than 130 mm Hg. D. Prepare for thrombolytic administration. E. Restrain affected limb to prevent injury.

A. Make frequent neurological assessments. C. Maintain MAP less than 130 mm Hg.

The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO 2 ) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which order should the nurse institute first? A. Mannitol 1 g intravenous B. Portable chest x-ray C. Seizure precautions D. Ancef 1 g intravenous

A. Mannitol 1 g intravenous

The nurse is preparing a client with an aortic aneurysm for surgery. The nurse notes that the client's systolic blood pressure has increased by 30 mm Hg compared with the reading 1 hour ago. What is the nurse's best action? A. Measure abdominal girth. B. Auscultate the abdomen. C. Increase the IV infusion rate. D. Reassess the blood pressure.

A. Measure abdominal girth

A nurse is recovering a client who has undergone surgical repair of an abdominal aortic aneurysm (AAA). The client develops coolness of the extremities and reports a bloated feeling in the abdomen. What is the nurse's best action? A. Measure the abdominal girth and check pulses. B. Raise the head of the bed to 90 degrees. C. Assess cardiac output and blood pressure. D. Auscultate and then palpate the abdomen.

A. Measure the abdominal girth and check pulses.

The nurse assesses a patient with a skull fracture and notes a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO 2 ) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? A. Monitor the patient's airway patency. B. Elevate the head of the patient's bed. C. Increase supplemental oxygen delivery. D. Support bony prominences with padding.

A. Monitor the patient's airway patency.

The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? A. Notify the surgeon and anesthesiologist. B. Wrap both the legs in a warming blanket. C. Document the findings and recheck in 15 minutes. D. Compare findings to the preoperative assessment of the pulses.

A. Notify the surgeon and anesthesiologist.

For which patients diagnosed with personality disorders would a family history of similar problems be most likely? (Select all that apply.) A. Obsessive-compulsive B. Antisocial C. Borderline D. Schizotypal E. Narcissistic

A. Obsessive-compulsive B. Antisocial C. Borderline D. Schizotypal

An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first? A. Obtain the blood pressure. B. Obtain blood for laboratory testing. C. Assess for the presence of an abdominal bruit. D. Determine any family history of kidney disease.

A. Obtain the blood pressure.

A 10-year-old cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources as priorities to stabilize the home situation? Select all that apply. A. Parental sessions to teach childrearing practices B. Anger management counseling for the father C. Continuing home visits to give support D. A safety plan for the wife and children E. Placing the children in foster care

A. Parental sessions to teach childrearing practices B. Anger management counseling for the father C. Continuing home visits to give support

Because an intervention was required to control a patient's aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion? Select all that apply. A. Patient behaviors associated with the incident B. Genetic factors associated with aggression C. Intervention techniques used by the staff D. Effects of environmental factors E. Theories of aggression

A. Patient behaviors associated with the incident C. Intervention techniques used by the staff D. Effects of environmental factors

A patient with low back pain is returning from an abdominal computed tomography (CT) scan that revealed an aortic aneurysm. For which finding should the nurse immediately intervene? A. Patient reports sudden severe flank pain. B. Patient BP goes from 144/78 mm Hg to 152/80 mm Hg. C. Patient reports a sense of abdominal fullness after eating. D. Patient informs the nurse of a family history of hypertension.

A. Patient reports sudden severe flank pain.

A nurse who works on the neurology unit just received change-of-shift report. Which patient will the nurse assess first? A. Patient with botulism who is experiencing difficulty swallowing B. Patient with Bell's palsy who has herpes vesicles in front of the ear C. Patient with neurosyphilis who has tabes dorsalis and decreased deep tendon reflexes D. Patient with an abscess caused by injectable drug use who needs tetanus immune globulin

A. Patient with botulism who is experiencing difficulty swallowing

A patient is demonstrating signs of increasing intracranial pressure (ICP). What physical actions should the nurse take to reduce this pressure? Select all that apply. A. Placing the head in a neutral position B. Turning into a left side-lying position C. Raising the head of the bed 60 degrees D. Elevating the foot of the bed 45 degrees E. Placing supine with a pillow under the head

A. Placing the head in a neutral position C. Raising the head of the bed 60 degrees

The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize? A. Practice and teamwork B. Spontaneity and surprise C. Caution and superior size D. Diversion and physical outlets

A. Practice and teamwork

When focusing on addressing issues identified by the 2000 Institute of Medicine report, the nursing faculty will access information associated with which initiative? A. Quality and Safety in Nursing Education B. Competency Outcomes and Performance Model (COPA) C. The National Organization of Nurse Practitioner Faculties (NONPF) D. Academic Center for Evidence-Based Practice (ACE)

A. Quality and Safety in Nursing Education

The nurse is caring for a patient with hypotension caused by neurogenic shock. What action should the nurse take to reduce the risk of developing orthostatic hypotension? A. Raise the head of the bed slowly B. Elevate the foot of the bed 30 degrees C. Place in the supine position with the head flat D. Keep the head of the bed elevated at 60 degrees

A. Raise the head of the bed slowly

Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? A. Refer requests and questions related to care to the case manager. B. Encourage the patient to discuss feelings of fear and inferiority. C. Provide negative reinforcement for acting-out behavior. D. Ignore, rather than confront, inappropriate behavior.

A. Refer requests and questions related to care to the case manager

What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder? A. Respect the patient's need for periods of social isolation. B. Prevent the patient from violating the nurse's rights. C. Teach the patient how to select clothing for outings. D. Engage the patient in community activities.

A. Respect the patient's need for periods of social isolation.

What should the nurse who is licensed in Georgia and moves to Oregon should do initially in preparation for seeking a nursing position as a pediatric nurse? A. Review Oregon's nurse practice act related to licensure for endorsement. B. Request application forms to be grandfathered in as a licensed registered nurse in Oregon. C. Request certification in Oregon rather than licensure, so as not to have to retake the NCLEX-RN. D. Contact the American Nurses Credentialing Center to determine whether licensure in Georgia will transfer to Oregon.

A. Review Oregon's nurse practice act related to licensure for endorsement

After repair of an abdominal aortic aneurysm, the nurse notes that the patient does not have popliteal, posterior tibial, or dorsalis pedis pulses. The legs are cool and mottled. Which action is appropriate for the nurse to take first? A. Review the preoperative assessment form for data about the pulses. B. Notify the surgeon and anesthesiologist. C. Document that the pulses are absent and recheck in 30 minutes. D. Elevate the lower extremities on pillows.

A. Review the preoperative assessment form for data about the pulses.

After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions? A. Risk for injury related to physical abuse from partner B. Social isolation related to lack of a community support system C. Ineffective coping related to uneven distribution of power within a relationship D. Deficient knowledge related to resources for escape from an abusive relationship

A. Risk for injury related to physical abuse from partner

What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? A. Risk for other-directed violence B. Risk for self-directed violence C. Impaired social interaction D. Ineffective denial

A. Risk for other-directed violence

A patient diagnosed with borderline personality disorder was hospitalized several times after self-mutilating episodes. The patient remains impulsive. Which nursing diagnosis is the initial focus of this therapy? A. Risk for self-directed violence B. Impaired skin integrity C. Risk for injury D. Powerlessness

A. Risk for self-directed violence

A patient diagnosed with borderline personality disorder was hospitalized several times after multiple episodes of head banging and carving on both wrists. The patient remains impulsive. Which nursing diagnosis is the initial focus of this patient's care? A. Self-mutilation B. Impaired skin integrity C. Risk for injury D. Powerlessness

A. Self-mutilation

A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in de-escalation for this scenario? Select all that apply. A. Stating the expectation that the patient will stay in control B. Asking the patient, "Do you want to go into seclusion?" C. Telling the patient, "You are behaving inappropriately." D. Offering to provide the patient with medication to help E. Speaking in a firm but calm voice

A. Stating the expectation that the patient will stay in control D. Offering to provide the patient with medication to help E. Speaking in a firm but calm voice

Which behavior best demonstrates aggression? A. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart. B. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. C. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." D. Telling the medication nurse, "I am not going to take that, or any other, medication you try to give me."

A. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart.

A patient learns of having a 1 cm abdominal aortic aneurysm. What should the nurse emphasize when discussing the health problem with this patient? A. Stop smoking B. Increase physical activity C. Engage in stress management D. Reduce the intake of saturated fat

A. Stop smoking

A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic? A. Support the victim to separate issues of vulnerability from blame. B. Emphasize the importance of using a buddy system in public places. C. Reassure the victim that the outcome of the situation will be positive. D. Pose questions about the rape and help the patient explore why it happened.

A. Support the victim to separate issues of vulnerability from blame

A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome? A. The acute phase reaction B. The long-term phase C. A delayed reaction D. The angry stage

A. The acute phase reaction

A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? A. The patient has new onset weakness of both legs. B. The patient complains of chronic severe back pain. C. The patient starts to cry and says, "I feel hopeless." D. The patient expresses anxiety about having surgery.

A. The patient has new onset weakness of both legs.

A patient presents to the ED complaining of severe substernal chest pressure radiating to his left shoulder and back that started about 16 hours ago. The patient delayed coming to the ED hoping the pain would go away. The patient's 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK MB are both elevated. The hospital does not have the capability for percutaneous coronary intervention. Thrombolysis is one possible treatment. Based on these data, the nurse correctly comes to what conclusion? A. The patient is not a candidate for thrombolysis. B. The patient's history makes him a good candidate for thrombolysis. C. Thrombolysis is appropriate for a candidate having a non-Q wave MI. D. Thrombolysis should be started immediately.

A. The patient is not a candidate for thrombolysis. (must be symptomatic for less than 12 hours)

When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? A. The patient takes warfarin (Coumadin) daily. B. The patient's blood pressure is 162/94 mm Hg. C. The patient is unable to remember the accident. D. The patient complains of a severe dull headache.

