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1. A patient with alcohol withdrawal comes into the ER what is a correct
question the nurse should ask.
a What have you been drinking
b when was your last drink
c. Have you always drank
d. how does your family feel about you drinking - ANSWER b
the nurse must assess to find out what the timeframe of withdrawal is
2. A patient who has just received Narcan is demanding to leave the hospital
what is the nurses best response.
a. You are not allowed to leave at this time
b. You must have someone pick you up
c. If you leave you have the potential to overdose again
d. You must be medically cleared by the doctor before you can leave -
ANSWER c
the patient is allowed to leave at any time, the nurse must educate the patient on
the potential to overdose again as the effects of Narcan do not last
3. A person experiencing hallucinations is found sitting in a neighbors garden
picking flowers naked what is the most correct intervention
, a. Bring the person into the hospital
b. allow the person to continue this behavior
c. Ask the person what the hallucinations are telling them to do
d. Tell the person they must take their medication - ANSWER c.
a person cannot be brought in because of this act, it is important to find out why
and what the hallucinations are telling them to do. as long as the person is safe
there is no need to bring them in
4. What does the CIWA scale do
a. assessment guidelines for alcohol withdrawal stages
b. assessment to administer Ativan PRN
c. tells the nurse what type of withdrawal the patient is experiencing
d. Tells the nurse the type of alcohol the patient is using - ANSWER b
shows the amount of Ativan the patient needs by assessing symptoms
5. A nurse is caring for a patient with Alzheimers the patient is currently
getting ready for the day what is the most appropriate intervention for the
nurse
a. Put on the patients clothes without their help
b. tell the patient to put on their shirt and walk away
c. Tell the patient to put their arm in the sleeve then over their head
d. allow the patient to stay in bed if not understanding - ANSWER c
the patient requires simple direction and the nurse must encourage
independence by allowing the patient to perform the task while explaining to
the patient how to
,6. A patient with Alzheimers is currently stating they are in the 1950s and must
get to work what is an appropriate intervention
select all that apply
a. Tell the patient you will help them get to work
b. hang calendars and clocks to help reorient the patient
c. Tell the patient it is 2023 and have them help fold laundry
d. Allow the patient to continue to think it is 1950 - ANSWER b and c
The nurse must reorient the patient
7. A patient is diagnosed with delirium what is the cause of this
a. a mental disease caused by dementia
b. The patient has a UTI
c. The patients brain is deteriorating
d. The patient has never had a underlying problem - ANSWER b
Delirium is caused by underlying issues such as UTI, surgery, medications etc.
8. A patient in the psych unit suffering from schizophrenia is refusing to take
medication what is the most appropriate response by the nurse
a. You must take your medication you have no choice
b. I will be very happy with you if you take your medication
c. Tell me the reason for not wanting to take the medication
d. Why do you not want to take your medication - ANSWER C
The nurse must find out why the patient does not want to take medication
the other answers are nontheraputic
9. What is an appropriate intervention for a patient experiencing delirium
, a. Keep a well stimulated environment with loud noises and low lights
b. approach the patient slowly from the back
c. Provide a routine created by the patient and nurse
d. restrain the patient - ANSWER C
a patient experincing delirium requires a consistent environment
the nurse should approach the patient from the front not the back and have a
low stimulated environment that is well lit
10.A patient with Alzheimers is in the Mild stage what will this look like
select all that apply
a. The patient has impaired communication
b. The patient is unable to identify objects and words
c. The patient forgets what they ate for lunch today
d. the patient has noticed they forget things
e. the patient is experiencing depression
f. the patient needs help choosing proper clothes - ANSWER c, d, e,
The patient still has function but is able to work and be social
the patient is still able to experience depression in the early stage
11.A patient taking first generation antipsychotics is experiencing EPS what
medication can the nurse expect to treat these
a. Aricept
b. Olanzapine (Zyprexa)
c. Congetin
d. Suboxone - ANSWER C
congetin treats EPS
12.A patient who is going through alcohol withdrawal is needing medication
what medication can the nurse expect to be ordered
A Narcan