NUR 265 Exam 2
1. Adult health assessment and identification of abnormal findings
2. Respiratory disorders, oxygenation, airway management, and respiratory
priorities
3. Cardiac disorders, perfusion, heart failure, and dysrhythmia recognition
4. Renal problems, urinary changes, dialysis concepts, and fluid management
5. Endocrine disorders, glucose management, and hormone-related emergencies
6. Fluid and electrolyte imbalances and appropriate nursing interventions
7. Pain management, medication safety, and adverse-effect monitoring
8. Infection recognition, prevention, and treatment-related nursing responsibilities
9. Patient education, health literacy, and discharge preparation
10. Priority interventions, clinical reasoning, delegation, and patient safety
1. During routine assessment, a nurse enters a room and finds a postoperative
patient suddenly confused, restless, and breathing rapidly. Which assessment
should occur first?
A. Begin discharge teaching immediately
B. Assess airway, breathing, and oxygenation ✓
C. Review the complete dietary history
D. Ask the patient to describe the previous night's sleep
, Rationale: Sudden confusion and tachypnea can indicate hypoxemia or acute
deterioration, making ABC assessment the priority.
2. While reviewing the patient's or student's data, a patient reports severe chest
pressure with diaphoresis and nausea. Which nursing action should receive the
highest priority while additional evaluation is arranged?
A. Assess vital signs and obtain rapid cardiac assessment according to protocol
✓
B. Offer a large meal before testing
C. Delay assessment until the pain resolves
D. Encourage the patient to walk to reduce anxiety
Rationale: Chest pressure with autonomic symptoms may indicate acute
coronary syndrome and requires immediate assessment and escalation.
3. When preparing the individual for care, which nurse response best
demonstrates therapeutic communication when a patient says, 'Nobody here
understands what I am going through'?
A. There is nothing to worry about because the staff will fix everything.
B. It sounds as though you feel misunderstood; tell me more about that
experience. ✓
C. You should try to think more positively about your situation.
D. I understand exactly how you feel because I have felt that way too.
, Rationale: The response acknowledges the patient's feelings and invites further
expression without imposing judgment or false reassurance.
4. After a new finding is reported, a patient receiving an antipsychotic develops
high fever, severe muscle rigidity, and altered consciousness. Which complication
should the nurse suspect?
A. Mild orthostatic hypotension
B. Simple medication tolerance
C. Neuroleptic malignant syndrome ✓
D. Expected therapeutic response
Rationale: Fever, rigidity, and altered mental status are classic warning signs of
neuroleptic malignant syndrome, a medical emergency.
5. While evaluating the situation at the bedside, which finding in a patient taking
lithium should prompt the nurse to assess immediately for possible toxicity?
A. A stable appetite with no neurologic changes
B. Mild thirst after exercise
C. Coarse tremor accompanied by vomiting and increasing confusion ✓
D. Occasional preference for salty foods
Rationale: Progressive gastrointestinal and neurologic symptoms can signal
lithium toxicity and require prompt evaluation.
6. During a follow-up assessment, a patient expresses a specific suicide plan and
states that the means are immediately available. What is the nurse's priority
, intervention?
A. Ask the patient to promise not to self-harm and end the assessment
B. Leave the patient alone to encourage independent coping
C. Tell the patient that suicide would permanently hurt the family
D. Maintain immediate safety and initiate continuous observation according to
policy ✓
Rationale: A specific plan with available means indicates high risk; immediate
safety and continuous observation take priority.
7. When the nurse or officer reassesses the situation, which finding is most
characteristic of mania and should be reported as clinically significant?
A. Markedly decreased need for sleep with increased goal-directed activity ✓
B. Slowed speech and social withdrawal
C. Sleeping ten hours nightly with stable energy
D. Consistent fatigue following routine activities
Rationale: Decreased need for sleep with increased energy and goal-directed
activity is characteristic of mania.
8. As part of safe clinical decision-making, a patient experiencing alcohol
withdrawal becomes tremulous, diaphoretic, agitated, and disoriented. Which
complication is the nurse particularly concerned about?