A. The patient takes warfarin (Coumadin) daily.

What statement presents accurate information concerning nurse practice acts? A. They are written and passed by state legislators. B. They cannot be influenced by special interest groups. C. They reflect the primary concerns of professional nurses. D. They are affected by other interprofessional practices.

A. They are written and passed by state legislators.

The nurse is administering medications to a patient. Which actions by the nurse during this process are consistent with promoting safe delivery of care (select all that apply)? A. Throws away a medication that is not labeled B. Uses a hand sanitizer before preparing a medication C. Identifies the patient by the room number on the door D. Checks lab test results before administering a diuretic E. Gives the patient a list of current medications upon discharge

A. Throws away a medication that is not labeled B. Uses a hand sanitizer before preparing a medication D. Checks lab test results before administering a diuretic E. Gives the patient a list of current medications upon discharge

A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the evaluation phase of the nursing process? A. To determine if interventions have been effective in meeting patient outcomes B. To document the nursing care plan in the progress notes of the medical record C. To decide whether the patient's health problems have been completely resolved D. To establish if the patient agrees that the nursing care provided was satisfactory

A. To determine if interventions have been effective in meeting patient outcomes

The nurse is reviewing a client's laboratory results. The nurse correlates elevations in which values as risk factors for atherosclerosis (Select all that apply.) A. Total cholesterol, 280 mg/dL B. High-density cholesterol, 50 mg/dL C. Triglycerides, 200 mg/dL D. Serum albumin, 4 g/dL E. Low-density cholesterol, 160 mg/dL

A. Total cholesterol, 280 mg/dL C. Triglycerides, 200 mg/dL E. Low-density cholesterol, 160 mg/dL

When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? A. Urinary catheter care B. Nasogastric (NG) tube feeding C. Continuous cardiac monitoring D. Maintain a warm room temperature E. Administration of H2 receptor blockers

A. Urinary catheter care C. Continuous cardiac monitoring D. Maintain a warm room temperature E. Administration of H2 receptor blockers

A nurse practicing in the early 1900s was awarded a permissive license. What action was required by this type of license? A. While licensure was voluntary; if you failed the examination, you could not use the title RN. B. To qualify for licensure, you were required to complete a maximum of 1 year of formalized nurse training. C. All candidates were required to take and pass an exam provided by the state board of nursing. D. The nurses were required to select either a written or an oral form of the licensure examination.

A. While licensure was voluntary; if you failed the examination, you could not use the title RN.

A nurse works a rape telephone hotline. Communication with potential victims should focus on: A. explaining immediate steps victims should take. B. providing callers with a sympathetic listener. C. obtaining information for law enforcement. D. arranging counseling.

A. explaining immediate steps victims should take.

An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult: A. expresses frustration verbally instead of physically. B. explains the rationale for behaviors to the victim. C. identifies three personal strengths. D. agrees to seek counseling.

A. expresses frustration verbally instead of physically.

The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who: A. have been abused. B. are attention seeking. C. have eating disorders. D. are developmentally delayed.

A. have been abused.

A patient with a history of a 4-cm abdominal aortic aneurysm is admitted to the emergency department with severe back pain and bilateral flank ecchymoses. The vital signs are blood pressure (BP) 90/58, pulse 138, and respirations 34. The nurse plans interventions for the patient based on the expectation that treatment will include A. immediate surgery. B. a STAT angiogram. C. a paracentesis when vital signs are stabilized with fluid replacement. D. admission to intensive care for observation and diagnostic testing.

A. immediate surgery

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the day room. While following the patient into the day room, the nurse should: A. make sure there is adequate physical space between the nurse and patient. B. move into a position that places the patient close to the door. C. maintain one arm's-length distance from the patient. D. begin talking to the patient about appropriate behavior.

A. make sure there is adequate physical space between the nurse and patient.

A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to A. prevent falls. B. stabilize mood. C. avoid aspiration. D. improve memory.

A. prevent falls.

The nurse is preparing a community program on the metrics to improve cardiovascular health. What should be included in this program? Select all that apply. A.Healthy diet B. Alcohol intake C. Physical activity D. Smoking cessation E. Lower blood pressure

A.Healthy diet C. Physical activity D. Smoking cessation E. Lower blood pressure

A nurse in the emergency department assesses an unresponsive victim of rape. The victim's friend reports, "That guy gave her salty water before he raped her." Which question is most important for the nurse to ask of the victim's friend? A. "Does the victim have any kidney disease?" B. "Has the victim consumed any alcohol?" C. "What time was she given salty water?" D. "Did you witness the rape?"

B. "Has the victim consumed any alcohol?"

Which statement by a 40-year-old patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? A. "I will return if I feel dizzy or nauseated." B. "I am going to drive home and go to bed." C. "I do not even remember being in an accident." D. "I can take acetaminophen (Tylenol) for my headache."

B. "I am going to drive home and go to bed."

A patient says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your patients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? A. "I'm not comfortable doing that," and then ignore subsequent requests for early medication. B. "I understand that you have pain, but giving medicine too soon would not be safe." C. "I'll have to check with your doctor about that; I will get back to you after I do." D. "It would be unsafe to give the medicine early; none of us will do that."

B. "I understand that you have pain, but giving medicine too soon would not be safe."

Which statement by a patient who is being discharged 5 days after an abdominal aortic aneurysm repair and graft indicates that the discharge teaching has been effective? A. "I will call the doctor if my temperature is higher than 101° F." B. "I will tell my dentist about this surgery the next time I have an appointment." C. "I should not need to take anything but acetaminophen (Tylenol) for my pain." D. "I am eager to get home so that I can pick up my 6-year-old granddaughter."

B. "I will tell my dentist about this surgery the next time I have an appointment."

A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim? A. "Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs." B. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." C. "Do you have any male friends who have also been victims of sexual assault?" D. "Why do you think you became a victim of sexual assault?"

B. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person."

An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention? A. "I hate all of you!" B. "My fingers are tingly." C. "You wait until I tell my lawyer." D. "The other patient started the fight."

B. "My fingers are tingly."

The nurse is providing education to nursing staff on quality care initiatives. Which statement would be the most accurate description of the impact of health care financing on quality care? A. "Hospitals are reimbursed for all costs incurred if care is documented electronically." B. "Payment for patient care is primarily based on clinical outcomes and patient satisfaction." C. "If a patient develops a catheter related infection, the hospital receives additional funding." D. "Because hospitals are accountable for overall care, it is not nursing's responsibility to monitor care delivered by others."

B. "Payment for patient care is primarily based on clinical outcomes and patient satisfaction."

The patient's spouse is feeling overwhelmed about cooking different dinners for the patient and the rest of the family to satisfy a cholesterol reducing diet. Which response by the nurse is best? A. "It will be worth it to have a healthy spouse, won't it?" B. "The low-cholesterol diet is one from which everyone can benefit." C. "As long as you change at least a few things in the diet, it will be okay." D. "You can go on the diet with him, and then let the children eat whatever they want."

B. "The low-cholesterol diet is one from which everyone can benefit."

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best? A. "This type of monitoring system is complex and it is managed by skilled staff." B. "The monitoring system helps show whether blood flow to the brain is adequate." C. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." D. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

B. "The monitoring system helps show whether blood flow to the brain is adequate."

The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement, if made by the student nurse, indicates that teaching was successful? A. "The nursing process is a scientific based method of diagnosing the patient's health care problems." B. "The nursing process is a problem solving tool used to identify and treat patients' health care needs." C. "The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans." D. "The nursing process is used primarily to explain nursing interventions to other health care professionals."

B. "The nursing process is a problem solving tool used to identify and treat patients' health care needs."

A student asks, "What are core competencies?" The nursing instructor demonstrates an understanding of core competencies when providing what response? A. "They are a part of a trend used in nursing education to reduce attrition in prelicensure students." B. "They are the skills necessary to provide for safe, competent nursing practice." C. "They are remediation for students is unable to perform psychomotor skills correctly." D. "They are critical thinking exercises aimed to improve reading and math skills."

B. "They are the skills necessary to provide for safe, competent nursing practice."

The nurse is completing a Mini Mental Status Examination with a patient. What should the nurse ask to evaluate remote memory? A. "Where did you park your car?" B. "Where did you work in the 1970s?" C. "Remember the colors red, green, blue, and yellow." D. "What television show was on this morning during breakfast?"

B. "Where did you work in the 1970s?"

A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as A. 9. B. 11. C. 13 D. 15.

B. 11.

A patient with increased intracranial pressure (ICP) is sensitive to fluid volume shifts. Which approach would be the safest to reduce this patient's cerebral edema? A. Mannitol B. 3% normal saline C. Bacteriostatic saline D. Preservative-free saline

B. 3% normal saline

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO 2 ) 99% on supplemental oxygen at 3 L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the orders, which order is of the highest priority? A. Furosemide 20 mg intravenous push as needed B. 500 mL albumin intravenous infusion C. Decadron 10 mg intravenous push D. Dilantin 50 mg intravenous push

B. 500 mL albumin intravenous infusion

Which situation describes consensual sex rather than rape? A. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. B. A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision. C. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. D. A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient.

B. A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision.

A patient with increased intracranial pressure (ICP) has a body temperature of 100°F. What action should the nurse take to address this temperature elevation? A. Place head in a neutral position B. Administer antipyretic as prescribed C. Auscultate lung sounds and increase fluids D. Send a urine sample for culture and sensitivity

B. Administer antipyretic as prescribed

The primary care provider orders fosphenytoin, 1.5 g intravenous (IV) loading dose for a 75kg patient in status epilepticus. What is the most important action by the nurse? A. Contact the primary care provider to discuss the order. B. Administer drug at a slow infusion rate C. Mix medication with 0.9% normal saline. D. Administer via central line.

B. Administer drug at a slow infusion rate

The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO 2 ) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order should the nurse implement first? A. Obtain stat serum electrolytes. B. Administer lorazepam. C. Obtain stat portable chest x-ray. D. Administer phenytoin.

