COMPLEX ADULT HEALTH PREMIUM EXAM PAPER TESTED QUESTIONS CORRECT
ANSWERS
Question:
Which of the following statements regarding pain and anxiety are true? (Select all that apply.) a.
Anxiety is a state marked by apprehension, agitation, autonomic arousal, and/or fearful withdrawal.
b. Critically ill patients often experience anxiety, but they rarely experience pain. c. Pain and anxiety
are often interrelated and may be difficult to differentiate because their physiological and behavioral
manifestations are similar. d. Pain is defined by each patient; it is whatever the person experiencing
the pain says it is.
Answer:
a,c,d
Question:
Choose the items that are common to both pain and anxiety. (Select all that apply.) a. Cyclical
exacerbation of one another b. Require good nursing assessment for proper treatment c. Response
only to real phenomena d. Subjective in nature.
Answer:
a,b,d
Question:
Anxiety differs from pain in that: (Select all that apply.) a. it is confined to neurological processes in
the brain. b. it is linked to reward and punishment centers in the limbic system. c. it is subjective. d.
there is no actual tissue injury.
Answer:
a,b,d
Question:
,In the healthy individual, pain and anxiety: (Select all that apply.) a. activate the sympathetic
nervous system. b. decrease stress levels. c. help remove one from harm. d. increase performance
levels.
Answer:
a,c,d
Question:
The nurse is caring for a 48-year-old patient who is intubated and on a ventilator following
extensive abdominal surgery. Although the patient is responsive, the nurse is not able to read the
patient's lips as the patient attempts to mouth the words. Which of the following assessment tools
would be the most appropriate for the nurse to use when assessing the patient's pain level? (Select all
that apply.) a. The FACES scale b. Pain IntensityScale c. The PQRST method d. The Visual
Analogue Scale.
Answer:
a,d
Question:
In the critically ill patient, an incomplete assessment and/or management of pain or anxiety may be
hampered by which of the following? (Select all that apply.) a. Administration of neuromuscular
blocking agents b. Delirium c. Effective nurse communication and assessment skills d. Nonverbal
patients.
Answer:
a,b,d
Question:
The nurse is caring for a postoperative patient in the critical care unit. The physician has ordered
patient-controlled analgesia (PCA) for the patient. The nurse understands that the PCA: (Select all
that apply.) a. is a safe and effective method for administering analgesia. b. has potentially fewer
side effects than other routes of analgesic administration. c. is an ideal method to provide critically
ill patients some control over their treatment. d. provides good quality analgesia.
Answer:
a,b,d
,Question:
A patient requires neuromuscular blockade (NMB) as part of treatment of refractive increased
intracranial pressure. The nursing care for this patient includes: (Select all that apply.) a.
administration of sedatives concurrently with neuromuscular blockade. b. dangling the patient's feet
over the edge of the bed and assisting the patient to sit up in a chair at least twice each day. c.
ensuring that deep vein thrombosis prophylaxis is initiated. d. providing interventions for eye care,
oral care, and skin care.
Answer:
a,c,d
Question:
The nurse is assessing the critically ill patient for delirium. The nurse recognizes which
characteristics that indicate hyperactive delirium? (Select all that apply.) a. Agitation b. Apathy c.
Biting d. Hitting e. Restlessness.
Answer:
a,c,d,e
Question:
Family assessment is essential in order to meet family needs. Which of the following must be
assessed first to assist the nurse in providing family-centered care? a. Assessment of patient and
family's developmental stages and needs b. Description of the patient's home environment c.
Identification of immediate family, extended family, and decision makers d. Observation and
assessment of how family members function with each other.
Answer:
c
Question:
The constant noise of a ventilator, monitor alarms, and infusion pumps predisposes the patient to: a.
anxiety. b. pain. c. powerlessness. d. sensory overload.
Answer:
, d
Question:
The wife of a patient who is hospitalized in the critical care unit following resuscitation for a sudden
cardiac arrest at work demands to meet with the nursing manager. She states, "I want you to reassign
my husband to another nurse. His current nurse is not in the room enough to make sure he is okay."
The nurse recognizes that this response most likely is due to the wife's: a. desire to pursue a lawsuit
if the assignment is not changed. b. inability to participate in the husband's care. c. lack of prior
experience in a critical care setting. d. sense of loss of control of the situation.
Answer:
D Demanding behaviors often occur when the family member has a sense of loss of control or has
had adverse outcomes in a previous hospitalization. Prevention of a lawsuit is not relevant to this
scenario. No information is provided regarding whether the family member is participating in care
or not. It is not known if she had a prior negative experience or not.
Question:
The VALUE mnemonic is a helpful strategy to enhance communication with family members of
critically ill patients. Which of the following statements describes a VALUE strategy? a. View the
family as guests on the unit. b. Acknowledge family emotions. c. Learn as much as you can about
family structure and function. d. Use a trained interpreter if the family does not speak English. e.
Evaluate each encounter with the family.
Answer:
B The VALUE mnemonic includes the following: V-Value what the family tells you.
A-Acknowledge family emotions. L-Listen to the family members. U-Understand the patient as a
person. E-Elicit (ask) questions of family members.
Question:
The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle
crash. The patient's Glasgow Coma Score is 3 and intermittently withdraws when painful stimuli are
introduced. The patient is ventilator dependent and occasionally takes a spontaneous breath. The
physician explains to the family that the patient has severe neurological impairment and he does not
expect the patient to recover consciousness. The nurse recognizes that this patient is: a. an organ
donor. b. brain dead. c. in a persistent vegetative state. d. terminally ill.
