RECALLS 8 - NP5
SITUATION: Light Yagami, 20-years-old, suffers from extreme mood swings from episodes of mania to depression. He cycles between symptoms of mania, normal mood, and depression. He is diagnosed with Bipolar mixed type. -- Which of the following nursing interventions are appropriate for Light who is exhibiting manipulative behavior? Select all that apply. I. Clearly communicate expected behaviors to the client. II. Establish boundaries and make it clear that the client is not in charge of the nursing unit. III. Help the client recognize and implement ways of setting limits on personal behaviors. IV. Follow through with the consequences of behavior in a non-punitive manner. V. Avoid using punitive measures, such as excluding the client from therapy groups, as a way to enforce rules. VI. Engage the client in identifying the consequences of behaving in ways that are considered unacceptable. A. 1, 2, 5, 6 B. 2, 3, 4, 6 C. 1, 3, 4, 6 D. All of the above
1, 3, 4, 5, 6
SITUATION: Nurse Monie is working as a substance abuse nurse in the hospital. She has been taking care of patients with alcohol dependence and drug abuse. The following questions apply. -- Nurse Monie is caring for a patient named Goldie admitted 3 days ago. Goldie has a long history of heavy alcohol use. Which most acute complications should nurse Monie monitor Goldie for? I. Seizures II. Infections III. Gastrointestinal bleeding IV. Pancreatitis V. Delirium tremens A. 1,5 B. 1,2 C. 2,4 D. 3,5
A. 1,5
SITUATION: Raquelle, a 40-year-old female, is admitted to the hospital with complaints of weakness, dizziness, and dry mouth. Her vital signs reveal a blood pressure of 90/60 mmHg, heart rate of 110 beats per minute, and respiratory rate of 22 breaths per minute. Raquelle's medical history includes hypertension, and she takes antihypertensive medications regularly. Nurse Aira suspects fluid volume deficit and plans to initiate appropriate interventions. -- Which assessment finding in Raquelle is consistent with fluid volume deficit? A. Blood pressure of 90/60 mmHg. B. Heart rate of 60 beats per minute. C. Respiratory rate of 12 breaths per minute. D. Presence of hypertension in medical history.
A. Blood pressure of 90/60 mmHg.
SITUATION: Jason, a 7-year-old boy is brought to the pediatric clinic by his parents due to concerns about his behavior at school and home. The parents report that he has difficulty paying attention, is easily distracted, and often fails to finish tasks or follow instructions. The Jason's teacher also notices that he frequently interrupts others, fidgets in his seat, and has difficulty waiting for his turn during classroom activities. The healthcare provider suspects attention-deficit/hyperactivity disorder (ADHD) and plans to conduct a comprehensive assessment. -- Which of the following symptoms is characteristic of inattention in ADHD? A. Difficulty organizing tasks and activities B. Hyperactivity and excessive talking C. Frequent temper outbursts and irritability D. Avoidance of social interactions
A. Difficulty organizing tasks and activities
SITUATION: The newly registered nurse is assigned in the neuro ward of their community hospital where she was tasked to care for patients diagnosed with conditions affecting the neurological system. The following questions apply. -- Frequent neurological monitoring is done to assess for changes in the sensorium of a patient. Which of the following describes if the ICP is untreated and progresses? A. Displacement of brain tissue B. Increase in cerebral circulation and perfusion C. Increase in serum pH D. Improved brain tissue oxygenation
A. Displacement of brain tissue
SITUATION: Maria is a 72-year-old woman living with Alzheimer's disease. Her family has noticed recent changes in her behavior, including increased forgetfulness, difficulty completing familiar tasks, and confusion about time and place. They brought her to the healthcare facility for a check-up. The nurse is conducting an assessment to determine Maria's cognitive status and plan appropriate care. -- Which of the following medications is commonly prescribed to slow down the progression of Alzheimer's disease and improve cognitive function? A. Donepezil (Aricept) B. Memantine (Namenda) C. Lorazepam (Ativan) D. Metoprolol (Lopressor)
A. Donepezil (Aricept)
SITUATION: Nurse Pol comes across patient Maggie, an 18-year-old female client, who has generalized anxiety disorder (GAD). She exhibits uneasiness, wringing of hands, rapid breathing, and has been pacing the hallway for the past 20 minutes -- Nurse Pol places a high regard on lowering Maggie's anxiety level. The nurse should prioritize which action in this situation? A. Encouraging the client to sit down and take deep breaths B. Administering a prescribed anti-anxiety medication. C. Offering the client a warm beverage to help them relax. D. Engaging the client in a conversation about their feelings.
A. Encouraging the client to sit down and take deep breaths
SITUATION: Nurse Wendy is taking care of Young-woo, a 6-year-old child diagnosed with autism spectrum disorder (ASD). The nurse applies her knowledge in helping Young-woo with her daily activities. -- Nurse Wendy is observing Young-woo. Which behavior, when identified by Nurse Wendy, is a common characteristic of ASD? A. Frequent tantrums and outbursts B. Advanced language skills for age C. Extensive eye contact during conversations D. Strong interest in team sports
A. Frequent tantrums and outbursts
SITUATION: The nurse is assigned in the ENT ward of the hospital where he deals with various patients with sensory deficits. The following questions apply. -- A patient of the nurse told him that she has glaucoma. Which of the following assessment findings would suggest a confirmation of this condition? A. Halos around the lights B. Floating spots in the vision C. A yellow haze around everything D. A curtain coming across vision
A. Halos around the lights
SITUATION: Nurse Pol comes across patient Maggie, an 18-year-old female client, who has generalized anxiety disorder (GAD). She exhibits uneasiness, wringing of hands, rapid breathing, and has been pacing the hallway for the past 20 minutes -- Which medication is a commonly used benzodiazepine anxiolytic? A. Lorazepam B. Fluoxetine C. Sertraline D. Venlafaxine
A. Lorazepam
SITUATION: Jason, a 7-year-old boy is brought to the pediatric clinic by his parents due to concerns about his behavior at school and home. The parents report that he has difficulty paying attention, is easily distracted, and often fails to finish tasks or follow instructions. The Jason's teacher also notices that he frequently interrupts others, fidgets in his seat, and has difficulty waiting for his turn during classroom activities. The healthcare provider suspects attention-deficit/hyperactivity disorder (ADHD) and plans to conduct a comprehensive assessment. -- Jason is prescribed pemoline (Cyclert) to manage symptoms. What is the nurse's priority action related to this medication? A. Monitor the child's liver function regularly B. Encourage increased physical activity to enhance medication effectiveness C. Assess for improvement in attention and concentration D. Monitor for signs of gastrointestinal upset
A. Monitor the child's liver function regularly
SITUATION: Nurse Emy is a psychiatric nurse in the hospital. She has patients with eating disorders. The following questions apply. -- Nurse Blank came up with a nursing diagnosis of low self-esteem for a patient diagnosed with an eating disorder. Which of the following would aid in addressing the patient's nursing diagnosis? A. Offer independent decision-making opportunities B. Review previously successful coping strategies C. Provide a quiet environment with decreased stimulation D. Allow the client to remain in a dependent role throughout treatment
A. Offer independent decision-making opportunities
SITUATION: Sherlock, a 60-year-old male, presents to the emergency department with sudden onset vision loss in his left eye. He reports seeing flashes of light and describes a "curtain" blocking his vision. On further assessment, the nurse suspects retinal detachment. The ophthalmologist is on the way to evaluate Sherlock's condition. Nurse John prepares to provide immediate care and educates the client and family about retinal detachment. -- Nurse John is caring for Sherlock who underwent retinal detachment surgery. Which post-operative position should the nurse encourage the client to maintain to promote optimal healing? A. Prone position. B. Supine position with the head elevated. C. Semi-Fowler's position with the legs elevated. D. Sitting position.