B. Administer lorazepam.

The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO 2 ) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? A. Administer over 2 minutes. B. Administer over 5 minutes. C. Mix medication with 0.9% normal saline. D. Administer via central line.

B. Administer over 5 minutes.

An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take? A. Ask the family to stay in the waiting room until the initial assessment is completed. B. Allow the family to stay with the patient and briefly explain all procedures to them. C. Refer the family members to the hospital counseling service to deal with their anxiety. D. Call the family's pastor or spiritual advisor to take them to the chapel while care is given.

B. Allow the family to stay with the patient and briefly explain all procedures to them.

A patient is diagnosed with a subarachnoid hemorrhage caused by a cerebral aneurysm that has a wide neck and tortuous vascular anatomy. For which procedure should the nurse prepare teaching material for this patient? A. Aneurysm coiling B. Aneurysm clipping C. Reinforcing aneurysm wall D. Evacuation of the hematoma

B. Aneurysm clipping

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the clients blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) A. Administer pain medication. B. Assess distal pulses every 10 minutes. C. Have the client sign a surgical consent. D. Notify the Rapid Response Team. E. Take vital signs every 10 minutes.

B. Assess distal pulses every 10 minutes. D. Notify the Rapid Response Team. E. Take vital signs every 10 minutes.

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is reporting a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? A. Administer acetaminophen as ordered for the headache. B. Assess for a kinked urinary catheter and assess for bowel impaction. C. Encourage the patient to take slow, deep breaths. D. Notify the physician of the patient's blood pressure.

B. Assess for a kinked urinary catheter and assess for bowel impaction.

Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? A. Cardiac monitoring for bradycardia B. Assessment of respiratory rate and effort C. Application of pneumatic compression devices to legs D. Administration of methylprednisolone (Solu-Medrol) infusion

B. Assessment of respiratory rate and effort

The nurse is collecting data on a patient with an aortic aneurysm. Which manifestation should the nurse expect to find? A. Paralysis B. Back pain C. Chest pain D. Ankle edema

B. Back pain

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? A. A 4-ounce steak, French fries, iceberg lettuce B. Baked chicken breast, broccoli, tomatoes C. Fried catfish, cornbread, peas D. Spaghetti with meat sauce, garlic bread

B. Baked chicken breast, broccoli, tomatoes

A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? (Select all that apply.) A. Reclusive behavior B. Callous attitude C. Perfectionism D. Aggression E. Clinginess f. Anxiety

B. Callous attitude D. Aggression

The nurse is preparing a patient for insertion of an intraventricular catheter intracranial pressure (ICP) monitoring device. What is an advantage of this device? A. Must be inserted in the operating room B. Catheter tip located in the lateral ventricle C. Less mechanical drift of the measurement over time D. Lower rate of infection because of no fluid reservoir

B. Catheter tip located in the lateral ventricle

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? A. Have the patient gently blow the nose. B. Check the drainage for glucose content. C. Teach the patient that rhinorrhea is expected after a head injury. D. Obtain a specimen of the fluid to send for culture and sensitivity.

B. Check the drainage for glucose content.

After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome? A. Decreased motor activity B. Confusion and disbelief C. Flashbacks and dreams D. Fears and phobias

B. Confusion and disbelief

An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important? A. The patient's vital signs B. Consent signed by the patient C. Supervision and credentials of the examiner D. Storage location of the patient's personal effects

B. Consent signed by the patient

A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication? A. Aoritis B. Deep vein thrombosis C. Thoracic aortic aneurysm D. Raynauds disease

B. Deep vein thrombosis

What actions should a nurse who wishes to practice in another state take initially? (Select all that apply.) A. Prepare to retake the NCLEX-RN for that state. B. Determine whether the state is a compact state. C. Inquire about obtaining licensure by endorsement. D. Prepare to revoke the original licensure. E. Petition the state to be "Grandfathered" a state license.

B. Determine whether the state is a compact state. C. Inquire about obtaining licensure by endorsement.

A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? A. Carbamazepine (Tegretol) B. Dexmedetomidine (Precedex) C. Diazepam (Valium) D. Mannitol (Osmitrol)

B. Dexmedetomidine (Precedex)

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? A. Document the increase in intracranial pressure. B. Ensure that the patient's neck is in neutral position. C. Notify the health care provider about the change in pressure. D. Increase the rate of the prescribed propofol (Diprivan) infusion.

B. Ensure that the patient's neck is in neutral position.

The nurse is preparing teaching material to help a patient with atherosclerosis manage lifestyle changes. What should the nurse emphasize in this teaching? A. Limit cigarette smoking B. Follow a low-fat, low-cholesterol diet C. Consider adopting an active lifestyle D. Take medications when symptoms occur

B. Follow a low-fat, low-cholesterol diet

A patient has a history of impulsively acting out anger by striking others. Select the most appropriate intervention for avoiding similar incidents. A. Teach the patient about herbal preparations that reduce anger. B. Help the patient identify incidents that trigger impulsive anger. C. Explain that restraint and seclusion will be used if violence occurs. D. Offer one-on-one supervision to help the patient maintain control.

B. Help the patient identify incidents that trigger impulsive anger.

What feelings are most commonly experienced by nurses working with abusive families? A. Outrage toward the victim and discouragement regarding the abuser B. Helplessness regarding the victim and anger toward the abuser C. Unconcern for the victim and dislike for the abuser D. Vulnerability for self and empathy with the abuser

B. Helplessness regarding the victim and anger toward the abuser

Which assessment finding presents the greatest risk for violent behavior directed at others? A. Severe agoraphobia B. History of spousal abuse C. Bizarre somatic delusions D. Verbalized hopelessness and powerlessness

B. History of spousal abuse

After surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action should the nurse take? A. Administer IV diuretic medications. B. Increase the IV fluid infusion per protocol. C. Increase the infusion rate of IV vasodilators. D. Elevate the head of the patient's bed to 45 degrees.

B. Increase the IV fluid infusion per protocol.

The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse? A. Stop the infusion for 5 minutes. B. Increase the dose by 2.5 mg/hr. C. Notify the physician of the BP. D. Begin weaning the infusion.

B. Increase the dose by 2.5 mg/hr.

Several hours after a patient had an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 45 mL. What should the nurse anticipate will be prescribed? A. Hemoglobin count B. Increased IV fluids C. Additional antibiotics D. Serum creatinine level

B. Increased IV fluids

What demographic change has the greatest impact on the practice of nurses, nursing students, and faculty? A. The increasing percentage of adults aged 50-55 years B. Increasing numbers of obese children and adults C. Changes responsible for families becoming more nuclear D. Social programs that are essentially eliminating poverty

B. Increasing numbers of obese children and adults

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? A. Keep the head of bed elevated. B. Insert nasogastric tube to low suction. C. Turn patient side to side every 2 hours D. Apply cold packs intermittently to face.

B. Insert nasogastric tube to low suction.

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? A. Teach the patient the Credé method. B. Instruct the patient how to self-catheterize. C. Catheterize for residual urine after voiding. D. Assist the patient to the toilet every 2 hours.

B. Instruct the patient how to self-catheterize.

A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self management? (Select all that apply.) A. Does not want to purchase a thermometer B. Is allergic to acetaminophen (Tylenol) C. Laughing, says "Strenuous? What's that?" D. Lives alone and is new in town with no friends E. Plans to have a beer and go to bed once home

B. Is allergic to acetaminophen (Tylenol) D. Lives alone and is new in town with no friends E. Plans to have a beer and go to bed once home

A person interested in employment in the health care sector has less than 1 year to devote to education and wants to focus on functional aspects of patient care in a long-term facility. Which type of nursing program should this person request information about? A. Bachelor's degree in nursing (BSN) B. Licensed practical nurse (LPN) C. Associate degree in nursing D. Master's degree in nursing

B. Licensed practical nurse (LPN)

When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? A. Presence of flatus B. Loose, bloody stools C. Hypoactive bowel sounds D. Abdominal pain with palpation

B. Loose, bloody stools

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client? A. Hydroxyzine (Atarax) B. Lorazepam (Ativan) C. Metoclopramide (Reglan) D. Morphine sulfate

B. Lorazepam (Ativan)

The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? A. Keep the neck in the hyperextended position. B. Maintain proper head and neck alignment. C. Prepare for immediate endotracheal intubation. D. Remove cervical collar upon arrival to the ED.

B. Maintain proper head and neck alignment.

What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation? A. Supporting behavioral change B. Maintaining consistent limits C. Monitoring suicide attempts D. Using aversive therapy

B. Maintaining consistent limits

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? A. Maintain body temperature. B. Monitor blood pressure. C. Pad all bony prominences. D. Use proper hand washing.

B. Monitor blood pressure.

Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? A. Record hourly chest tube drainage. B. Monitor fluid intake and urine output. C. Check the abdominal incision for any redness. D. Teach the reason for a prolonged recovery period.

B. Monitor fluid intake and urine output.

A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? A. Benzodiazepine B. Mood stabilizing medication C. Monoamine oxidase inhibitor (MAOI) D. Cholinesterase inhibitor

B. Mood stabilizing medication

The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what? A. Development of an atrial-septal defect B. Myocardial ischemia C. Formation of a pulmonary embolism D. Release of potassium ions from cardiac cells

B. Myocardial ischemia

On which website would a nurse find a list of current compact states that allow for a single license recognized in multiple states? A. National League for Nursing (NLN) B. National Council of State Boards of Nursing (NCSBN) C. American Association of Colleges of Nursing (AACN) D. Commission on Collegiate Nursing Education (CCNE)

B. National Council of State Boards of Nursing (NCSBN)

A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse's priority? A. Complete the physical assessment. B. Notify the health care provider to obtain a seclusion order. C. Document the incident objectively in the patient's medical record. D. Explain to the patient that seclusion will be discontinued when self-control is regained

B. Notify the health care provider to obtain a seclusion order.

A patient recovering from a hemorrhagic stroke has a blood pressure of 90/50 mm Hg. What action should the nurse take? A. Increase the head of the bed B. Notify the health-care provider C. Place the head in a neutral position D. Reassess the pressure in 15 minutes

B. Notify the health-care provider

A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? A. Auscultate for bowel sounds. B. Notify the provider immediately. C. Order an abdominal flat-plate x-ray. D. Palpate the mass and measure its size.

