NSG 430/ NSG430 Exam 1 (NEW 2026/ 2027 Update) Adult Health Nursing II Complete Guide| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- GCU

NSG 430/ NSG430 Exam 1 (NEW 2026/ 2027 Update) Adult Health Nursing II Complete Guide| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- GCU Q. What is the most well known problem solving process ANSWER Traditional Q. What is the most prominent con of traditional problem solving? ANSWER No objective (time consuming and lengthy) Q. What type of problem solving model is known for establishing an objective? ANSWER Managerial Q. What is the most contemporary problem solving model? ANSWER Integrated Q. What type of problem solving model evaluates outcomes and prevents reoccurrences? ANSWER Integrated Q. What is the name for the formal position or hired to be in the position? ANSWER Manager Q. What is the difference between a manager and a leader? ANSWER The key differences between leadership and management stem from different goals related to focus, position, and outcomes. Management = defense - Identifies recurring problems Leadership = offense - Critical thinker, future oriented & a creative problem solver Q. What are the goals of a manager? ANSWER A manager does things right Focuses on the present and compliance "Who can do this better? How can we do it better?" Outcome goal: Compliance Q. What are the four management functions? ANSWER Planning Organizing Directing Controlling Q. What are the goals of a leader? ANSWER Leadership is gained by the ability to influence others A leader does the right thing Focuses on future and change "What does this mean?" Outcome goal: Improvement Q. What is AONE/AONL? ANSWER American Organization of Nurse Executives/Leadership Published 5 competencies to support nurse manager development, they are: - Communication and relationship building - Knowledge of the healthcare environment - Leadership skills - Professionalism - Business Skills Q. What is a clinical nurse leader (CNL)? ANSWER Master's-prepared nurses who oversee and manage care in various settings Clinical experts who may, on occasion, actively provide direct patient care Not intended to be administrators or managers Provide and manage care for patients, individuals, families, and communities Prepared to facilitate a culture of safety for specific groups of patients Q. What are the levels of management? ANSWER Top level - CEO, CNO, VP, CFO, CN Middle level - Nsg. Supv., Managers, HN, Unit managers First Level - Primary care nurses/staff nurses Q. True or False: Charge nurse is considered middle management ANSWER False (non-traditional role, not hired with that direct purpose) Q. Who is held accountable for what happens on the floor 24/7? ANSWER Nurse manager Q. Charge nurses are an example of what level? ANSWER First Q. What are the three main responsibilities of a charge nurse? ANSWER Planning, coordinating, and evaluating unit nursing activities. Q. Case managers are an example of what level? ANSWER First Q. Unit managers are an example of what level? ANSWER Middle Q. What is the Magnet Recognition Program? ANSWER American Nurses Credentialing Center awards this to facilities that provide high quality pt care & attract & retain well qualified nurses Q. What are the three traditional leadership theories? ANSWER Trait Behavioral Contingency Q. What is contingency leadership? ANSWER Aka situational leadership This model was among the first to view an organization as a social system of contingencies. Contingency theory varies between authoritarian and permissive (laissez-faire) Q. What is authoritative leadership? ANSWER Aka micromanaging Strong control is maintained over the work group Others are motivated by coercion Others are directed with commands Communication flows downward Decision making does not involve others Emphasis is on difference in status ("I" and "you") Criticism is punitive Q. What is the outcome of authoritative leadership? ANSWER Well-defined group actions that are usually predictable, reducing frustration in the work group and giving members a feeling of security Productivity is usually high, but creativity, self-motivation, and autonomy are reduced Q. Where is authoritative leadership found? ANSWER Authoritarian leadership is frequently found in very large bureaucracies such as the armed forces Q. What is democratic leadership? ANSWER Less control is maintained Economic and ego awards are used to motivate Others are directed through suggestions and guidance Communication flows up and down Decision making involves others Emphasis is on "we" rather than I and you Criticism is constructive Q. What is laissez-faire leadership? ANSWER Grants responsibility and authority to the group and lets staff act as they wish Takes a hands-off approach. Is permissive, with little or no control or direction Uses upward and downward communication between members of the group. Q. What type of leaders seek input from their followers and include them in decision making when possible? ANSWER Democratic Q. What are stakeholders? ANSWER Those entities in an organization's environment that play a role in the organization's health and performance or that are affected by the organization Q. What is the difference between internal and external stakeholders? ANSWER Internal - nurse in a hospital or the dietitian in a nursing home External - local school of nursing, home health agencies, and managed care providers who contract with consumers in the area Q. Cultural bridging recognizes that organizations encompass and/or are what? ANSWER Diverse cultures and societies International nurses Generational diversity Sharing of cultural differences Q. What are internal climates? ANSWER Values, feelings, temperament and stress levels of the sender and receive What are external climates? Weather, temperature, timing Also includes status, power and authority as barriers to manager subordinate communication Whether/weather ppl comfortable Which type of interactional leadership focuses on what needs to be done and making things happen? Transactional Which type of interactional leadership focuses on common values and effects? Transformational Which type of interactional leadership motivates/inspires and empowering/visionary? Transformational Which type of interactional leadership focuses on day to day and causes? Transactional Which type of interactional leadership uses trade offs/contingency awards and has limited shared values? Transactional Who focuses on the process of the group: leaders or managers? Leaders What influences the quality of a decision most