The nurse is caring for a 33 year old male who was admitted for a carbamazepine
overdose. The nurse knows to monitor the patient carefully for signs and symptoms of
which of the following complications?
Give this one a try later!
Hyponatremia
Feedback
The nurse should recall that carbamazepine overdose is associated with
SIADH, a well-known cause of hyponatremia.
When administering Haldol to a patient with hyperactive delirium, you should closely
monitor for which of the following?
A. Reflexive tachycardia
B. Shortened PR interval
C. Prolonged QT interval
D. 2nd Degree Type 1 Heart Block
,Give this one a try later!
C. Prolonged QT interval
A patient recently placed into hospice care is being transferred from the ICU to the
step-down unit. The family requests to spend the night, which is contrary to unit
policy. The best intervention would be to:
Give this one a try later!
Allow one family member to stay, and evaluate the patient's response
Feedback
Many patients respond well to having a family member stay with them. In
cases of critically-ill or dying patients, visiting policies may be overridden
to accommodate the needs of the patient. Management should be
consulted during the decision-making process.
The nurse is caring for a 59 year old male patient who is being treated for acute
respiratory failure with bilevel positive airway pressure (BIPAP). Which of the following
nursing diagnoses would be MOST appropriate for this patient?
Give this one a try later!
Risk for impaired skin integrity
Feedback
The nurse should recognize that successful BIPAP therapy requires a mask
that is snugly fitted to the patient's face, which represents a threat to the
patient's skin integrity. This requires close monitoring of the patient's facial
skin to ensure that breakdown does not occur.
,A 47-year-old male patient is admitted with a diagnosis of hepatic encephalopathy
accompanied by severe dehydration. Which of the following treatments should the
nurse anticipate?
Give this one a try later!
Potassium replacement
Feedback
Due to high aldosterone levels associated with liver failure, this patient will
likely need potassium replacement. Once dehydration is corrected, ascites
may be treated by using a potassium-sparing diuretic to increase water
excretion. Dietary sodium should be restricted.
A nurse is caring for a patient with a recent history of an ischemic (embolic) stroke. To
evaluate the patient's current status, the nurse uses the National Institutes of Health
Stroke Scale (NIHSS). This scale evaluates eleven separate items, which include all of
the following EXCEPT:
A. Language skills
B. Hearing response
C. Limb ataxia
D. Horizontal eye movements
Give this one a try later!
B. Hearing response
Feedback
The eleven items evaluated on the NIHSS include level of consciousness,
horizontal eye movement, visual field test, facial palsy, motor arm, motor
leg, limb ataxia, sensory loss, language skills, speech, and
extinction/inattention. Hearing is not directly tested, although several items
require the patient to follow verbal directions. The scale advises certain
point levels for patients who are normally deaf or mute, and suggests
alternate methods of testing certain items on the scale.
, Several telemetry nurses have formed a committee to develop written educational
pamphlets for patients discharged from their unit. In order for these pamphlets to be
beneficial for the majority of their patients, the committee should:
Give this one a try later!
Write pamphlet information at a fourth-grade reading level
Feedback
Patients have diverse reading abilities. Written educational information
should be designed to include easy-to-read, lay language at a fourth-
grade reading level in order to benefit the majority of patients.
The 26-year-old son of a Korean family is being evaluated for a possible congenital
heart defect. The parents appear to be fluent in English, but the father asks only a few
questions about the patient's plan of care. Which of the following resources would be
most useful for the nurse caring for this patient?
Give this one a try later!
Online information about Korean culture and family relationships
Feedback
Greater understanding of cultural and family relationships will help this
nurse understand hierarchies and other dynamics that may contribute to
this family's participation in their son's care.
A 22-year-old male patient is admitted for observation following a linear temporal
skull fracture from a skiing accident. Upon admission at 2 pm, the patient was alert and
oriented, and reports that he "passed out for a second" immediately after his accident.
At 4 pm, the nurse notes that the patient's Glasgow Coma Scale (GCS) is 8. The nurse
should:
A. Continue to monitor for changes
B. Place the patient in Trendelenburg position
overdose. The nurse knows to monitor the patient carefully for signs and symptoms of
which of the following complications?