B. Notify the provider immediately

Which assessments will the nurse make to monitor a patient's cerebellar function (select all that apply)? A. Assess for graphesthesia. B. Observe arm swing with gait. C. Perform the finger-to-nose test. D. Check ability to push against resistance. E. Determine ability to sense heat and cold.

B. Observe arm swing with gait. C. Perform the finger-to-nose test.

A patient with neurogenic shock has a sustained heart rate of 38 beats per minute. Based on this observation, for what should the nurse prepare the patient? A. Intravenous fluids B. Pacemaker insertion C. Cardiac catheterization D. Arterial blood gas analysis

B. Pacemaker insertion

Which finding for a patient who has a head injury should the nurse report immediately to the health care provider? A. Intracranial pressure is 16 mm Hg when patient is turned. B. Pale yellow urine output is 1200 mL over the last 2 hours. C. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg. D. Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours.

B. Pale yellow urine output is 1200 mL over the last 2 hours.

What statement accurately describes what it means to practice in a compact state? A. The nurse must abide solely by the practice act of the largest state. B. Patients' rights in relation to the nurse practice act are protected by the mutual recognition model. C. The nurse must pay for a license in all states that participate in the mutual recognition model. D. The nurse must refer to the nurse practice act for the list of skills that can be performed.

B. Patients' rights in relation to the nurse practice act are protected by the mutual recognition model.

The number of reported medical errors demonstrates a need for what priority intervention? A. Simulation experiences B. Performance competency exercises C. Comprehensive instructor-constructed examinations D. Detailed care planning exercises

B. Performance competency exercises

A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? A. Impending brain herniation B. Poor prognosis and cognitive function C. Probable complete recovery D. Unable to tell from this information

B. Poor prognosis and cognitive function

A patient is diagnosed with an abdominal aneurysm measuring 5 cm. Which teaching material should the nurse prepare for this patient? A. Dietary changes B. Preoperative and postoperative care C. Actions to reduce high blood pressure D. Activities to prevent aneurysm rupture

B. Preoperative and postoperative care

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) A. Assist the provider to place a central venous access device. B. Prepare for continuous blood pressure and pulse monitoring. C. Administer the client's prescribed beta blocker. D. Give the client nothing by mouth 3 to 6 hours before the procedure. E. Explain to the client that dobutamine will simulate exercise for this examination

B. Prepare for continuous blood pressure and pulse monitoring. D. Give the client nothing by mouth 3 to 6 hours before the procedure. E. Explain to the client that dobutamine will simulate exercise for this examination

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? A. Administer IV furosemide (Lasix). B. Prepare the patient for craniotomy. C. Initiate high-dose barbiturate therapy. D. Type and crossmatch for blood transfusion.

B. Prepare the patient for craniotomy.

An unconscious male patient has just arrived in the emergency department after a head injury caused by a motorcycle crash. Which order should the nurse question? A. Obtain x-rays of the skull and spine. B. Prepare the patient for lumbar puncture. C. Send for computed tomography (CT) scan. D. Perform neurologic checks every 15 minutes.

B. Prepare the patient for lumbar puncture.

Which cerebrospinal fluid analysis result will be most important for the nurse to communicate to the health care provider? A. Specific gravity 1.007 B. Protein 65 mg/dL (0.65 g/L) C. Glucose 45 mg/dL (1.7 mmol/L) D. White blood cell (WBC) count 4 cells/mL

B. Protein 65 mg/dL (0.65 g/L)

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? A. Coordinate the transfer of the patient to the operating room. B. Provide discharge instructions about monitoring neurologic status. C. Transport the patient to radiology for magnetic resonance imaging (MRI). D. Arrange to admit the patient to the neurologic unit for 24 hours of observation.

B. Provide discharge instructions about monitoring neurologic status

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? A. Document the BP and ICP in the patient's record. B. Report the BP and ICP to the health care provider. C. Elevate the head of the patient's bed to 60 degrees. D. Continue to monitor the patient's vital signs and ICP.

B. Report the BP and ICP to the health care provider.

A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which action by the nurse is best? A. Clarify that abusive language will not be tolerated. B. Request that the patient provide input for the plan of care. C. Perform care without responding to the patient's comments. D. Reassure the patient about the competence of the nursing staff.

B. Request that the patient provide input for the plan of care.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? A. Self-awareness enhances the nurse's advocacy role. B. Strong negative feelings interfere with assessment and judgment. C. Strong positive feelings lead to healthy transference with the victim. D. Positive feelings promote the development of sympathy for patients.

B. Strong negative feelings interfere with assessment and judgment.

Nursing legislation is to be current and reviewed annually by specific dates. If a nurse practice act fails to be reviewed, it is automatically rescinded under which law? A. Nurse review act B. Sunset legislation C. Mandatory revocation D. Grandfathering

B. Sunset legislation

A patient with a history of anger and impulsivity was hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolded nursing staff for "not knowing enough to give me pain medicine when I need it." Which nursing intervention would best address this problem? A. Teach the patient to use coping strategies such as deep breathing and progressive relaxation to reduce the pain. B. Talk with the health care provider about changing the pain medication from PRN to patient-controlled analgesia. C. Tell the patient that verbal assaults on nurses will not shorten the wait for analgesic medication. D. Talk with the patient about the risks of dependency associated with overuse of analgesic medication.

B. Talk with the health care provider about changing the pain medication from PRN to patient-controlled analgesia.

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? A. Pulse 102 beats/min B. Temperature 101.6° F C. Intracranial pressure 15 mm Hg D. Mean arterial pressure 90 mm Hg

B. Temperature 101.6° F

A client with a diagnosed abdominal aortic aneurysm (AAA) develops lower back pain radiating to the groin. What is the nurse's interpretation of this information? A. The aneurysm clotted and is obstructing blood flow. B. The aneurysm is expanding and is preparing to rupture. C. The client feels the inflammation of the aneurysm. D. This is a normal sensation associated with an AAA.

B. The aneurysm is expanding and is preparing to rupture.

A nurse uses that health care concern as an example to best describe globalization of health care needs? A. The emergence of epidemic hepatitis A B. The pandemic of H1N1 "swine flu" C. Reemergence of polio D. An increase in chronic illnesses

B. The pandemic of H1N1 "swine flu"

Nurses in Tennessee, Mississippi, and Arkansas gather for a conference related to improving quality and safety in practice and nursing education. They are awarded continuing education (CE) credit for participation and evaluation of the conference. One nurse from California states, "I need these CEs to renew my license." The nurse from Mississippi replies, "You do not need CEs for license renewal or advance practice certification renewal." Which statement about CEs would help these nurses? A. All states require proof of continuing education for renewal of license with the number of hours varying. B. The purpose of continuing education is to ensure competence of the workforce after graduation, but each state determines if CEs are required. C. Continuing education is required if nurses work across state lines. D. Initial licensure provides evidence of a minimum safety and competence, so it is illegal for states to require continuing education for renewal of license.

B. The purpose of continuing education is to ensure competence of the workforce after graduation, but each state determines if CEs are required.

When preparing to complete a competency examination involving a neurologic assessment in a simulation laboratory, the nurse reviews the critical elements, which consist of what components? A. The steps that propose a risk of injury or death to a client B. The required criteria incorporated into the assessment for the desired outcome C. The fundamental strategies unique to complex dynamic care environments D. The objective data used to determine the likelihood that the client will recover

B. The required criteria incorporated into the assessment for the desired outcome

A group of registered nurses with associate nursing (and) degrees are concerned that the minimum educational standard for licensure as a registered nurse is being raised to the bachelor's (BSN) level. After contacting the American Nurses Association, they learn they will be "grandfathered" in. Under the "grandfather clause," what action will be required of nurses with associate degrees? A. They will be required to complete a bridge program to earn a BSN and then be tested only on material that was not part of the ASN curriculum. B. They will continue to use the title "registered nurse" earned by their original success with the licensure process. C. They will have 10 years to obtain a BSN or the license will be revoked. D. They will use whatever title is established by their state's board of nursing for associate degree nurses.

B. They will continue to use the title "registered nurse" earned by their original success with the licensure process.

Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink? A. Barium swallow B. Transesophageal echocardiogram C. MUGA scan D. Stress test

B. Transesophageal echocardiogram

What was the first university to establish a department of nursing to offer nursing graduates a baccalaureate degree? A. Columbia Teachers College B. Yale University C. Harvard University D. The New York Regents Program

B. Yale University

An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the dayroom. The nurse should enter the day room: A. and say, "Would you like to come to your room and take some medication your health care provider prescribed for you?" B. accompanied by 3 staff members and say, "Please come to your room so I can give you some medication that will help you regain control." C. and place the patient in a basket hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." D. accompanied by a male security guard and tell the patient, "Come to your room willingly so I can give you this medication, or the guard and I will take you there."

B. accompanied by 3 staff members and say, "Please come to your room so I can give you some medication that will help you regain control."

A 69-year old patient is admitted to the hospital for elective repair of an abdominal aortic aneurysm. The history includes hypertension for 25 years, hyperlipidemia for 15 years, and smoking for 50 years. The patient asks the nurse what caused the aneurysm. The nurse's best response includes the information that A. congenital weakness of arterial walls eventually results in an aneurysm. B. atherosclerotic plaques damage the artery and may lead to aneurysms. C. chronic infections of blood vessel walls may have contributed to the aneurysm. D. uncontrolled hypertension, hyperlipidemia, and smoking caused the aneurysm.