ANSWERS
Question:
Which of the following statements regarding pain and anxiety are true? (Select all that apply.) a.
Anxiety is a state marked by apprehension, agitation, autonomic arousal, and/or fearful withdrawal.
b. Critically ill patients often experience anxiety, but they rarely experience pain. c. Pain and anxiety
are often interrelated and may be difficult to differentiate because their physiological and behavioral
manifestations are similar. d. Pain is defined by each patient; it is whatever the person experiencing
the pain says it is.
Answer:
a,c,d
Question:
Choose the items that are common to both pain and anxiety. (Select all that apply.) a. Cyclical
exacerbation of one another b. Require good nursing assessment for proper treatment c. Response
only to real phenomena d. Subjective in nature.
Answer:
a,b,d
Question:
Anxiety differs from pain in that: (Select all that apply.) a. it is confined to neurological processes in
the brain. b. it is linked to reward and punishment centers in the limbic system. c. it is subjective. d.
there is no actual tissue injury.
Answer:
a,b,d
Question:
,In the healthy individual, pain and anxiety: (Select all that apply.) a. activate the sympathetic
nervous system. b. decrease stress levels. c. help remove one from harm. d. increase performance
levels.
Answer:
a,c,d
Question:
The nurse is caring for a 48-year-old patient who is intubated and on a ventilator following
extensive abdominal surgery. Although the patient is responsive, the nurse is not able to read the
patient's lips as the patient attempts to mouth the words. Which of the following assessment tools
would be the most appropriate for the nurse to use when assessing the patient's pain level? (Select all
that apply.) a. The FACES scale b. Pain IntensityScale c. The PQRST method d. The Visual
Analogue Scale.
Answer:
a,d
Question:
In the critically ill patient, an incomplete assessment and/or management of pain or anxiety may be
hampered by which of the following? (Select all that apply.) a. Administration of neuromuscular
blocking agents b. Delirium c. Effective nurse communication and assessment skills d. Nonverbal
patients.
Answer:
a,b,d
Question:
The nurse is caring for a postoperative patient in the critical care unit. The physician has ordered
patient-controlled analgesia (PCA) for the patient. The nurse understands that the PCA: (Select all
that apply.) a. is a safe and effective method for administering analgesia. b. has potentially fewer
side effects than other routes of analgesic administration. c. is an ideal method to provide critically
ill patients some control over their treatment. d. provides good quality analgesia.
Answer:
a,b,d
,Question:
A patient requires neuromuscular blockade (NMB) as part of treatment of refractive increased
intracranial pressure. The nursing care for this patient includes: (Select all that apply.) a.
administration of sedatives concurrently with neuromuscular blockade. b. dangling the patient's feet
over the edge of the bed and assisting the patient to sit up in a chair at least twice each day. c.
ensuring that deep vein thrombosis prophylaxis is initiated. d. providing interventions for eye care,
oral care, and skin care.
Answer:
a,c,d
Question:
The nurse is assessing the critically ill patient for delirium. The nurse recognizes which
characteristics that indicate hyperactive delirium? (Select all that apply.) a. Agitation b. Apathy c.
Biting d. Hitting e. Restlessness.
Answer:
a,c,d,e
Question:
Family assessment is essential in order to meet family needs. Which of the following must be
assessed first to assist the nurse in providing family-centered care? a. Assessment of patient and
family's developmental stages and needs b. Description of the patient's home environment c.
Identification of immediate family, extended family, and decision makers d. Observation and
assessment of how family members function with each other.
Answer:
c
Question:
The constant noise of a ventilator, monitor alarms, and infusion pumps predisposes the patient to: a.
anxiety. b. pain. c. powerlessness. d. sensory overload.
Answer:
, d
Question:
The wife of a patient who is hospitalized in the critical care unit following resuscitation for a sudden
cardiac arrest at work demands to meet with the nursing manager. She states, "I want you to reassign
my husband to another nurse. His current nurse is not in the room enough to make sure he is okay."
The nurse recognizes that this response most likely is due to the wife's: a. desire to pursue a lawsuit
if the assignment is not changed. b. inability to participate in the husband's care. c. lack of prior
experience in a critical care setting. d. sense of loss of control of the situation.
Answer:
D Demanding behaviors often occur when the family member has a sense of loss of control or has
had adverse outcomes in a previous hospitalization. Prevention of a lawsuit is not relevant to this
scenario. No information is provided regarding whether the family member is participating in care
or not. It is not known if she had a prior negative experience or not.
Question:
The VALUE mnemonic is a helpful strategy to enhance communication with family members of
critically ill patients. Which of the following statements describes a VALUE strategy? a. View the
family as guests on the unit. b. Acknowledge family emotions. c. Learn as much as you can about
family structure and function. d. Use a trained interpreter if the family does not speak English. e.
Evaluate each encounter with the family.
Answer:
B The VALUE mnemonic includes the following: V-Value what the family tells you.
A-Acknowledge family emotions. L-Listen to the family members. U-Understand the patient as a
person. E-Elicit (ask) questions of family members.
Question:
The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle
crash. The patient's Glasgow Coma Score is 3 and intermittently withdraws when painful stimuli are
introduced. The patient is ventilator dependent and occasionally takes a spontaneous breath. The
physician explains to the family that the patient has severe neurological impairment and he does not
expect the patient to recover consciousness. The nurse recognizes that this patient is: a. an organ
donor. b. brain dead. c. in a persistent vegetative state. d. terminally ill.