A. Prone position.
SITUATION: Trauma Nurse Ian is caring for Vince, a patient who has suffered a severe head injury from falling from a 5-storey building and is at risk for increased intracranial pressure (ICP). -- Which of the following breathing patterns suggests rising intracranial pressure affecting the brain stem? A. Rapid, shallow respirations. B. Slow, regular respirations C. Deep, controlled respirations. D. Normal, rhythmic respirations.
A. Rapid, shallow respirations.
SITUATION: A nurse is assigned in the eye center of the hospital. She is taking care of patients with Cataract. The following questions apply. -- After cataract surgery, what is the most important topic that nurse Ende should discuss to the client? A. Remain in a semi-Fowler's position B. Position the feet higher than the body C. Lie on the operative side D. Place the head in the dependent position
A. Remain in a semi-Fowler's position
SITUATION: The newly registered nurse is assigned in the neuro ward of their community hospital where she was tasked to care for patients diagnosed with conditions affecting the neurological system. The following questions apply. -- A patient had a craniotomy 2 days ago and is now receiving mannitol IV to decrease ICP. which of the following laboratory values should the nurse monitor the client? A. Serum osmolarity B. WBC Count C. Serum cholesterol D. Erythrocyte Sedimentation Rate (ESR)
A. Serum osmolarity
SITUATION: Junior is a 65-year-old male who has been admitted to the emergency department due to complications related to cocaine abuse. His friends found him unconscious at a party and immediately called for help. Junior has a history of substance abuse, primarily cocaine, and has experienced multiple adverse effects related to his drug use. The healthcare team is assessing his condition and planning appropriate care -- Which of the following symptoms is associated with cocaine withdrawal? A. Suicidal ideation B. Increased appetite C. Bradycardia D. Hypersomnia
A. Suicidal ideation
SITUATION: Nurse Monie is working as a substance abuse nurse in the hospital. She has been taking care of patients with alcohol dependence and drug abuse. The following questions apply. -- The HCP ordered Thiamine for a patient of Nurse Monie who is also being treated for alcohol dependence. Which of the following best explains the reason why thiamine is given? A. Thiamine prevents the neuropathy and confusion associated with chronic alcohol use. B. Thiamine reduces the risk of withdrawal seizures. C. Thiamine aids to reverse the malnutrition often associated with alcohol abuse. D. Thiamine improves peripheral circulation.
A. Thiamine prevents the neuropathy and confusion associated with chronic alcohol use.
SITUATION: Nurse Bubba is caring for a patient named Lab, who is diagnosed with Parkinson's Disease (PD). The following questions apply. -- When doing the NCP, nurse Bubba wants to collaborate with the physical therapist for managing the patient's mobility issues. Which of the following goals should be established for the patient with PD? A. To maintain joint flexibility B. To build muscle strength C. To improve muscle endurance D. To reduce ataxia
A. To maintain joint flexibility
SITUATION: The nurse is assigned in the ENT ward of the hospital where he deals with various patients with sensory deficits. The following questions apply. -- A patient of the nurse was diagnosed to have an acute infection of the middle ear. Which of the following supports this diagnosis? A. Unilateral pain in the ear B. Green, foul-smelling drainage C. Sensation of congestion in the ear D. Reports of hearing loss
A. Unilateral pain in the ear
SITUATION: The newly registered nurse is assigned in the neuro ward of their community hospital where she was tasked to care for patients diagnosed with conditions affecting the neurological system. The following questions apply. -- Which should the nurse monitor for improvement if a patient with myasthenic crisis underwent plasmapheresis? A. Vital capacity B. Leg strength C. Ptosis D. Diplopia
A. Vital capacity
SITUATION: Jason, a 7-year-old boy is brought to the pediatric clinic by his parents due to concerns about his behavior at school and home. The parents report that he has difficulty paying attention, is easily distracted, and often fails to finish tasks or follow instructions. The Jason's teacher also notices that he frequently interrupts others, fidgets in his seat, and has difficulty waiting for his turn during classroom activities. The healthcare provider suspects attention-deficit/hyperactivity disorder (ADHD) and plans to conduct a comprehensive assessment. -- One of the drugs used in ADHD is methyphenidate (Ritalin). Jason's parents express concerns about the drug and its potential impact on their child's growth, if prescribed. What is the nurse's best response? A. "Methylphenidate has been shown to cause significant growth delay in most children with ADHD." B. "Growth delay is a potential side effect of methylphenidate, but it occurs only in a small percentage of children." C. "Growth delay is a common side effect of methylphenidate, but it is usually temporary and resolves after discontinuing the medication." D. "Methylphenidate does not have any impact on a child's growth, so y
B. "Growth delay is a potential side effect of methylphenidate, but it occurs only in a small percentage of children."
SITUATION: The nurse is assigned in the ENT ward of the hospital where he deals with various patients with sensory deficits. The following questions apply. -- The nurse will be alerted of possible hearing loss if one of his patients told him which of the following? A. "I clean my ears every day after I take a shower." B. "I keep turning up the sound on my television." C. "My ears hurt, especially when I yawn." D. "I get dizzy when I get up from the chair."
B. "I keep turning up the sound on my television."
SITUATION: Light Yagami, 20-years-old, suffers from extreme mood swings from episodes of mania to depression. He cycles between symptoms of mania, normal mood, and depression. He is diagnosed with Bipolar mixed type. -- Light suddenly takes off all his clothes in the facility's lobby where most of the other clients stay during the day. The nurse knows that setting limits should be done. What would be the most appropriate statement or intervention from the nurse in this situation? A. Ignoring the behavior. B. "Light, let's go to your room and find a shirt and some pants." C. "I've told you many times not to do that anymore, Light. I am disappointed." D. Restrain Light.