B. atherosclerotic plaques damage the artery and may lead to aneurysms.

When auscultating over the patient's abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a A. thrill. B. bruit. C. murmur. D. normal finding.

B. bruit.

A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should: (select all that apply) A. arrange for the victim to shower. B. explain that bathing destroys evidence. C. give the victim a basin of water and towels. D. offer the victim a shower after evidence is collected. E. explain that bathing facilities are not available in the emergency department.

B. explain that bathing destroys evidence. D. offer the victim a shower after evidence is collected.

The nurse will explain to the patient who has a T2 spinal cord transection injury that A. use of the shoulders will be limited. B. function of both arms should be retained. C. total loss of respiratory function may occur. D. tachycardia is common with this type of injury.

B. function of both arms should be retained.

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have A. expressive aphasia. B. impaired judgment. C. right-sided weakness. D. difficulty swallowing.

B. impaired judgment.

A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is A. nonadherence. B. impaired social interaction. C. disturbed personal identity. D. diversional activity deficit.

B. impaired social interaction

An unconscious teenager is treated in the emergency department. The teenager's friends suspect a rape occurred at a party. Priority action by the nurse should focus on: A. preserving rape evidence. B. maintaining physiologic stability. C. determining what drugs were ingested. D. obtaining a description of the rape from a friend.

B. maintaining physiologic stability

A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge? The patient will: A. facilitate counseling for the abuser. B. name two community resources for help. C. demonstrate insight into the abusive relationship. D. reexamine cultural beliefs about marital commitment.

B. name two community resources for help.

When the nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, the information that is most significant when the nurse is assessing for the return of peristalsis is A. absence of abdominal distention. B. passing of flatus with ambulation. C. dark brown nasogastric (NG) tube drainage. D. moderate abdominal tenderness.

B. passing of flatus with ambulation

Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are A. affable, generous. B. perfectionist, inflexible. C. suspicious, holds grudges D. dramatic speech, impulsive.

B. perfectionist, inflexible.

A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should A. maintain a stern and authoritarian affect. B. provide care in a matter-of-fact manner. C. encourage the patient to express anger. D. be very rigid and challenging.

B. provide care in a matter-of-fact manner.

A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person's rights, the nurse should: A. say, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." B. provide written information about physical and emotional reactions the person may experience. C. explain the need and importance of infectious disease and pregnancy tests. D. give verbal information about legal resources in the community.

B. provide written information about physical and emotional reactions the person may experience.

When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to A. drive a car with powered hand controls. B. push a manual wheelchair on a flat surface. C. turn and reposition independently when in bed. D. transfer independently to and from a wheelchair.

B. push a manual wheelchair on a flat surface.

A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be assessed as A. denial. B. splitting. C. defensive. D. reaction formation.

B. splitting

A nursing action that is indicated for the collaborative problem of potential complication: cardiac dysrhythmia in a patient who has had a repair of a descending thoracic aortic aneurysm is to A. assess level of consciousness and orientation hourly. B. titrate oxygen to keep O2 saturation greater than 90%. C. turn the patient every 1 to 2 hours while on bed rest. D. monitor hourly fluid intake and urine output levels.

B. titrate oxygen to keep O2 saturation greater than 90%.

A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about A. low back pain. B. trouble swallowing. C. abdominal tenderness. D. changes in bowel habits.

B. trouble swallowing.

The nurse is providing discharge education to a client after repair of an abdominal aortic aneurysm (AAA). What priority instruction does the nurse include? A. "No restrictions on driving your car are necessary." B. "Avoid sleeping on your left side for 6 weeks." C. "Avoid lifting heavy objects for about 3 months." D. "You will have a distended abdomen for 2 weeks."

C. "Avoid lifting heavy objects for about 3 months."

Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? A. "I think you are the best nurse on the unit." B. "I'm never going to get high on drugs again." C. "I felt empty and wanted to hurt myself, so I called you." D. "I hate my mother. I called her today, and she wasn't home."

C. "I felt empty and wanted to hurt myself, so I called you."

A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: A. "What is going on?" B. "Please be quiet and sit down in this chair immediately." C. "I'd like to talk with you about how you're feeling right now." D. "You must go to your room and try to get control of yourself."

C. "I'd like to talk with you about how you're feeling right now."

A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful? A. "I have a rash on my buttocks. It itches all the time." B. "Now I know what I did that triggered the attack on me." C. "I'm sleeping better although I still have an occasional nightmare." D. "I have lost 8 pounds since the attack, but I needed to lose some weight."

C. "I'm sleeping better although I still have an occasional nightmare."

A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse will say: A. "You must come away from the door." B. "You have been a widow for many years." C. "You want to go home to prepare your husband's dinner?" D. "Your husband gets angry if you do not have dinner ready on time?"

C. "You want to go home to prepare your husband's dinner?"

The primary care provider has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The orders are for 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24-hour dose for the 70-kg patient? A. 2478 mg B. 5000 mg C. 10,794 mg D. 12,750 mg

C. 10,794 mg The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg ´ 70 kg) + (5.4 mg ´ 70 kg) ´ 23 hours = 10,794 mg.

After receiving report, which patient admitted to the emergency department should the nurse assess first? A. 67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse B. 58-year-old who is taking anticoagulants for atrial fibrillation and has black stools C. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain D. 39-year-old who has right calf tenderness, redness, and swelling after a long plane ride

C. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO 2 ) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5° F. Which order should the nurse institute first? A. Blood cultures (2 specimens) for temperature > 101° F B. Acetaminophen 650 mg per rectum C. 500 mL albumin infusion intravenously D. Decadron 20 mg intravenous push every 4 hours

C. 500 mL albumin infusion intravenously

A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg.; blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? A. 54 mm Hg B. 72 mm Hg C. 90 mm Hg D. 126 mm Hg

C. 90 mm Hg CPP = MAP - ICP. In this case, CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg.

The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. The patient's Glasgow Coma Score is 3 and intermittently withdraws when painful stimuli are introduced. The patient is ventilator dependent and occasionally takes a spontaneous breath. The primary care provider explains to the family that the patient has severe neurological impairment and it is not expected that the patient will ever recover consciousness. What concept does this situation depict? A. An organ donor B. Brain death C. A persistent vegetative state D. Terminally ill

C. A persistent vegetative state

The nurse is reinforcing teaching provided to a patient with an aneurysm. Which patient statement indicates correct understanding of a dissecting aneurysm? A. An outpouching of one side of the arterial wall. B. A communication between an artery and a vein. C. A separation of the inner layer of the arterial wall. D. An enlargement of the entire circumference of the artery.

C. A separation of the inner layer of the arterial wall.

The nurse is caring for an older adult patient who had surgery to repair a fractured hip. The patient needs continued nursing care and physical therapy to improve mobility before returning home. The nurse will help to arrange for transfer of this patient to which facility? A. A skilled care facility B. A residential care facility C. A transitional care facility D. An intermediate care facility

C. A transitional care facility

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, "That patient should not be allowed to get away with that behavior." Which response poses the greatest barrier to the nurse's ability to provide therapeutic care? A. Startle reactions B. Difficulty sleeping C. A wish for revenge D. Preoccupation with the incident

C. A wish for revenge

Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? A. A support group B. A mental health center C. A women's shelter D. Vocational counseling

C. A women's shelter

Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient's needs and maintain a therapeutic milieu? A. Ability to achieve true intimacy B. Flexibility and adaptability to stress C. Ability to provoke interpersonal conflict D. Inability to develop trusting relationships

C. Ability to provoke interpersonal conflict

The advanced practice nurse who is seeking information about requirements for practice in a specialized area should contact what nursing organization? A. American Nurses Association (ANA) B. National League for Nursing (NLN) C. American Nurses Credentialing Center (ANCC) D. National Council of State Boards of Nursing (NCSBN)

C. American Nurses Credentialing Center (ANCC)

The nurse is caring for a patient with an abdominal aortic aneurysm. Which statement indicates that the patient understands this condition? A. A blood clot in a vein. B. An incompetent valve in a large vein. C. An outpouching in the wall of an artery. D. A deposit of plaque in the wall of an artery.

C. An outpouching in the wall of an artery.

A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? A. Check for a fecal impaction. B. Give the prescribed analgesic. C. Assess the blood pressure (BP). D. Notify the health care provider.

C. Assess the blood pressure (BP)

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia? A. Support selection of a high-protein diet. B. Discuss options for sexuality and fertility. C. Assist in planning a prescribed bowel program. D. Use quad coughing to strengthen cough efforts.

C. Assist in planning a prescribed bowel program.

Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? A. Narcissistic B. Histrionic C. Avoidant D. Paranoid

C. Avoidant

The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? A. Weak pedal pulses B. Absent bowel sounds C. Blood pressure 137/88 mm Hg D. 25 mL urine output over last hour

C. Blood pressure 137/88 mm Hg

The nurse is concerned that a patient is at high risk for having a stroke. What finding did the nurse use to make this clinical decision? A. BMI 24.8 B. Heart rate 90 bpm C. Blood pressure 182/90 mm Hg D. Pulse oximetry 98% on room air

C. Blood pressure 182/90 mm Hg

An adolescent seeks medical care after being in a street fight. Which observation indicates that this patient has sustained a basilar skull fracture? A. Hyperthermia B. Episodic tachycardia C. Bruising around the ears D. Rapid deterioration to comatose

C. Bruising around the ears

A patient is suspected of having an abdominal aortic aneurysm. For which gold standard diagnostic test should the nurse prepare teaching for this client? A. Cardiac MRI B. Abdominal ultrasound C. CT scan with IV contrast D. Transthoracic echocardiography (TTE)

C. CT scan with IV contrast

A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? A. Document intracranial pressure every hour. B. Turn and reposition the patient every 2 hours. C. Check capillary blood glucose level every 6 hours. D. Monitor cerebrospinal fluid color and volume hourly.