Give this one a try later!
Hyponatremia
Feedback
The nurse should recall that carbamazepine overdose is associated with
SIADH, a well-known cause of hyponatremia.
When administering Haldol to a patient with hyperactive delirium, you should closely
monitor for which of the following?
A. Reflexive tachycardia
B. Shortened PR interval
C. Prolonged QT interval
D. 2nd Degree Type 1 Heart Block
,Give this one a try later!
C. Prolonged QT interval
A patient recently placed into hospice care is being transferred from the ICU to the
step-down unit. The family requests to spend the night, which is contrary to unit
policy. The best intervention would be to:
Give this one a try later!
Allow one family member to stay, and evaluate the patient's response
Feedback
Many patients respond well to having a family member stay with them. In
cases of critically-ill or dying patients, visiting policies may be overridden
to accommodate the needs of the patient. Management should be
consulted during the decision-making process.
The nurse is caring for a 59 year old male patient who is being treated for acute
respiratory failure with bilevel positive airway pressure (BIPAP). Which of the following
nursing diagnoses would be MOST appropriate for this patient?
Give this one a try later!
Risk for impaired skin integrity
Feedback
The nurse should recognize that successful BIPAP therapy requires a mask
that is snugly fitted to the patient's face, which represents a threat to the
patient's skin integrity. This requires close monitoring of the patient's facial
skin to ensure that breakdown does not occur.
,A 47-year-old male patient is admitted with a diagnosis of hepatic encephalopathy
accompanied by severe dehydration. Which of the following treatments should the
nurse anticipate?
Give this one a try later!
Potassium replacement
Feedback
Due to high aldosterone levels associated with liver failure, this patient will
likely need potassium replacement. Once dehydration is corrected, ascites
may be treated by using a potassium-sparing diuretic to increase water
excretion. Dietary sodium should be restricted.
A nurse is caring for a patient with a recent history of an ischemic (embolic) stroke. To
evaluate the patient's current status, the nurse uses the National Institutes of Health
Stroke Scale (NIHSS). This scale evaluates eleven separate items, which include all of
the following EXCEPT:
A. Language skills
B. Hearing response
C. Limb ataxia
D. Horizontal eye movements
Give this one a try later!
B. Hearing response
Feedback
The eleven items evaluated on the NIHSS include level of consciousness,
horizontal eye movement, visual field test, facial palsy, motor arm, motor
leg, limb ataxia, sensory loss, language skills, speech, and
extinction/inattention. Hearing is not directly tested, although several items
require the patient to follow verbal directions. The scale advises certain
point levels for patients who are normally deaf or mute, and suggests
alternate methods of testing certain items on the scale.
, Several telemetry nurses have formed a committee to develop written educational
pamphlets for patients discharged from their unit. In order for these pamphlets to be
beneficial for the majority of their patients, the committee should:
Give this one a try later!
Write pamphlet information at a fourth-grade reading level
Feedback
Patients have diverse reading abilities. Written educational information
should be designed to include easy-to-read, lay language at a fourth-
grade reading level in order to benefit the majority of patients.
The 26-year-old son of a Korean family is being evaluated for a possible congenital
heart defect. The parents appear to be fluent in English, but the father asks only a few
questions about the patient's plan of care. Which of the following resources would be
most useful for the nurse caring for this patient?
Give this one a try later!
Online information about Korean culture and family relationships
Feedback
Greater understanding of cultural and family relationships will help this
nurse understand hierarchies and other dynamics that may contribute to
this family's participation in their son's care.
A 22-year-old male patient is admitted for observation following a linear temporal
skull fracture from a skiing accident. Upon admission at 2 pm, the patient was alert and
oriented, and reports that he "passed out for a second" immediately after his accident.
At 4 pm, the nurse notes that the patient's Glasgow Coma Scale (GCS) is 8. The nurse
should:
A. Continue to monitor for changes
B. Place the patient in Trendelenburg position