B. "Light, let's go to your room and find a shirt and some pants."
SITUATION: Trauma Nurse Ian is caring for Vince, a patient who has suffered a severe head injury from falling from a 5-storey building and is at risk for increased intracranial pressure (ICP). -- Vince becomes agitated when Nurse Ian will not allow him to open the television set in his ward so that he can watch his favorite basketball game. What should the nurse do next? Select all that apply. I. Find a television so the client can view the basketball game. II. Determine if the client's pupils are equal and react to light. III. Ask the client if he has a headache. IV. Administer a sedative A. 1, 3 B. 2, 3 C. 3, 4 D. All of the above.
B. 2, 3
SITUATION: Light Yagami, 20-years-old, suffers from extreme mood swings from episodes of mania to depression. He cycles between symptoms of mania, normal mood, and depression. He is diagnosed with Bipolar mixed type. -- Light who is experiencing acute manic episodes has been prescribed lithium carbonate 500mg three times a day and risperidone 2mg twice daily by the physician. The rationale for this medication regimen is: A. The client's symptoms of acute mania resemble those commonly seen in undiagnosed schizophrenia. B. Antipsychotic medication is prescribed to control behavioral excitement until mood stabilization is achieved. C. The client's compliance with medication may improve if the prescribed medication allows for some experience of hypomania. D. Antipsychotic medication is effective in preventing psychotic symptoms often linked to the use of mood stabilizers.
B. Antipsychotic medication is prescribed to control behavioral excitement until mood stabilization is achieved.
SITUATION: Nurse Pol comes across patient Maggie, an 18-year-old female client, who has generalized anxiety disorder (GAD). She exhibits uneasiness, wringing of hands, rapid breathing, and has been pacing the hallway for the past 20 minutes -- Nurse Pol is conducting an assessment on a Maggie and determines that she has moderate anxiety. Which approach is most appropriate for Nurse Pol to use when questioning Maggie? A. Use open-ended questions to encourage the patient to express their feelings and thoughts about anxiety. B. Ask specific and direct questions to gather detailed information about the patient's anxiety symptoms. C. Avoid asking questions about the patient's anxiety to prevent them from becoming more agitated. D. Use leading questions to guide the patient toward discussing their anxiety triggers.
B. Ask specific and direct questions to gather detailed information about the patient's anxiety symptoms.
SITUATION: Jane, a 72-year-old female, is admitted to the medical-surgical unit for post-operative care after undergoing abdominal surgery. She has a history of diabetes and requires insulin administration. The nurse is responsible for providing various nursing skills to ensure Jane's safety and recovery. -- Jane is prescribed oral medications, including an enteric-coated tablet that should be taken with food. She has difficulty swallowing large tablets. What should the nurse do to assist Jane in taking the medication? A. Crush the tablet and mix it with applesauce. B. Ask the healthcare provider to change the medication form. C. Provide the medication with a small sip of water. D. Cut the tablet into smaller pieces.
B. Ask the healthcare provider to change the medication form.
SITUATION: A nurse is assigned in the eye center of the hospital. She is taking care of patients with Cataract. The following questions apply. -- Which of the following should nurse Ende instruct the patient to avoid the increase of intraocular pressure after the surgery? A. Lying supine B. Coughing C. Deep breathing D. Ambulation
B. Coughing
SITUATION: A nurse is assigned in the eye center of the hospital. She is taking care of patients with Cataract. The following questions apply. -- What is the expected outcome if the patient is to instill phenylephrine hydrochloride prior to cataract surgery? A. Dilation of the pupil and blood vessel B. Dilation of the pupil and constriction of the blood vessels C. Constriction of the pupil and constriction of blood vessels D. Constriction of the pupil and dilation of the blood vessels
B. Dilation of the pupil and constriction of the blood vessels
SITUATION: Junior is a 65-year-old male who has been admitted to the emergency department due to complications related to cocaine abuse. His friends found him unconscious at a party and immediately called for help. Junior has a history of substance abuse, primarily cocaine, and has experienced multiple adverse effects related to his drug use. The healthcare team is assessing his condition and planning appropriate care -- Which organ is primarily responsible for metabolizing and eliminating drugs like cocaine from the body? A. Kidneys B. Liver C. Lungs D. Heart
B. Liver
SITUATION: Maria is a 72-year-old woman living with Alzheimer's disease. Her family has noticed recent changes in her behavior, including increased forgetfulness, difficulty completing familiar tasks, and confusion about time and place. They brought her to the healthcare facility for a check-up. The nurse is conducting an assessment to determine Maria's cognitive status and plan appropriate care. -- Which cognitive assessment tool is specifically designed to evaluate the cognitive status of individuals with Alzheimer's disease? A. Montreal Cognitive Assessment (MoCA) B. Mini-Mental State Examination (MMSE) C. Clock Drawing Test (CDT) D. Geriatric Depression Scale (GDS)
B. Mini-Mental State Examination (MMSE)
SITUATION: Jane, a 72-year-old female, is admitted to the medical-surgical unit for post-operative care after undergoing abdominal surgery. She has a history of diabetes and requires insulin administration. The nurse is responsible for providing various nursing skills to ensure Jane's safety and recovery. -- Jane is prescribed to receive a subcutaneous injection of enoxaparin for deep vein thrombosis prophylaxis. What technique should the nurse use when administering the injection? A. Insert the needle at a 90-degree angle into the muscle. B. Pinch the skin and insert the needle at a 45-degree angle. C. Insert the needle with a quick, dart-like motion. D. Administer the injection into the fatty tissue of the abdomen.
B. Pinch the skin and insert the needle at a 45-degree angle.
SITUATION: Raquelle, a 40-year-old female, is admitted to the hospital with complaints of weakness, dizziness, and dry mouth. Her vital signs reveal a blood pressure of 90/60 mmHg, heart rate of 110 beats per minute, and respiratory rate of 22 breaths per minute. Raquelle's medical history includes hypertension, and she takes antihypertensive medications regularly. Nurse Aira suspects fluid volume deficit and plans to initiate appropriate interventions. -- What intervention is the priority for the nurse to manage Raquelle's fluid volume deficit? A. Administering intravenous diuretics. B. Providing oral rehydration solutions. C. Encouraging increased salt intake. D. Restricting fluid intake.
B. Providing oral rehydration solutions.
SITUATION: Light Yagami, 20-years-old, suffers from extreme mood swings from episodes of mania to depression. He cycles between symptoms of mania, normal mood, and depression. He is diagnosed with Bipolar mixed type. -- Light is experiencing a manic episode. Which nursing intervention is the highest priority during this phase? A. Encouraging the patient to engage in physical exercise. B. Providing the patient with a quiet and calming environment. C. Administering an antipsychotic medication to control agitation. D. Encouraging the patient to participate in group therapy sessions.