C. Check capillary blood glucose level every 6 hours.

A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate? A. Measurement of a patient's urine output by UAP B. Administration of oral medications by LPN/LVN C. Check for the presence of bowel sounds and flatulence by UAP D. Care of a patient with diabetes by RN who usually works on the pediatric unit

C. Check for the presence of bowel sounds and flatulence by UAP

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? A. Client who has been diagnosed with meningitis with a fever of 101° F (38.3° C) B. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) C. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate D. Client who is waiting for subarachnoid bolt insertion with the consent form already signed

C. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate

The nurse is preparing to administer a routine dose of phenytoin. The primary care provider orders phenytoin 500 mg intravenous every 6 hours. What is the best action by the nurse? A. Administer over 2 minutes. B. Administer with 0.9% normal saline intravenous. C. Contact the primary care provider to discuss the order. D. Assess cardiac rhythm.

C. Contact the primary care provider to discuss the order.

A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which intervention uses a cognitive technique to help the patient? A. Wordlessly discontinue the dressing change and then leave the room. B. Stop the dressing change, saying, "Perhaps you would like to change your own dressing." C. Continue the dressing change, saying, "This dressing change is needed so your wound will not get infected." D. Continue the dressing change, saying, "Unfortunately, you have no choice in this because your health care provider ordered this dressing change."

C. Continue the dressing change, saying, "This dressing change is needed so your wound will not get infected."

Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider? A. Back pain that increases with coughing B. Depression about the diagnosis of a tumor C. Decreasing sensation and ability to move the legs D. Anxiety about scheduled surgery to remove the tumor

C. Decreasing sensation and ability to move the legs

Which statements concerning licensure as a registered nurse are correct? (Select all that apply.) A. Nurses who graduate from different types of nursing education programs are granted different types of licenses, those with a baccalaureate degree having the most expanded role. B. A nursing license cannot be revoked, only suspended. C. Each nurse practice act describes requirements for initial licensure. D. It is illegal for states to ask about the mental or physical status of an applicant. E. Students who graduate in the top 10% of their class are exempt from taking the NCLEX-RN for licensure. F. Candidates for licensure must present proof of graduation as required by the state.

C. Each nurse practice act describes requirements for initial licensure. F. Candidates for licensure must present proof of graduation as required by the state.

A patient is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? A. 12-lead electrocardiogram B. Cardiac catheterization C. Echocardiogram D. Electrophysiology study

C. Echocardiogram

An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely? A. Sexual B. Physical C. Emotional D. Economic

C. Emotional

When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? A. It provides an outlet for feelings of anger and frustration. B. It respects the patient's wishes, so assertiveness will develop. C. External controls are necessary due to failure of internal control. D. Anxiety is reduced when staff assumes responsibility for the patient's behavior.

C. External controls are necessary due to failure of internal control.

Which nursing model is referred to as the "class without walls" since it is not limited by geographic location? A. Mobility B. Career ladder (2 + 2) C. External degree D. Second degree

C. External degree

A patient has been admitted to the hospital for surgery and tells the nurse, "I do not feel comfortable leaving my children with my parents." Which action should the nurse take next? A. Reassure the patient that these feelings are common for parents. B. Have the patient call the children to ensure that they are doing well. C. Gather more data about the patient's feelings about the child-care arrangements. D. Call the patient's parents to determine whether adequate child care is being provided.

C. Gather more data about the patient's feelings about the child-care arrangements.

An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving? A. Tension-building B. Acute battering C. Honeymoon D. Stabilization

C. Honeymoon

The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? A. Hyperactive reflex activity below the level of injury B. Involuntary, spastic movements of the arms and legs C. Hypotension, bradycardia, and warm, pink extremities D. Lack of sensation or movement below the level of injury

C. Hypotension, bradycardia, and warm, pink extremities

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? A. Both pressures are high. B. Both pressures are low. C. ICP is high; CPP is normal. D. ICP is high; CPP is low.

C. ICP is high; CPP is normal.

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO 2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? A. Altered cerebral spinal fluid production and reabsorption B. Decreased cerebral blood volume due to vessel constriction C. Increased cerebral blood volume due to vessel dilation D. No effect on cerebral blood flow (PaCO 2 of 60 mm Hg is normal)

C. Increased cerebral blood volume due to vessel dilation

The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathing the patient? A. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure. B. Because the patient is unconscious, complete care as quickly and quietly as possible. C. Inform the patient of the day and time, and what kind of care you are providing. D. Turn the television on to the evening news so that you and the patient can be updated to current events.

C. Inform the patient of the day and time, and what kind of care you are providing.

A nurse is preparing a patient for scheduled transesophageal echocardiography. What action should the nurse perform? A. Instruct the patient to drink 1 liter of water before the test. B. Administer IV benzodiazepines and opioids. C. Inform the patient that she will remain on bed rest following the procedure. D. Inform the patient that an access line will be initiated in her femoral artery.

C. Inform the patient that she will remain on bed rest following the procedure.

The nurse is explaining the development of atherosclerosis to a patient. What should the nurse emphasize as beginning this process? A. Oxidation B. Inflammatory process C. Injury to the vessel wall D. Trapping of low-density lipoproteins

C. Injury to the vessel wall

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? A. Blood pressure B. Oxygen saturation C. Intracranial pressure D. Hemoglobin and hematocrit

C. Intracranial pressure

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? A. Encourage coughing and deep breathing. B. Position the patient with knees and hips flexed. C. Keep the head of the bed elevated to 30 degrees. D. Cluster nursing interventions to provide rest periods.

C. Keep the head of the bed elevated to 30 degrees.

A patient is being evaluated for medication therapy to treat atherosclerosis. For which health problem would a statin be contraindicated? A. Diverticulitis B. Celiac disease C. Liver cirrhosis D. Type 2 diabetes mellitus

C. Liver cirrhosis

When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? A. Presence of flatus B. Hypoactive bowel sounds C. Maroon-colored liquid stool D. Abdominal pain with palpation

C. Maroon-colored liquid stool

The nurse is assessing a patient who sustained a traumatic brain injury several years ago. What finding should the nurse expect when completing the assessment? A. Dysphagia B. Hemiparesis C. Memory loss D. Visual field deficits

C. Memory loss

The nurse is caring for a patient with a diffuse axonal injury. What treatment plan should the nurse expect to be prescribed for this patient? A. Craniotomy B. Wound debridement C. Monitor and observe D. Evacuation of the hematoma

C. Monitor and observe

A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be able to be sexually active. Which initial response by the nurse is best? A. Reflex erections frequently occur, but orgasm may not be possible. B. Sildenafil (Viagra) is used by many patients with spinal cord injury. C. Multiple options are available to maintain sexuality after spinal cord injury. D. Penile injection, prostheses, or vacuum suction devices are possible options.

C. Multiple options are available to maintain sexuality after spinal cord injury.

The NCLEX examination is created and administered by which nursing body? A. American Association of Colleges of Nursing (AACN) B. American Nurses Association (ANA) C. National Council of State Boards of Nursing (NCSBN) D. National League for Nursing (NLN)

C. National Council of State Boards of Nursing (NCSBN)

The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? A. Can ambulate independently B. May have trouble swallowing C. Needs frequent re-orientation D. Will need near-total care

C. Needs frequent re-orientation

A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)? A. Monitor for shortness of breath or fatigue after ambulation. B. Instruct the patient about the need to alternate activity and rest. C. Obtain the patient's blood pressure and pulse rate after ambulation. D. Determine whether the patient is ready to increase the activity level.

C. Obtain the patient's blood pressure and pulse rate after ambulation.

Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? A. Lithium (Eskalith) B. Trazodone (Desyrel) C. Olanzapine (Zyprexa) D. Valproic acid (Depakene)

C. Olanzapine (Zyprexa)

Which scenario predicts the highest risk for directing violent behavior toward others? A. Major depression with delusions of worthlessness B. Obsessive-compulsive disorder; performs many rituals C. Paranoid delusions of being followed by alien monsters D. Completed alcohol withdrawal; beginning a rehabilitation program

C. Paranoid delusions of being followed by alien monsters

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse's anger? A. Offer the waiting spouse a cup of coffee. B. Explain that the patient's condition is not life threatening. C. Periodically provide an update and progress report on the patient. D. Suggest that the spouse return home until the patient's treatment is complete.

C. Periodically provide an update and progress report on the patient.

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? A. Have the patient blow the nose until clear. B. Insert bilateral cotton nasal packing. C. Place a nasal drip pad under the nose. D. Suction the left nares until the drainage clears.

C. Place a nasal drip pad under the nose.

Which information about a 30-year old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? A. Intracranial pressure of 15 mm Hg B. Cerebrospinal fluid (CSF) drainage of 25 mL/hour C. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg D. Cardiac monitor shows sinus tachycardia at 128 beats/minute

C. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg

What is the primary purpose of licensure for professional registered nurses? A. Preventing the misuse of the title nurse B. Demonstrating a specialized body of knowledge C. Protecting the public from physical and emotional harm D. Enhancing recognition for the nursing profession

C. Protecting the public from physical and emotional harm

The nurse is caring for a patient in a barbiturate coma for increased intracranial pressure (ICP). What should the nurse assess to determine this patient's cerebral function? A. Gag reflex B. Glasgow coma scale C. Pupillary size and reaction D. Blood pressure and heart rate

C. Pupillary size and reaction

The nurse is preparing to monitor intracranial pressure (ICP) with a fluid filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) A. Use of a heparin flush solution B. Manually flushing the device "prn" C. Recording ICP as a "mean" value D. Use of a pressurized flush system E. Zero referencing the transducer system

C. Recording ICP as a "mean" value E. Zero referencing the transducer system

What is a nurse's legal responsibility if child abuse or neglect is suspected? A. Discuss the findings with the child's parent and health care provider. B. Document the observation and suspicion in the medical record. C. Report the suspicion according to state regulations. D. Continue the assessment.