A. Expected relaxation and sleepiness
B. Progression to severe withdrawal with seizures or delirium ✓
1. Adult health assessment and identification of abnormal findings
2. Respiratory disorders, oxygenation, airway management, and respiratory
priorities
3. Cardiac disorders, perfusion, heart failure, and dysrhythmia recognition
4. Renal problems, urinary changes, dialysis concepts, and fluid management
5. Endocrine disorders, glucose management, and hormone-related emergencies
6. Fluid and electrolyte imbalances and appropriate nursing interventions
7. Pain management, medication safety, and adverse-effect monitoring
8. Infection recognition, prevention, and treatment-related nursing responsibilities
9. Patient education, health literacy, and discharge preparation
10. Priority interventions, clinical reasoning, delegation, and patient safety
1. During routine assessment, a nurse enters a room and finds a postoperative
patient suddenly confused, restless, and breathing rapidly. Which assessment
should occur first?
A. Begin discharge teaching immediately
B. Assess airway, breathing, and oxygenation ✓
C. Review the complete dietary history
D. Ask the patient to describe the previous night's sleep
, Rationale: Sudden confusion and tachypnea can indicate hypoxemia or acute
deterioration, making ABC assessment the priority.
2. While reviewing the patient's or student's data, a patient reports severe chest
pressure with diaphoresis and nausea. Which nursing action should receive the
highest priority while additional evaluation is arranged?
A. Assess vital signs and obtain rapid cardiac assessment according to protocol
✓
B. Offer a large meal before testing
C. Delay assessment until the pain resolves
D. Encourage the patient to walk to reduce anxiety
Rationale: Chest pressure with autonomic symptoms may indicate acute
coronary syndrome and requires immediate assessment and escalation.
3. When preparing the individual for care, which nurse response best
demonstrates therapeutic communication when a patient says, 'Nobody here
understands what I am going through'?
A. There is nothing to worry about because the staff will fix everything.
B. It sounds as though you feel misunderstood; tell me more about that
experience. ✓
C. You should try to think more positively about your situation.
D. I understand exactly how you feel because I have felt that way too.
, Rationale: The response acknowledges the patient's feelings and invites further
expression without imposing judgment or false reassurance.
4. After a new finding is reported, a patient receiving an antipsychotic develops
high fever, severe muscle rigidity, and altered consciousness. Which complication
should the nurse suspect?
A. Mild orthostatic hypotension
B. Simple medication tolerance
C. Neuroleptic malignant syndrome ✓
D. Expected therapeutic response
Rationale: Fever, rigidity, and altered mental status are classic warning signs of
neuroleptic malignant syndrome, a medical emergency.
5. While evaluating the situation at the bedside, which finding in a patient taking
lithium should prompt the nurse to assess immediately for possible toxicity?
A. A stable appetite with no neurologic changes
B. Mild thirst after exercise
C. Coarse tremor accompanied by vomiting and increasing confusion ✓
D. Occasional preference for salty foods
Rationale: Progressive gastrointestinal and neurologic symptoms can signal
lithium toxicity and require prompt evaluation.
6. During a follow-up assessment, a patient expresses a specific suicide plan and
states that the means are immediately available. What is the nurse's priority
, intervention?
A. Ask the patient to promise not to self-harm and end the assessment
B. Leave the patient alone to encourage independent coping
C. Tell the patient that suicide would permanently hurt the family
D. Maintain immediate safety and initiate continuous observation according to
policy ✓
Rationale: A specific plan with available means indicates high risk; immediate
safety and continuous observation take priority.
7. When the nurse or officer reassesses the situation, which finding is most
characteristic of mania and should be reported as clinically significant?
A. Markedly decreased need for sleep with increased goal-directed activity ✓
B. Slowed speech and social withdrawal
C. Sleeping ten hours nightly with stable energy
D. Consistent fatigue following routine activities
Rationale: Decreased need for sleep with increased energy and goal-directed
activity is characteristic of mania.
8. As part of safe clinical decision-making, a patient experiencing alcohol
withdrawal becomes tremulous, diaphoretic, agitated, and disoriented. Which
complication is the nurse particularly concerned about?
A. Expected relaxation and sleepiness
B. Progression to severe withdrawal with seizures or delirium ✓