B. Providing the patient with a quiet and calming environment.
SITUATION: Raquelle, a 40-year-old female, is admitted to the hospital with complaints of weakness, dizziness, and dry mouth. Her vital signs reveal a blood pressure of 90/60 mmHg, heart rate of 110 beats per minute, and respiratory rate of 22 breaths per minute. Raquelle's medical history includes hypertension, and she takes antihypertensive medications regularly. Nurse Aira suspects fluid volume deficit and plans to initiate appropriate interventions. -- During Raquelle's care, Nurse Aira plans to monitor her intake and output (I&O) closely. Which observation requires immediate attention? A. Raquelle's urinary output is 300 mL over 4 hours. B. Raquelle drinks 1 liter of water throughout the day. C. Raquelle's nasogastric tube output is 50 mL in 2 hours. D. Raquelle's stool output is 200 grams in 6 hours.
B. Raquelle drinks 1 liter of water throughout the day.
SITUATION: Raquelle, a 40-year-old female, is admitted to the hospital with complaints of weakness, dizziness, and dry mouth. Her vital signs reveal a blood pressure of 90/60 mmHg, heart rate of 110 beats per minute, and respiratory rate of 22 breaths per minute. Raquelle's medical history includes hypertension, and she takes antihypertensive medications regularly. Nurse Aira suspects fluid volume deficit and plans to initiate appropriate interventions. -- Nurse Aira reviews Raquelle's laboratory results, and her blood reports show elevated blood urea nitrogen (BUN) and hematocrit levels. What do these findings indicate in the context of fluid volume deficit? A. Raquelle is experiencing fluid volume excess. B. Raquelle's kidney function is impaired. C. Raquelle is at risk of developing anemia. D. Raquelle has increased circulating blood volume
B. Raquelle's kidney function is impaired.
SITUATION: Student Nurse Louisse is about to take the board exam in November 2023. She should be knowledgeable of the different neurologic disorders that are commonly asked by the examiners. The following questions apply -- The relative of the patient with MS asked the nurse how she can be of help to her aunt. Which of the following would be the most beneficial? A. Psychotherapy B. Regular exercise C. Day care D. Weekly visits by other persons with MS
B. Regular exercise
SITUATION: The nurse is assigned in the ENT ward of the hospital where he deals with various patients with sensory deficits. The following questions apply. -- The nurse was in a local park when he noticed a teenager who accidentally fell on a stick and was lodged in his eye. She is correct when she did which of the following at the scene? A. Carefully remove the stick form the eye B. Stabilize the stick as best as possible C. Flush the eye with water if available D. Place the young man in a high-Fowler's position.
B. Stabilize the stick as best as possible
SITUATION: Student Nurse Louisse is about to take the board exam in November 2023. She should be knowledgeable of the different neurologic disorders that are commonly asked by the examiners. The following questions apply -- All but one are typical manifestations of MS: A. Double vision B. Sudden bursts of energy C. Weakness in the extremities D. Muscle tremors
B. Sudden bursts of energy
SITUATION: Nurse Wendy is taking care of Young-woo, a 6-year-old child diagnosed with autism spectrum disorder (ASD). The nurse applies her knowledge in helping Young-woo with her daily activities. -- Nurse Wendy identifies Impaired Social Interaction as a nursing diagnosis for a Young-woo based on which assessment finding? A. The child frequently engages in head-banging behavior against the wall. B. The child exhibits a refusal to cuddle with her parent. C. The child babbled during infancy. D. The child engages in self-biting behavior.
B. The child exhibits a refusal to cuddle with her parent.
SITUATION: Nurse Bubba is caring for a patient named Lab, who is diagnosed with Parkinson's Disease (PD). The following questions apply. -- When patient Lab was diagnosed with PD, he was prescribed levodopa therapy. The nurse would document that the therapy regimen is successful when she observed: A. A change in the mood of the patient B. The muscle rigidity of the patient is decreased C. Appetite of the patient is enhanced D. Alertness of the patient is increased
B. The muscle rigidity of the patient is decreased
During which time should the nurse schedule the most demanding ADLs to minimize the effects of diminishing motor activities? A. Early in the morning, when the client's energy level is high B. To coincide with the peak action of drug therapy C. Immediately after a rest period D. When the family member will be available
B. To coincide with the peak action of drug therapy
SITUATION: Trauma Nurse Ian is caring for Vince, a patient who has suffered a severe head injury from falling from a 5-storey building and is at risk for increased intracranial pressure (ICP). -- The healthcare provider orders mannitol for Vince with increased intracranial pressure (ICP). What is the rationale for using mannitol in this situation? A. To lower blood pressure and reduce intracranial pressure. B. To induce diuresis and promote fluid excretion from the brain. C. To prevent seizures and improve neurological function. D. To decrease cerebral blood flow and oxygen delivery to the brain.
B. To induce diuresis and promote fluid excretion from the brain.
SITUATION: Nurse Bubba is caring for a patient named Lab, who is diagnosed with Parkinson's Disease (PD). The following questions apply. -- Nurse Bubba is aware that the initial sign that patient Lab would manifest is which of the following? A. Rigidity B. Tremor C. Bradykinesia D. Akinesia
B. Tremor
SITUATION: Sherlock, a 60-year-old male, presents to the emergency department with sudden onset vision loss in his left eye. He reports seeing flashes of light and describes a "curtain" blocking his vision. On further assessment, the nurse suspects retinal detachment. The ophthalmologist is on the way to evaluate Sherlock's condition. Nurse John prepares to provide immediate care and educates the client and family about retinal detachment. -- Sherlock is recovering after retinal detachment surgery. What is the priority post-operative instruction given by Nurse John? A. Avoid all eye contact with bright light sources. B. Use prescribed eye drops as directed by the ophthalmologist. C. Perform eye exercises every hour to improve vision. D. Immediately resume all normal daily activities to promote recovery.
B. Use prescribed eye drops as directed by the ophthalmologist.
SITUATION: A nurse is assigned in the eye center of the hospital. She is taking care of patients with Cataract. The following questions apply. -- A patient of nurse Ende expressed her fears and concerns of being conscious during cataract surgery. What statement of nurse ende is the most appropriate? A. Have you ever had any adverse reactions to local anesthesia in the past? B. What is it that disturbs you about the idea of being awake? C. By using local anesthetic, you won't have nausea and vomiting after the surgery D. There's really nothing to fear about being awake. You'll be given medication that will help you relax.
B. What is it that disturbs you about the idea of being awake?
SITUATION: The nurse is assigned in the ENT ward of the hospital where he deals with various patients with sensory deficits. The following questions apply. -- Pepay is a 72-year-old female diagnosed with macular degeneration. During discharge, which statement made by Pepay would alert the nurse that she needs further teaching? A. "I should use magnification devices as much as possible." B. "I will look at my Amsler Grid once a week." C. "I am going to use a low-watt bulb in my house." D. "I am going to contact a low-vision center to evaluate my home."
