NUR 265 Exam 3
1. Complex adult assessment and interpretation of significant clinical changes
2. Cardiovascular and respiratory priorities including acute deterioration
3. Neurologic disorders, assessment findings, and emergency interventions
4. Renal and endocrine disorders with associated laboratory abnormalities
5. Gastrointestinal and hepatic conditions, complications, and nursing priorities
6. Fluid, electrolyte, and acid-base disturbances with clinical management
7. Medication safety, pharmacologic effects, and monitoring for adverse reactions
8. Postoperative complications, infection, bleeding, and recovery priorities
9. Patient education, discharge planning, and self-management strategies
10. Clinical judgment, prioritization, delegation, and escalation of care
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. Review the complete dietary history
C. Ask the patient to describe the previous night's sleep
D. Assess airway, breathing, and oxygenation ✓
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. Delay assessment until the pain resolves
B. Offer a large meal before testing
C. Encourage the patient to walk to reduce anxiety
D. Assess vital signs and obtain rapid cardiac assessment according to protocol
✓
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. I understand exactly how you feel because I have felt that way too.
B. You should try to think more positively about your situation.
C. There is nothing to worry about because the staff will fix everything.
D. It sounds as though you feel misunderstood; tell me more about that
experience. ✓
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. Simple medication tolerance
B. Mild orthostatic hypotension
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. Mild thirst after exercise
B. A stable appetite with no neurologic changes
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. Tell the patient that suicide would permanently hurt the family
, B. Ask the patient to promise not to self-harm and end the assessment
C. Maintain immediate safety and initiate continuous observation according to
policy ✓
D. Leave the patient alone to encourage independent coping
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. Slowed speech and social withdrawal
B. Markedly decreased need for sleep with increased goal-directed activity ✓
C. Consistent fatigue following routine activities
D. Sleeping ten hours nightly with stable energy
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. Progression to severe withdrawal with seizures or delirium ✓
B. Improved hydration without intervention
C. Development of a harmless skin rash
D. Expected relaxation and sleepiness
1. Complex adult assessment and interpretation of significant clinical changes
2. Cardiovascular and respiratory priorities including acute deterioration
3. Neurologic disorders, assessment findings, and emergency interventions
4. Renal and endocrine disorders with associated laboratory abnormalities
5. Gastrointestinal and hepatic conditions, complications, and nursing priorities
6. Fluid, electrolyte, and acid-base disturbances with clinical management
7. Medication safety, pharmacologic effects, and monitoring for adverse reactions
8. Postoperative complications, infection, bleeding, and recovery priorities
9. Patient education, discharge planning, and self-management strategies
10. Clinical judgment, prioritization, delegation, and escalation of care
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. Review the complete dietary history
C. Ask the patient to describe the previous night's sleep
D. Assess airway, breathing, and oxygenation ✓
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. Delay assessment until the pain resolves
B. Offer a large meal before testing
C. Encourage the patient to walk to reduce anxiety
D. Assess vital signs and obtain rapid cardiac assessment according to protocol
✓
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. I understand exactly how you feel because I have felt that way too.
B. You should try to think more positively about your situation.
C. There is nothing to worry about because the staff will fix everything.
D. It sounds as though you feel misunderstood; tell me more about that
experience. ✓
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. Simple medication tolerance
B. Mild orthostatic hypotension
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. Mild thirst after exercise
B. A stable appetite with no neurologic changes
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. Tell the patient that suicide would permanently hurt the family
, B. Ask the patient to promise not to self-harm and end the assessment
C. Maintain immediate safety and initiate continuous observation according to
policy ✓
D. Leave the patient alone to encourage independent coping
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. Slowed speech and social withdrawal
B. Markedly decreased need for sleep with increased goal-directed activity ✓
C. Consistent fatigue following routine activities
D. Sleeping ten hours nightly with stable energy
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. Progression to severe withdrawal with seizures or delirium ✓
B. Improved hydration without intervention
C. Development of a harmless skin rash
D. Expected relaxation and sleepiness
