Graded A+
1. Which of the following therapeutic communication techniques is NOT
appropriate for a nurse to use with a client in a mental health unit?
Giving advice and approval or disapproval
Listening
Restating
Maintaining neutral responses
2. A 68-year-old man presents with new onset of headaches. He describes the
pain as bilateral frontal to occipital and worst when he arises in the morning
and when coughing. He feels much better by mid-afternoon. The history is
most consistent with headche caused by:
brain tumor.
tension-type with geriatric presentation.
increased ICP.
vascular compromise.
3. What condition is indicated by new-onset headaches that are most severe in
the morning and when coughing in a 74-year-old male?
Migraine with aura
Tension-type headache
Increased intracranial pressure
Cluster-type headache
,4. The triage nurse in the emergency department (ED) assesses 4 clients. Which
client is in need of emergent care?
A 28 year old experiencing a migraine headache for three days.
A two year old with excessive drooling and a weak cough.
A 9 month old with temperature of 103°F (39.4°C).
A 52 year old who has a partially amputated finger.
5. What is a key consideration when determining which clients can be safely
discharged from a medical-surgical unit?
Patient's insurance coverage
Availability of family support
Stability of the patient's condition
Length of hospital stay
6. Why might a minor headache after a concussion require further instruction
from the nurse?
A minor headache is always a sign of severe injury.
A minor headache is a normal symptom and does not require further
instruction.
A minor headache may indicate ongoing issues that need
monitoring and could suggest complications.
A minor headache is unrelated to concussion recovery.
7. What is the priority action for a nurse when admitting a client with major
depression?
Administer to the client the prescribed antidepressant
, Have the client's possessions searched for sharps
Ask the client if suicide has been contemplated
Determine if the client was voluntarily admitted
8. What is the significance of a Hemoglobin A1c level of 13% in a patient with
type 2 Diabetes Mellitus?
It suggests the patient is in remission.
It indicates the patient is at risk for hypoglycemia.
It shows the patient has normal blood glucose levels.
It indicates poor long-term blood glucose control.
9. A patient presents with fatigue and other symptoms suggestive of
hypothyroidism. What initial nursing intervention should be prioritized in the
care plan?
Focus solely on dietary recommendations.
Immediately start thyroid hormone replacement therapy.
Conduct a thorough assessment of the patient's symptoms and
history.
Refer the patient to a specialist without assessment.
10. Describe the rationale for administering IV fluids containing dextrose to a
patient with diabetic ketoacidosis and a serum glucose level of 240 mg/dL.
IV fluids containing dextrose are used to treat hyperkalemia in DKA
patients.
IV fluids containing dextrose are used to prevent seizures in DKA
patients.
, IV fluids containing dextrose help to stabilize blood glucose levels
and prevent further complications.
IV fluids containing dextrose are primarily for hydration and have no
effect on glucose levels.
11. Which laboratory test is essential to review before starting carbamazepine
treatment?
Renal function tests
Liver function tests
Complete blood cell count
Pancreatic enzyme studies
12. If a patient with diabetic ketoacidosis continues to show signs of dehydration
despite receiving IV fluids containing dextrose, what should the nurse's next
step be?
Reassess the patient's fluid status and consider administering
additional IV fluids.
Increase the dextrose concentration in the IV fluids.
Monitor the patient for signs of hypoglycemia.
Administer NPH insulin subcutaneously to lower glucose levels.
13. Why is it important for a nurse to reassess a patient after a fall, even if no
injuries are initially evident?
Reassessing the patient helps to ensure that any delayed
symptoms or complications are identified promptly.
Reassessing is only needed if the patient complains of pain.
Reassessing allows the nurse to complete paperwork more quickly.