C. "I am going to use a low-watt bulb in my house."
SITUATION: Sherlock, a 60-year-old male, presents to the emergency department with sudden onset vision loss in his left eye. He reports seeing flashes of light and describes a "curtain" blocking his vision. On further assessment, the nurse suspects retinal detachment. The ophthalmologist is on the way to evaluate Sherlock's condition. Nurse John prepares to provide immediate care and educates the client and family about retinal detachment. -- Nurse John is providing discharge instructions to a Sherlock. Which statement made by Sherlock indicates a need for further clarification? A. "I will avoid rubbing my eyes to prevent complications." B. "I should notify my doctor immediately if I experience increased eye pain." C. "I can resume my normal daily activities right away." D. "I will take all prescribed eye drops as directed."
C. "I can resume my normal daily activities right away."
SITUATION: The newly registered nurse is assigned in the neuro ward of their community hospital where she was tasked to care for patients diagnosed with conditions affecting the neurological system. The following questions apply. -- After the nurse had taught the client about the importance of taking her medication and pacing her activities, the patient is correct when she said that: A. "I will live longer, but ultimately, my disease will take my life." B. "My symptoms will be controlled, and eventually I will be healed." C. "I should be able to control my disease and enjoy a healthy lifestyle." D. "My fatigue will be relieved but I should expect episodes of muscle weakness."
C. "I should be able to control my disease and enjoy a healthy lifestyle."
SITUATION: Nurse Monie is working as a substance abuse nurse in the hospital. She has been taking care of patients with alcohol dependence and drug abuse. The following questions apply. -- Nurse Monie is preparing to administer chlordiazepoxide to a patient. The HCP ordered 75mg for the patient. The medication is manufactured in 25mg per capsule. How many capsules should she give the patient? A. 4 B. 3.8 C. 3 D. 3.5
C. 3
SITUATION: Sherlock, a 60-year-old male, presents to the emergency department with sudden onset vision loss in his left eye. He reports seeing flashes of light and describes a "curtain" blocking his vision. On further assessment, the nurse suspects retinal detachment. The ophthalmologist is on the way to evaluate Sherlock's condition. Nurse John prepares to provide immediate care and educates the client and family about retinal detachment. -- Which symptom described by the Sherlock is characteristic of retinal detachment? A. Central vision loss. B. Peripheral vision loss. C. A "curtain" blocking vision. D. Increased tear production.
C. A "curtain" blocking vision.
SITUATION: Maria is a 72-year-old woman living with Alzheimer's disease. Her family has noticed recent changes in her behavior, including increased forgetfulness, difficulty completing familiar tasks, and confusion about time and place. They brought her to the healthcare facility for a check-up. The nurse is conducting an assessment to determine Maria's cognitive status and plan appropriate care. -- Which neurotransmitter is primarily affected in Alzheimer's disease, leading to cognitive decline and memory impairment? A. Serotonin B. Dopamine C. Acetylcholine D. GABA
C. Acetylcholine
SITUATION: A nurse is assigned in the eye center of the hospital. She is taking care of patients with Cataract. The following questions apply. -- While the student nurse is administering eye drops for a patient with cataract, what should her Clinical Instructor instruct her to do? A. Move the dropper in the inner canthus of the eye B. Have the patient raise his eyebrows C. Administer eye drops in the center of lower lid D. Have the patient squeeze both eyes after administering the drops
C. Administer eye drops in the center of lower lid
SITUATION: Nurse Pol comes across patient Maggie, an 18-year-old female client, who has generalized anxiety disorder (GAD). She exhibits uneasiness, wringing of hands, rapid breathing, and has been pacing the hallway for the past 20 minutes -- Maggie is prescribed with an anxiolytic medication. Nurse Pol knows that which nursing intervention is essential when administering an anxiolytic? A. Monitor the patient's blood glucose levels regularly. B. Encourage the patient to engage in physical exercise. C. Assess the patient's vital signs before and after administration. D. Advise the patient to avoid sunlight exposure while on medication.
C. Assess the patient's vital signs before and after administration.
SITUATION: Nurse Maya is assigned in the Psychiatric ward of the hospital where she has to take care of patients with personality disorders. The following questions apply. -- avoidant and dependent behavior are considered to be a: A. Cluster A Personality disorder B. Cluster B personality disorder C. Cluster C personality disorder D. Cluster D personality disorder
C. Cluster C personality disorder
SITUATION: Student Nurse Louisse is about to take the board exam in November 2023. She should be knowledgeable of the different neurologic disorders that are commonly asked by the examiners. The following questions apply -- The following are realistic outcomes to establish for a client with MS except? The client will develop A. Joint mobility B. Muscle strength C. Cognition D. Mood elevation
C. Cognition
SITUATION: Nurse Monie is working as a substance abuse nurse in the hospital. She has been taking care of patients with alcohol dependence and drug abuse. The following questions apply. -- Nurse Monie was alerted when a relative of her patient she's caring for presents with complaints of generalized fatigue. Which among the following should alert Nurse Monie for possible marijuana use? A. Flashbacks B. Gastric disturbances C. Conjunctival infection D. Paranoia
C. Conjunctival infection
SITUATION: Nurse Emy is a psychiatric nurse in the hospital. She has patients with eating disorders. The following questions apply. -- Which outcome should a nurse consider as the most important for a patient newly diagnosed with anorexia nervosa? A. Achieves minimum normal weight B. Resumes normal menstrual cycle C. Consumes adequate calories for age, height, and metabolic needs D. Perceives body weight and shape as normal and acceptable
C. Consumes adequate calories for age, height, and metabolic needs
SITUATION: Junior is a 65-year-old male who has been admitted to the emergency department due to complications related to cocaine abuse. His friends found him unconscious at a party and immediately called for help. Junior has a history of substance abuse, primarily cocaine, and has experienced multiple adverse effects related to his drug use. The healthcare team is assessing his condition and planning appropriate care -- Which clinical manifestation is a common sign of acute cocaine intoxication? A. Bradycardia B. Hypotension C. Dilated pupils D. Slurred speech
C. Dilated pupils
SITUATION: Trauma Nurse Ian is caring for Vince, a patient who has suffered a severe head injury from falling from a 5-storey building and is at risk for increased intracranial pressure (ICP). -- Which assessment finding observed by Nurse Ian indicates an increased intracranial pressure in Vince? A. Decreased blood pressure B. Increased heart rate C. Dilated pupils D. Increased respiratory rate
C. Dilated pupils
SITUATION: Nurse Wendy is taking care of Young-woo, a 6-year-old child diagnosed with autism spectrum disorder (ASD). The nurse applies her knowledge in helping Young-woo with her daily activities. -- Nurse Wendy identifies that which of the following t is the primary goal of treatment for children with autism spectrum disorder (ASD)? A. Curing the condition and eliminating all symptoms B. Eliminating repetitive behaviors completely C. Enhancing communication and social skills D. Improving academic performance and cognitive abilities
C. Enhancing communication and social skills
SITUATION: The newly registered nurse is assigned in the neuro ward of their community hospital where she was tasked to care for patients diagnosed with conditions affecting the neurological system. The following questions apply. -- The nurse is caring for the patient who had a stroke. He only stares at the patient and does not speak, but he can follow instructions without any difficulty. The nurse understands the the patient is displaying: A. Receptive aphasia B. Global aphasia C. Expressive aphasia D. Both receptive and expressive aphasia
C. Expressive aphasia
SITUATION: Nurse Emy is a psychiatric nurse in the hospital. She has patients with eating disorders. The following questions apply. -- Nurse Emy was correct when he identified that the most common medication given to patients with anorexia nervosa is? A. Fluphenazine decanoate (Prolixin Decanoate). B. Clozapine (Clozaril). C. Fluoxetine (Prozac). D. Methylphenidate (Ritalin).