often? A) The decision maker's immediate superior B) The type of decision that needs to be made C) Questions asked and alternatives generated D) The time of day the decision is made C) Questions asked and alternatives generated What does knowledge about good decision making lead one to believe? A) Good decision makers are usually right-brain, intuitive thinkers B) Effective decision makers are sensitive to the situation and to others C) Good decisions are usually made by left-brain, logical thinkers D) Good decision making requires analytical rather than creative processes B) Effective decision makers are sensitive to the situation and to others What is the best definition of decision making? A) The planning process of management B) The evaluation phase of the executive role C) One step in the problem-solving process D) Required to justify the need for scarce items C) One step in the problem-solving process If decision making is triggered by a problem with what does it end? A) An alternative problem B) A chosen course of action C) An action that guarantees success D) A restatement of the solution B) A chosen course of action Why do our values often cause personal conflict in decision making? A) Some values are not realistic or healthy B) Not all values are of equal worth C) Our values remain unchanged over time D) Our values often collide with one another D) Our values often collide with one another Which statement is true concerning critical thinking? A) It is a simple approach to decision making B) It is narrower in scope than decision making C) It requires reasoning and creative analysis D) It is a synonym for the problem-solving process C) It requires reasoning and creative analysis What type of brain dominance creates a management style that is highly organized and detail oriented? A) Upper left brain B) Upper right brain C) Lower left brain D) Lower right brain C) Lower left brain Which statement demonstrates a characteristic of a critical thinker? Select all that apply. A) "Since that didn't work effectively, let's try something different." B) "The solution has to be something the patient is willing to do." C) "I'll talk to the patient's primary care giver about the problem." D) "Maybe there is no new solution to this particular problem." A) "Since that didn't work effectively, let's try something different." B) "The solution has to be something the patient is willing to do." C) "I'll talk to the patient's primary care giver about the problem." What is the value of using a structured approach to problem solving for the novice nurse? A) Facilitates effective time management B) Supports the acquisition of clinical reasoning C) Supplements the orientation process D) Encourages professional autonomy B) Supports the acquisition of clinical reasoning What is the advantage of using a payoff table when applicable? A) It assures the correct decision when dealing with financial situations B) It is very helpful when quantitative information about the topic is available C) It assists in the visualization of the available historic and current data D) It is easy to construct even for the novice decision maker C) It assists in the visualization of the available historic and current data Which represents the management functions that are incorporated into the management process? A) Planning, directing, organizing, staffing, and evaluating B) Planning, organizing, staffing, directing, and controlling C) Organizing, planning, staffing, directing, and evaluating D) Organizing, staffing, planning, implementing, and controlling B) Planning, organizing, staffing, directing, and controlling Managing conflict among staff members would occur in which part of the management process? A) Planning B) Organizing C) Directing D) Evaluating C) Directing Gardner states that integrated leaders-managers distinguish themselves from more traditional managers in six ways. Which is a distinguishing trait of a traditional manager rather than an integrated leader-manager? A) They are politically astute B) They look outward, toward the larger organization C) They extend influence only to their own group D) They emphasize vision, values, and motivation C) They extend influence only to their own group What is a distinguishing trait of integrated leader-managers? Select all that apply. A) Inward thinkers B) Long-term thinkers C) Concerned with employee motivation D) Possess influence beyond their own group B) Long-term thinkers C) Concerned with employee motivation D) Possess influence beyond their own group What is the typical focus of managers? Select all that apply. A) Establishing a legitimate source of power B) Delegating responsibilities to staff members C) Formulate the budget to achieve the stated goals D) Direct attention to the management of unwilling subordinates A) Establishing a legitimate source of power B) Delegating responsibilities to staff members C) Formulate the budget to achieve the stated goals Which activity is associated with a leadership role? Select all that apply. A) Mentoring two new managers B) Establishing goals for the coming year C) Advocating for employee regarding personal policies D) Providing a motivational speech at the new employee orientation All A) Mentoring two new managers B) Establishing goals for the coming year C) Advocating for employee regarding personal policies D) Providing a motivational speech at the new employee orientation The failure to engage in which activity is considered a fatal flaw of leadership? Select all that apply. A) Collaboration B) Communication C) Self-improvement D) Staff development All A) Collaboration B) Communication C) Self-improvement D) Staff development Which statement by a subordinate demonstrates the greatest problem for the leader? A) "Your plans for the changes will be difficult to implement." B) "I don't think you heard what the rest of us had to say." C) "Do you have an idea what direction we need to go?" D) "Can you tell me why my suggestion will not work?" A) "Your plans for the changes will be difficult to implement." Which function of the management process involves the performance evaluation of staff? A) Planning B) Organizing C) Staffing D) Controlling D) Controlling To decrease overtime, the manager of a surgical unit offers nurses who get their work finished on time for an entire 2-month period an extra day off with pay at regular time. What is this an example of? A) Bribing nurses B) Quantum leadership C) Principal agent theory D) Servant leadership C) Principal agent theory What is an example of a positive outcome of a leader's