C. Report the suspicion according to state regulations.

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? A. Inability to communicate B. Nutritional deficit C. Risk for acquiring an infection D. Risk for skin breakdown

C. Risk for acquiring an infection

As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? A. Reinforce this assertive action by the patient. Leave the medication on the table as requested. B. Respond to the patient, "I'm worried that you might not take it. I'll come back later." C. Say to the patient, "I must watch you take the medication. Please take it now." D. Ask the patient, "Why don't you want to take your medication now?"

C. Say to the patient, "I must watch you take the medication. Please take it now."

Which factor has steadily grown in its negative influence on nursing education and practice? A. The implementation of technology B. The narrowing scope of nursing practice C. Societal displays of incivility D. Distant learning programs

C. Societal displays of incivility

A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patients aneurysm? A. Sudden increase in blood pressure and a decrease in heart rate B. Cessation of pulsating in an aneurysm that has previously been pulsating visibly C. Sudden onset of severe back or abdominal pain D. New onset of hemoptysis

C. Sudden onset of severe back or abdominal pain

The nurse suspects that a patient is experiencing a hemorrhagic stroke from a ruptured cerebral aneurysm. What assessment finding caused the nurse to make this conclusion? A. Slurred speech B. Visual field deficits C. Sudden severe headache D. Lower extremity weakness

C. Sudden severe headache

The charge nurse is observing a new staff nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment? A. The new nurse tests for light touch before testing for pain. B. The new nurse has the patient close the eyes during testing. C. The new nurse asks the patient if the instrument feels sharp. D. The new nurse uses an irregular pattern to test for intact touch.

C. The new nurse asks the patient if the instrument feels sharp.

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse? A. The apical pulse is slightly irregular. B. The patient complains of a headache. C. The patient is more difficult to arouse. D. The blood pressure (BP) increases to 140/62 mm Hg.

C. The patient is more difficult to arouse.

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? A. The staff nurse assesses neurologic status every hour. B. The staff nurse elevates the head of the bed to 30 degrees. C. The staff nurse suctions the patient routinely every 2 hours. D. The staff nurse administers an analgesic before turning the patient.

C. The staff nurse suctions the patient routinely every 2 hours.

The nurse interviews a patient while completing the health history and physical examination. What is the purpose of the assessment phase of the nursing process? A. To teach interventions that relieve health problems B. To use patient data to evaluate patient care outcomes C. To obtain data with which to diagnose patient problems D. To help the patient identify realistic outcomes for health problems

C. To obtain data with which to diagnose patient problems

A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? A. Flattering the nurse B. Lying to other patients C. Verbal abuse of another patient D. Detached superficiality during counseling

C. Verbal abuse of another patient

The nurse is caring for a patient with neurogenic shock. What finding should the nurse expect to assess in this patient? A. Tachycardia B. Hypertension C. Warm dry skin D. Rapid shallow respirations

C. Warm dry skin

A new psychiatric technician says, "Schizophrenia ... schizotypal! What's the difference?" The nurse's response should include which information? A. A patient diagnosed with schizophrenia is not usually overtly psychotic. B. In schizotypal personality disorder, the patient remains psychotic much longer. C. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. D. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

C. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality

Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in: A. poor childrearing that did not teach respect for others. B. automatic thinking leading to cognitive distortions. C. a personality style that externalizes problems. D. delusions that others wish to deliver harm.

C. a personality style that externalizes problems.

What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will A. identify when feeling angry. B. use manipulation only to get legitimate needs met. C. acknowledge manipulative behavior when it is called to his or her attention. D. accept fulfillment of his or her requests within an hour rather than immediately.

C. acknowledge manipulative behavior when it is called to his or her attention

What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: A. identify when feeling angry. B. use manipulation only to get legitimate needs met. C. acknowledge manipulative behavior when it is called to his or her attention. D. accept fulfillment of his or her requests within an hour rather than immediately.

C. acknowledge manipulative behavior when it is called to his or her attention.

The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by A. adherence to a strict moral code. B. manipulative, controlling strategies. C. acting without thought on urges or desires. D. postponing gratification to an appropriate time.

C. acting without thought on urges or desires.

The provider prescribes a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be A. dopamine. B. dobutamine. C. adenosine D. atropine.

C. adenosine

The nurse identifies a nursing diagnosis of risk for altered peripheral tissue perfusion related to bypass graft thrombosis for a patient following an abdominal aneurysm repair. An appropriate intervention to prevent this problem in the immediate postoperative period is to A. use a cooling blanket to maintain the patient's temperature within a normal range to prevent hypercoagulability. B. place the patient in Trendelenburg position to reduce pressure at the suture line and prevent leaking of blood at the site. C. administer IV fluids at a rate to keep the arterial BP within a normal range. D. perform passive range-of-motion (ROM) exercises to the legs hourly to promote venous return.

C. administer IV fluids at a rate to keep the arterial BP within a normal range.

One month ago, a patient diagnosed with borderline personality disorder and a history of self- mutilation began dialectical behavior therapy. Today the patient phones to say, "I feel empty and want to hurt myself." The nurse should A. arrange for emergency inpatient hospitalization. B. send the patient to the crisis intervention unit for 8 to 12 hours. C. assist the patient to choose coping strategies for triggering situations. D. advise the patient to take an antianxiety medication to decrease the anxiety level.

C. assist the patient to choose coping strategies for triggering situations.

Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has: A. complaints of abdominal pain. B. repeated middle ear infections. C. bruises on extremities. D. diarrhea.

C. bruises on extremities.

The patient presents to the ED with sudden, severe sharp chest discomfort, radiating to the back and down both arms, as well as numbness in the left arm. While taking the patient's vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should: A. contact the physician and report the cardiac enzyme results. B. contact the physician and prepare the patient for thrombolytic therapy. C. contact the physician immediately and begin prepping the patient for surgery. D. give the patient aspirin and heparin.

C. contact the physician immediately and begin prepping the patient for surgery.

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as A. flexion withdrawal. B. localization of pain. C. decorticate posturing. D. decerebrate posturing.

C. decorticate posturing.

A 38-year-old patient has returned home following rehabilitation for a spinal cord injury. The home care nurse notes that the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The most appropriate action by the nurse at this time is to A. remind the patient about the importance of independence in daily activities. B. tell the spouse to stop because the patient is able to perform activities independently. C. develop a plan to increase the patient's independence in consultation with the patient and the spouse. D. recognize that it is important for the spouse to be involved in the patient's care and encourage that participation.

C. develop a plan to increase the patient's independence in consultation with the patient and the spouse.

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. The nurse will suspect A. cerebellar injury. B. a brainstem lesion. C. frontal lobe damage. D. a temporal lobe lesion.

C. frontal lobe damage.

Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as A. seductive. B. detached. C. manipulative. D. guilt-producing.

C. manipulative.

Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as: A. seductive. B. detached. C. manipulative. D. guilt-producing.

C. manipulative.

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? A. pH 7.38; PaCO 2 55 mm Hg; HCO 3 22 mEq/L; PaO 2 85 mm Hg B. pH 7.38; PaCO 2 40 mm Hg; HCO 3 24 mEq/L; PaO 2 70 mm Hg C. pH 7.38; PaCO 2 35 mm Hg; HCO 3 24 mEq/L; PaO 2 85 mm Hg D. pH 7.38; PaCO 2 28 mm Hg; HCO 3 26 mEq/L; PaO 2 65 mm Hg

C. pH 7.38; PaCO 2 35 mm Hg; HCO 3 24 mEq/L; PaO 2 85 mm Hg

A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to A. administer humidified oxygen by mask. B. suction the patient's mouth and nasopharynx. C. push upward on the epigastric area as the patient coughs. D. encourage incentive spirometry every 2 hours during the day.

C. push upward on the epigastric area as the patient coughs.

A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by: A. gently touching the patient's arm. B. asking the patient, "What do you need?" C. saying to the patient, "This is a safe place." D. directing the patient to cease the behavior.

C. saying to the patient, "This is a safe place."

A person's spouse filed charges after repeatedly being battered. The person sarcastically says, "I'm sorry for what I did. I need psychiatric help." Which statement by this person supports an antisocial personality disorder? A. "I have a quick temper, but I can usually keep it under control." B. "I've done some stupid things in my life, but I've learned a lesson." C. "I'm feeling terrible about the way my behavior has hurt my family." D. "I hit because I am tired of being nagged. My spouse deserves the beating."

D. "I hit because I am tired of being nagged. My spouse deserves the beating."

The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patient's input. The patient states, "How is this different from what the doctor does?" Which response would be most appropriate for the nurse to make? A. "The role of the nurse is to administer medications and other treatments prescribed by your doctor." B. "The nurse's job is to help the doctor by collecting information and communicating any problems that occur." C. "Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a longer time than the doctor." D. "In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health."

D. "In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health."

The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which statement, if made by the nurse, would be the most accurate? A. "Inferences from clinical research studies are used as a guide." B. "Patient care is based on clinical judgment, experience, and traditions." C. "Data are evaluated to show that the patient outcomes are consistently met." D. "Recommendations are based on research, clinical expertise, and patient preferences."

D. "Recommendations are based on research, clinical expertise, and patient preferences."

The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response. A. "Your plan is not adequate. You could still be raped or sexually assaulted." B. "I am glad you have this excellent safety plan. Would others like to comment?" C. "It's better to walk with someone or call security when you enter or leave a building." D. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

D. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

A patient with atherosclerosis asks why smoking cessation is important. What should the nurse respond to this patient? A. "Tobacco causes atherosclerosis." B. "Tobacco reduces the effects of cholesterol in the body." C. "Tobacco causes the blood pressure to drop and changes the cells within the arteries." D. "Tobacco smoke speeds the growth of atherosclerosis in coronary arteries, aorta, and the legs."