C. Fluoxetine (Prozac).
SITUATION: Nurse Maya is assigned in the Psychiatric ward of the hospital where she has to take care of patients with personality disorders. The following questions apply. -- Nurse Maya noted that Ace, a patient with paranoid PD and was given risperidone, restless and weak in lower extremities, and is drooling. What should nurse Maya do? A. Hold the next dose of risperidone, and document the findings. B. Monitor vital signs, and encourage the client to rest in the room. C. Give the ordered PRN dose of trihexyphenidyl (Artane). D. Get a fasting blood sugar measurement because of potential hyperglycemia.
C. Give the ordered PRN dose of trihexyphenidyl (Artane).
SITUATION: Jane, a 72-year-old female, is admitted to the medical-surgical unit for post-operative care after undergoing abdominal surgery. She has a history of diabetes and requires insulin administration. The nurse is responsible for providing various nursing skills to ensure Jane's safety and recovery. -- ane's blood glucose level is 280 mg/dL, and she requires insulin administration. How should the nurse prepare a 70/30 insulin? A. Inject air into the regular insulin vial, inject air into the NPH vial, then withdraw NPH, and finally withdraw regular insulin. B. Withdraw regular insulin first, then inject air into the NPH vial, inject air into the regular insulin vial, and finally withdraw NPH. C. Inject air into the NPH vial, inject air into the regular insulin vial, then withdraw regular insulin, and finally withdraw NPH. D. Withdraw NPH first, then inject air into the regular insulin vial, inject air into the NPH vial, and finally withdraw regular insulin.
C. Inject air into the NPH vial, inject air into the regular insulin vial, then withdraw regular insulin, and finally withdraw NPH.
SITUATION: Nurse Bubba is caring for a patient named Lab, who is diagnosed with Parkinson's Disease (PD). The following questions apply. -- When Nurse Bubba is teaching her patient Lab, among the following topics, which should the nurse give the most priority for discussion? A. Maintaining a balanced nutritional diet B. Enhancing the immune system C. Maintaining a safe environment D. Engaging in diversional activity
C. Maintaining a safe environment
SITUATION: Nurse Maya is assigned in the Psychiatric ward of the hospital where she has to take care of patients with personality disorders. The following questions apply. -- When Nurse Maya was assessing a patient, she was told by the patient that during his work in the eatery of the school, he used to spit on the dinner plates of students who are irritating. This information would be associated with which of the following? A. Paranoid Personality disorder B. Schizoid personality disorder C. Passive-aggressive personality disorder D. Antisocial personality disorder
C. Passive-aggressive personality disorder
SITUATION: The newly registered nurse is assigned in the neuro ward of their community hospital where she was tasked to care for patients diagnosed with conditions affecting the neurological system. The following questions apply. -- Another patient of the nurse had a stroke that affected the right hemisphere of her brain. Which symptom should the nurse expect? A. Right hemiparesis B. Expressive aphasia C. Poor impulse control D. Marked anxiety when learning new tasks
C. Poor impulse control
SITUATION: Junior is a 65-year-old male who has been admitted to the emergency department due to complications related to cocaine abuse. His friends found him unconscious at a party and immediately called for help. Junior has a history of substance abuse, primarily cocaine, and has experienced multiple adverse effects related to his drug use. The healthcare team is assessing his condition and planning appropriate care -- Junior has a history of bruxism due to him chronically abusing cocaine. Which intervention should the nurse prioritize when caring for Junior to address his dental concerns related to bruxism? A. Providing oral hygiene education B. Administering pain medication C. Recommending a dental nightguard D. Encouraging regular dental check-ups
C. Recommending a dental nightguard
SITUATION: Student Nurse Louisse is about to take the board exam in November 2023. She should be knowledgeable of the different neurologic disorders that are commonly asked by the examiners. The following questions apply -- The nurse would document that Baclofen is effective for the patient with MS if? A. Induces sleep B. Stimulate increase in appetite C. Relieves muscular spasticity D. Reduces the urine bacterial count
C. Relieves muscular spasticity
SITUATION: Nurse Bubba is caring for a patient named Lab, who is diagnosed with Parkinson's Disease (PD). The following questions apply. -- Patient Lab called to the clinic after 2 weeks of taking the Sinemet that was ordered by the physician. He said that the medicine is not effective for controlling his symptoms. What should the nurse do? A. Review the correct procedure for taking the medication B. Contact the physician to change the dose of the medication C. Remind the patient that it may take 1 to 2 months to observe the effects of the drug D. Ensure that the patient is eating foods high in pyridoxine and protein
C. Remind the patient that it may take 1 to 2 months to observe the effects of the drug
SITUATION: The newly registered nurse is assigned in the neuro ward of their community hospital where she was tasked to care for patients diagnosed with conditions affecting the neurological system. The following questions apply. -- A patient was admitted due to an ascending paralysis. He is scheduled for plasmapheresis. The nurse is correct when she said that this is done to: A. Remove excess fluid from the bloodstream. B. Restore protein levels in the blood. C. Remove circulating antibodies from the bloodstream. D. Infuse lipoproteins to restore the myelin sheath.
C. Remove circulating antibodies from the bloodstream.
SITUATION: Nurse Wendy is taking care of Young-woo, a 6-year-old child diagnosed with autism spectrum disorder (ASD). The nurse applies her knowledge in helping Young-woo with her daily activities. -- Nurse Wendy observes that Young-woo engages in repetitive behaviors, such as hand-flapping and lining up her father's law books in a specific order. Which rationale best explains these behaviors in children with ASD? A. These behaviors are attention-seeking tactics used by children with ASD to gain social interactions with peers and caregivers. B. Repetitive behaviors in children with ASD are a sign of cognitive impairment and difficulty adapting to new environments. C. Repetitive behaviors are a form of self-stimulation that provides comfort and helps regulate sensory input for children with ASD. D. These behaviors are a manifestation of oppositional defiant disorder (ODD), often comorbid with ASD, and can be managed with behavioral interventions.
C. Repetitive behaviors are a form of self-stimulation that provides comfort and helps regulate sensory input for children with ASD.