D. "Tobacco smoke speeds the growth of atherosclerosis in coronary arteries, aorta, and the legs."

A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response. A. "Rape can happen anywhere." B. "Blaming yourself increases your anxiety and discomfort." C. "You are right. You should not have been alone on the street at night." D. "You feel as though this would not have happened if you had not been alone."

D. "You feel as though this would not have happened if you had not been alone."

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? A. A 20-year-old patient whose cranial x-ray shows a linear skull fracture B. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13 C. A 40-year-old patient who lost consciousness for a few seconds after a fall D. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

D. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? A. A patient with meningitis complaining of photophobia B. A mechanically ventilated patient with a GCS of 6 C. A patient with bacterial meningitis on droplet precautions D. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F

D. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F

The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? A. Insert bilateral ear plugs. B. Monitor airway patency. C. Maintain neutral head position. D. Apply a small nasal drip pad.

D. Apply a small nasal drip pad.

The nurse is caring for a patient with an intracranial pressure ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol, which assessment finding by the nurse requires further action? A. ICP of 10 mm Hg B. CPP of 70 mm Hg C. GCS score of 5 D. CVP of 2 mm Hg

D. CVP of 2 mm Hg

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? A. Client with cerebral perfusion pressure of 72 mm Hg B. Client who has a Glasgow Coma Scale score of 12 C. Client with a PaCO2 of 36 mm Hg who is on a ventilator D. Client who has a temperature of 102° F (38.9° C)

D. Client who has a temperature of 102° F (38.9° C)

To request licensure to practice in France, a nurse licensed in the United States must engage in what initial step? A. Contacting the Graduates of Foreign Nursing Schools to complete a special examination B. Realizing that licensure in the United States is recognized as sufficient for practice in most countries C. Passing a language proficiency examination for the primary language of that part country is required prior to licensure. D. Contacting the International Council of Nurses (ICN) or the nursing regulatory board of that country

D. Contacting the International Council of Nurses (ICN) or the nursing regulatory board of that country

A nurse is assigned as a case manager for a hospitalized patient with a spinal cord injury. The patient can expect the nurse functioning in this role to perform which activity? A. Care for the patient during hospitalization for the injuries. B. Assist the patient with home care activities during recovery. C. Determine what medical care the patient needs for optimal rehabilitation. D. Coordinate the services that the patient receives in the hospital and at home.

D. Coordinate the services that the patient receives in the hospital and at home.

A new graduate from a master's entry program in nursing announces, "I just passed my clinical nurse leader certification examination." Certification as a clinical nurse leader provides acknowledgement of what nursing achievement? A. Earning the equivalence of a master's level nursing degree B. Attaining entry-level knowledge and skills C. The right to engage in an independent primary nursing practice D. Demonstrating advanced nursing skills and knowledge

D. Demonstrating advanced nursing skills and knowledge

A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I can't talk about it. Nothing happened. I have to forget." What is the patient's present coping strategy? A. Compensation B. Somatization C. Projection D. Denial

D. Denial

The nurse admits a patient to the emergency department with new onset of slurred speech and right sided weakness. What is the priority nursing action to assure effective care? A. Assess for the presence of a headache. B. Assess the patient's general orientation. C. Determine the patient's drug allergies. D. Determine the time of symptom onset.

D. Determine the time of symptom onset.

The nurse is caring for a patient experiencing cardiogenic shock. Which medication should the nurse expect to be prescribed to improve this patient's cardiac output? A. Nitroglycerin B. Morphine sulfate C.Norepinephrine (Levophed) D. Dobutamine hydrochloride (Dobutamine)

D. Dobutamine hydrochloride (Dobutamine)

A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long sleeved shirts. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action? A. Call the police. B. Arrange for hospitalization. C. Call the adult protective agency. D. Document injuries with a body map.

D. Document injuries with a body map.

While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take? A. Teach the patient about aneurysms. B. Notify the hospital rapid response team. C. Instruct the patient to remain on bed rest. D. Document the finding in the patient chart.

D. Document the finding in the patient chart.

Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Monitor the quality and presence of the pedal pulses. B. Teach the patient the signs of possible wound infection. C. Check the lower extremities for strength and movement. D. Help the patient to use a pillow to splint while coughing.

D. Help the patient to use a pillow to splint while coughing.

A patient is scheduled for a transesophageal echocardiogram (TEE). What information should the nurse expect to be provided from this test? A. Cardiac filling pressures B. Urine output 250 mL/2 hours C. Discomfort lying flat for six hours D. Hematoma formation at puncture site

D. Hematoma formation at puncture site

In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].) A. Infuse normal saline at 150 mL/hr. B. Monitor cardiac rhythm and blood pressure. C. Administer O2 using a non-rebreather mask. D. Immobilize the patient's head, neck, and spine. E. Transfer the patient to radiology for spinal computed tomography (CT).

D. Immobilize the patient's head, neck, and spine. C. Administer O2 using a non-rebreather mask. B. Monitor cardiac rhythm and blood pressure. A. Infuse normal saline at 150 mL/hr. E. Transfer the patient to radiology for spinal computed tomography (CT).

A patient recovering from cardiogenic shock is observed walking to the patient lounge. What should the nurse recommend to this patient? A. Call for help when wanting to walk B. Limit sitting out of bed to 30 minutes C. Increase activity by 15 minutes every day D. Important to obtain as much rest as possible

D. Important to obtain as much rest as possible

The nurse documenting the patient's progress in the care plan in the electronic health record before an interdisciplinary discharge conference is demonstrating competency in which QSEN category? A. Patient-centered care B. Quality improvement C. Evidence-based practice D. Informatics and technology

D. Informatics and technology

Which statement accurately describes the focus of the various types of nursing programs? A. Diploma programs focus on family and community, with an emphasis on health promotion. B. Most practicing RNs graduated from diploma programs because this was the first type of RN program. C. Baccalaureate programs focus on technical and hands-on nursing skills in diverse community settings. D. Master's programs such as that for the clinical nurse leader provide entry into practice with a focus on interdisciplinary and bedside nursing care for complex client populations.

D. Master's programs such as that for the clinical nurse leader provide entry into practice with a focus on interdisciplinary and bedside nursing care for complex client populations.

The nurse suspects that a patient in cardiogenic shock is experiencing oxygen deprivation. What would confirm the nurse's suspicion? A. Sudden drop in serum lactate level B. Slowly increasing serum calcium level C. Acute reduction in hemoglobin and hematocrit D. Metabolic acidosis upon arterial blood gas analysis

D. Metabolic acidosis upon arterial blood gas analysis

The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? A. Stimulate the patient hourly. B. Continue to monitor the patient. C. Elevate the head of the bed. D. Notify the primary care provider immediately.

D. Notify the primary care provider immediately.

A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? A. Ensure that informed consent is on the chart. B. Document these findings in the client's record. C. Give the prescribed preprocedure sedation. D. Notify the provider of the findings immediately

D. Notify the provider of the findings immediately

What was the first field of nursing to certify advanced practitioners? A. Adult nurse practitioners B. Nurse-midwifery C. Clinical nurse specialist D. Nurse anesthesia

D. Nurse anesthesia

Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)? A. Complete the initial admission assessment and plan of care. B. Document teaching completed before a diagnostic procedure. C. Instruct a patient about low-fat, reduced sodium dietary restrictions. D. Obtain bedside blood glucose on a patient before insulin administration.

D. Obtain bedside blood glucose on a patient before insulin administration.

The nurse suspects that a patient has atherosclerosis. What finding did the nurse use to make this clinical determination? A. Dizziness B. Headaches C. Nosebleeds D. Pain when walking

D. Pain when walking

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? A. Assesses the client for back pain B. Auscultates over abdominal bruit C. Measures the abdominal girth D. Palpates the abdomen in four quadrants

D. Palpates the abdomen in four quadrants

What term is used to identify that a student nurse's competency is determined based on actual client care rather than traditional testing methods? A. Core practice competencies B. Continuing competence C. Distance learning D. Performance-based assessment

D. Performance-based assessment

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment? A. Interpersonal relationships B. Work responsibilities C. Socialization skills D. Physical injuries

D. Physical injuries

A member of a nursing students study group comments, "We spend some time early in the class discussing key facts then most of the time working through case studies, then practicing on the simulator rather than caring for 'real' patients." This teaching-learning style represents what form of nursing education? A. Skill-based learning B. Objective Structured Clinical Examinations (OSCE) C. Peer-to-peer learning D. Practice-based competency

D. Practice-based competency

A patient is scheduled for a transesophageal echocardiogram (TEE). What information should the nurse expect to be provided from this test? A. Cardiac filling pressures B. Integrity of cardiac arteries C. Heart function during stress D. Presence of clots in the atria

D. Presence of clots in the atria

Which experience is best designed to support a nursing student's preparation for interprofessional team participation? A. Attending a seminar on interprofessional team cooperation B. Completing a preceptorship with an advanced practice nurse C. Carrying for three patients with varying medical diagnoses D. Presenting patient information at the daily care planning meeting

D. Presenting patient information at the daily care planning meeting

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? A. Hyperoxygenate during endotracheal suctioning. B. Elevate the patient's head of the bed 30 degrees. C. Apply bilateral heel protectors after repositioning. D. Provide rest periods between nursing interventions.

D. Provide rest periods between nursing interventions.

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102° F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what are the priority nursing actions? A. Ensure adequate periods of rest between nursing interventions. B. Insert an oral airway and monitor respiratory rate and depth. C. Maintain neutral head alignment and avoid extreme hip flexion. D. Reduce ambient room temperature and administer antipyretics.

D. Reduce ambient room temperature and administer antipyretics.

A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? A. Risk for injury B. Ineffective coping C. Impaired social interaction D. Risk for other-directed violence

D. Risk for other-directed violence