SITUATION: Jason, a 7-year-old boy is brought to the pediatric clinic by his parents due to concerns about his behavior at school and home. The parents report that he has difficulty paying attention, is easily distracted, and often fails to finish tasks or follow instructions. The Jason's teacher also notices that he frequently interrupts others, fidgets in his seat, and has difficulty waiting for his turn during classroom activities. The healthcare provider suspects attention-deficit/hyperactivity disorder (ADHD) and plans to conduct a comprehensive assessment. -- What is the first-line pharmacological treatment for ADHD in school-age children, such as Jason? A. Antipsychotic medications B. Selective serotonin reuptake inhibitors (SSRIs) C. Stimulant medications D. Benzodiazepines
C. Stimulant medications
SITUATION: Trauma Nurse Ian is caring for Vince, a patient who has suffered a severe head injury from falling from a 5-storey building and is at risk for increased intracranial pressure (ICP). -- Nurse Ian knows that Vince has been prescribed with an osmotic diuretic. What should he closely monitor while Vince is receiving this medication? A. Blood glucose levels. B. Serum potassium levels. C. Urine output. D. Respiratory rate and depth.
C. Urine output.
SITUATION: Nurse Emy is a psychiatric nurse in the hospital. She has patients with eating disorders. The following questions apply. -- Nurse Emy is evaluating if patient Jopay, who is diagnosed with bulimia nervosa, was able to meet the outcome in the Nursing care plan. Which behavior would show that the patient is meeting an expected outcome? A. Gains 1 pound after being in treatment for 3 weeks B. Self-purging decreases in frequency from daily o twice weekly C. Uses drawing to express feelings about body image and to deal with conflicts D. Engages staff in conversations that center on food.
C. Uses drawing to express feelings about body image and to deal with conflicts
SITUATION: Maria is a 72-year-old woman living with Alzheimer's disease. Her family has noticed recent changes in her behavior, including increased forgetfulness, difficulty completing familiar tasks, and confusion about time and place. They brought her to the healthcare facility for a check-up. The nurse is conducting an assessment to determine Maria's cognitive status and plan appropriate care. -- Which of the following interventions is essential in creating a safe environment for a patient with Alzheimer's disease? A. Encouraging complex mental activities to challenge their cognitive abilities B. Providing bright and colorful decorations to stimulate sensory perception C. Using a nightlight to prevent disorientation during the night D. Allowing complete independence in daily activities to maintain their dignity
C. Using a nightlight to prevent disorientation during the night
SITUATION: Nurse Bubba is caring for a patient named Lab, who is diagnosed with Parkinson's Disease (PD). The following questions apply. -- If patient Lab is to be switched from L-dopa to Sinemet, which should nurse Bubba monitor for? A. Euphoria B. Jaundice C. Vital sign fluctuation D. Sign and symptoms of diabetes
C. Vital sign fluctuation
SITUATION: Nurse Emy is a psychiatric nurse in the hospital. She has patients with eating disorders. The following questions apply. -- While doing an assessment, which of the following would confirm the diagnosis of anorexia nervosa? I. Refusal to eat II. Weighs less than 85% of expected weight for body size and image III. Age of onset: 25 years old IV. Intense fear of getting fat despite being underweight V. Heavy bleeding during menses A. 1, 3, 4 B. 1, 2, 5 C. 1, 2, 3, 4 D. 1, 2, 4
D. 1, 2, 4
SITUATION: The newly registered nurse is assigned in the neuro ward of their community hospital where she was tasked to care for patients diagnosed with conditions affecting the neurological system. The following questions apply. -- Which of the following are manifestations of the cholinergic crisis? I. Ptosis II. Fasciculation III. Abdominal cramps IV. Increased heart rate V. Decreased secretions and saliva VI. Respiratory rate of 6 and irregular rhythm A. 1, 3, 4 B. 3, 4, 5 C. 2, 3, 6 D. 1, 2, 6
D. 1, 2, 6
SITUATION: Student Nurse Louisse is about to take the board exam in November 2023. She should be knowledgeable of the different neurologic disorders that are commonly asked by the examiners. The following questions apply -- Which nursing activity is not indicated if the nurse is talking to a patient with MS? A. Encouraging the client to speak slowly. B. Encouraging the client to speak distinctly. C. Asking the client to repeat indistinguishable words. D. Asking the client to speak louder when tired.
D. Asking the client to speak louder when tired.
SITUATION: Jason, a 7-year-old boy is brought to the pediatric clinic by his parents due to concerns about his behavior at school and home. The parents report that he has difficulty paying attention, is easily distracted, and often fails to finish tasks or follow instructions. The Jason's teacher also notices that he frequently interrupts others, fidgets in his seat, and has difficulty waiting for his turn during classroom activities. The healthcare provider suspects attention-deficit/hyperactivity disorder (ADHD) and plans to conduct a comprehensive assessment. -- Jason's healthcare provider is conducting a comprehensive assessment to diagnose whether Jason has ADHD. Which of the following is an essential component of the assessment process? A. Blood pressure measurement B. Allergy testing C. Bone density evaluation D. Assessment of cognitive abilities
D. Assessment of cognitive abilities
SITUATION: Nurse Bubba is caring for a patient named Lab, who is diagnosed with Parkinson's Disease (PD). The following questions apply. -- At what time should the nurse give the medication to the patient to be taken? A. At bedtime B. All at one time C. 2 horse before mealtime D. At the time scheduled
D. At the time scheduled
SITUATION: Nurse Maya is assigned in the Psychiatric ward of the hospital where she has to take care of patients with personality disorders. The following questions apply. -- Which of the following is a distinct behavior for a patient diagnosed with histrionic personality disorder? A. Odd beliefs and magical thinking. B. Grandiose sense of self-importance. C. Preoccupation with orderliness and perfection. D. Attention-seeking flamboyance.
D. Attention-seeking flamboyance.
SITUATION: Jane, a 72-year-old female, is admitted to the medical-surgical unit for post-operative care after undergoing abdominal surgery. She has a history of diabetes and requires insulin administration. The nurse is responsible for providing various nursing skills to ensure Jane's safety and recovery. -- During a routine dressing change for Jane's surgical wound, the nurse observes yellowish drainage with an odor. What action should the nurse take? A. Irrigate the wound with normal saline solution. B. Apply an antimicrobial ointment to the wound. C. Continue with the dressing change as scheduled. D. Collect a wound culture sample for analysis
D. Collect a wound culture sample for analysis
SITUATION: Junior is a 65-year-old male who has been admitted to the emergency department due to complications related to cocaine abuse. His friends found him unconscious at a party and immediately called for help. Junior has a history of substance abuse, primarily cocaine, and has experienced multiple adverse effects related to his drug use. The healthcare team is assessing his condition and planning appropriate care -- Which life-threatening condition can occur as a result of cocaine use, characterized by an acute and severe elevation in body temperature? A. Rhabdomyolysis B. Serotonin syndrome C. Delirium tremens D. Excited delirium
D. Excited delirium
SITUATION: The newly registered nurse is assigned in the neuro ward of their community hospital where she was tasked to care for patients diagnosed with conditions affecting the neurological system. The following questions apply. -- The patient above suddenly developed an increasing temperature. What is the reason that the nurse should intervene to help lower the temperature of the patient? A. A normal temperature will strengthen the client's immune system against infection. B. Hyperthermia lowers the incidence of mortality. C. A normal temperature will decrease the score on the Glasgow coma scale. D. Hyperthermia increases the likelihood of a larger area of brain infarct.
D. Hyperthermia increases the likelihood of a larger area of brain infarct.
SITUATION: Sherlock, a 60-year-old male, presents to the emergency department with sudden onset vision loss in his left eye. He reports seeing flashes of light and describes a "curtain" blocking his vision. On further assessment, the nurse suspects retinal detachment. The ophthalmologist is on the way to evaluate Sherlock's condition. Nurse John prepares to provide immediate care and educates the client and family about retinal detachment. -- Upon diagnosis of retinal detachment, what should Nurse John prioritize as the first course of action? A. Initiate eye compress application. B. Provide instructions to the client regarding lying in a prone position. C. Remove all bed pillows to facilitate the process. D. Implement measures to promote restricted mobility.
D. Implement measures to promote restricted mobility.
SITUATION: Nurse Monie is working as a substance abuse nurse in the hospital. She has been taking care of patients with alcohol dependence and drug abuse. The following questions apply. -- A patient of Nurse Monie admitted that she has been using methamphetamine for recreational purposes. Which should be consistent with the information that the patient expressed to Nurse Monie? A. Hypotension and bradycardia B. Bruises and scrapes on the extremities C. Constricted pupils and fatigue D. Loss of appetite and recent weight loss
D. Loss of appetite and recent weight loss
SITUATION: Nurse Wendy is taking care of Young-woo, a 6-year-old child diagnosed with autism spectrum disorder (ASD). The nurse applies her knowledge in helping Young-woo with her daily activities. -- Young-woo is admitted to the pediatric unit due to pneumonia. Nurse Wendy knows that which intervention is appropriate to create an autism-friendly environment in the healthcare setting? A. Encouraging spontaneous social interactions B. Implementing rigid routines and schedules C. Using abstract language during communication D. Minimizing visual and auditory stimuli
D. Minimizing visual and auditory stimuli
SITUATION: Nurse Bubba is caring for a patient named Lab, who is diagnosed with Parkinson's Disease (PD). The following questions apply. -- Which of the following signs and symptoms should Patient Lab manifest as adverse effects of Sinemet? A. Dystonia and Akinesia B. Bradykinesia and agitation C. Muscle rigidity and Cardiac Dysrhythmia D. Orthostatic hypotension and dry mouth
D. Orthostatic hypotension and dry mouth
SITUATION: Nurse Maya is assigned in the Psychiatric ward of the hospital where she has to take care of patients with personality disorders. The following questions apply. -- During discharge for a patient with narcissistic personality disorder, which job would be most likely recommended? A. Home construction. B. Air traffic controller. C. Night watchman at the zoo. D. Prison warden.
D. Prison warden.
SITUATION: Jane, a 72-year-old female, is admitted to the medical-surgical unit for post-operative care after undergoing abdominal surgery. She has a history of diabetes and requires insulin administration. The nurse is responsible for providing various nursing skills to ensure Jane's safety and recovery. -- Jane is at risk of developing pressure ulcers due to immobility post-surgery. What is the nurse's priority intervention to prevent pressure ulcers? A. Apply moisture barrier creams to vulnerable areas. B. Use a pressure-relieving mattress on Jane's bed. C. Perform regular skin assessments during daily care. D. Reposition Jane every 2 hours or as needed.
D. Reposition Jane every 2 hours or as needed.
SITUATION: The newly registered nurse is assigned in the neuro ward of their community hospital where she was tasked to care for patients diagnosed with conditions affecting the neurological system. The following questions apply. -- What possible complication of the patient above should the nurse monitor for? A. Autonomic dysreflexia B. Septic emboli C. Increased ICP D. Respiratory failure
D. Respiratory failure
SITUATION: Maria is a 72-year-old woman living with Alzheimer's disease. Her family has noticed recent changes in her behavior, including increased forgetfulness, difficulty completing familiar tasks, and confusion about time and place. They brought her to the healthcare facility for a check-up. The nurse is conducting an assessment to determine Maria's cognitive status and plan appropriate care. -- Which of the following behavioral symptoms is common in the middle to later stages of Alzheimer's disease? A. Insomnia B. Hyperactivity and restlessness C. Increased appetite and weight gain D. Sundowning
D. Sundowning
SITUATION: Nurse Pol comes across patient Maggie, an 18-year-old female client, who has generalized anxiety disorder (GAD). She exhibits uneasiness, wringing of hands, rapid breathing, and has been pacing the hallway for the past 20 minutes -- When providing education to Maggie prescribed with benzodiazepine anxiolytics, Nurse Pol should emphasize: A. The necessity of engaging in vigorous physical activities to reduce anxiety. B. The potential to combine the medication with alcohol for increased effectiveness. C. The benefit of sharing the medication with family members who may also experience anxiety. D. The importance of avoiding sudden discontinuation of the medication.
D. The importance of avoiding sudden discontinuation of the medication.
SITUATION: Raquelle, a 40-year-old female, is admitted to the hospital with complaints of weakness, dizziness, and dry mouth. Her vital signs reveal a blood pressure of 90/60 mmHg, heart rate of 110 beats per minute, and respiratory rate of 22 breaths per minute. Raquelle's medical history includes hypertension, and she takes antihypertensive medications regularly. Nurse Aira suspects fluid volume deficit and plans to initiate appropriate interventions. -- Nurse Aira assesses Raquelle's skin turgor by gently pinching the skin on her forearm. Which finding indicates fluid volume deficit? A. The skin returns to its normal position immediately. B. The skin takes less than 3 seconds to return to its normal position. C. The skin remains elevated and returns slowly to its normal position. D. The skin remains elevated and shows tenting.
D. The skin remains elevated and shows tenting.
SITUATION: Nurse Bubba is caring for a patient named Lab, who is diagnosed with Parkinson's Disease (PD). The following questions apply. -- As a competent nurse, Nurse Bubba would set which of the following goals to be the most realistic? A. To cure the disease B. To stop progression of the disease C. To begin for terminal care preparations D. To maintain optimal body function
D. To maintain optimal body function
SITUATION: Light Yagami, 20-years-old, suffers from extreme mood swings from episodes of mania to depression. He cycles between symptoms of mania, normal mood, and depression. He is diagnosed with Bipolar mixed type. -- Light reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The drug level of lithium carbonate is at 3.0 mEq/L. The nurse plans the care for Light based on which representation of this level? A. Normal B. Slightly above normal C. Excessively below normal D. Toxic
D. Toxic