emotional intelligence? A) Emotions are held in check B) Emotions are used effectively C) Expression of one's emotions is expected D) Expression of one's emotions is encouraged B) Emotions are used effectively A transition has occurred in the twenty-first-century industrial age leadership to what type of leadership? A) Relationship age B) Quantum C) Authentic D) Thought A) Relationship age Which statement about organizational centrality is true? A) It refers to the decision-making structure in an organization B) It occurs when there is consonance of subunit cultures in the organization C) It is a position on the organizational chart where types of communication occur D) It occurs primarily in line relationships C) It is a position on the organizational chart where types of communication occur What is needed to change a unit culture that has become firmly entrenched? A) New leadership B) A change agent with management skills C) Identification with a unit that is not entrenched D) Administration support A) New leadership What is the primary responsibility of the committee chairperson during a committee meeting? A) Keeping members on task B) Asking questions C) Resolving conflicts D) Providing information on each agenda item A) Keeping members on task What is the leadership role when a unit is attempting to overcome the decentralization of patient care? A) Determining what changes will be made to the plan of care B) Facilitating the group's work C) Identifying the patient care problems D) Selecting solutions to problems B) Facilitating the group's work When considering the interprofessional approach to healthcare, to whom does the nurse owe accountability? Select all that apply. A) The physician B) Their patients C) Their unit manager D) Their director of nursing All A) The physician B) Their patients C) Their unit manager D) Their director of nursing Which statement is true concerning a bureaucratic organization? Select all that apply. A) It is commonly referred to as a line organization B) It is typically found in large health-care organizations C) They resemble Weber's original design of organization D) Its authority is represented by its staff organizational chart All A) It is commonly referred to as a line organization B) It is typically found in large health-care organizations C) They resemble Weber's original design of organization D) Its authority is represented by its staff organizational chart What are the three components of decision making? Clinical Reasoning Problem Solving Critical Thinking Critical thinking is also known as? Reflective thinking What is critical thinking? Higher order thinking Examine assumptions Explore alternatives Reflective thinking What is clinical reasoning? Critical thinking + clinical judgement Higher order thinking Identify problems Direct actions Reasons about a situation as it unfolds, based on knowledge and experience Which decision making process is broad and general? Critical Thinking Which decision making process is based on patho and knowledge of medications (how does this lower the BP)? Clinical Reasoning Which decision making process involves bringing in your knowledge and experience? Clinical Reasoning Which decision making process is about handling a situation as it unfolds? Clinical Reasoning Which decision making process is based on knowledge and experience? Clinical Reasoning Which decision making process always includes a decision-making step? Problem Solving Which decision making process attempts to find the root of the problem? Problem Solving Which decision making process identifies problems? Clinical Reasoning What is the first step in managerial decision-making model? A) Identify the problem. B) Evaluate alternatives. C) Gather data. D) Set objectives D) Set objectives Which is a characteristic of a successful decision maker? A) Impulsiveness B) Courage C) Decisiveness D) Whimsy B) Courage Which is NOT a factor in solving a problem successfully? A) Using an evidence-based approach B) Doing all work independently C) Stating a clear objective D) Watching for faulty logic B) Doing all work independently What are the four qualities of a successful decision maker? Courage - to take risks Sensitivity - to situation and others Energy - to make things happen Creativity - to develop new ways to solve problems. Nurse Jones is the Unit Director for 2 North Unit. While leading the morning huddle; she informed the unit of the scheduling requirements and the deadline period for requests. This information supports which of the below roles? A) Leadership B) Management C) Motivator D) Visionary B) Management Nurse Murphy, manager of 6N is formulating goals, developing action statement & rules. She is implementing which management function. A) Controlling B) Directing C) Organizing D) Planning D) Planning What is the most critical leadership skill? Communication - core of management activity (versus decision making being a core management function) Women communicate more _____ Collaboratively Men communicate more _____ Straightforward What is a chain of command? One of the key elements within the organizational structure, along with span of control, managerial levels, and centrality. A chain of command is an organizational structure that documents how each member of a company reports to one another. What is downward communication? Usually form manager to staff Traditional Primarily directive What is upward communication? Usually from staff to management Allows employee input Staff satisfaction high Supervisor passes up Staff satisfaction is less when it comes to what type of communication? Downward - satisfaction less for subordinates Employee handbook, reports, job descriptions are all examples of what type of communication? Downward How can hierarchical layers be removed and the organization be decentralized? What is the result? A Flat Organization flattens the chain of command by removing hierarchical layers and decentralizing the organization which then increases the managerial span of control. Staff meetings and suggestion boxes are all examples of what type of communication? Upward Bias and filtering increase as information is passed is what direction? Upward What is horizontal communication? Managers interact with others on the same hierarchical level Worker to worker What is diagonal communication? Managers interact with personal and managers form other departments and groups such as physicians Tends to be less formal Which channel of communication tends to be less formal (not the most informal)? A) Horizontal B) Diagonal C) Upward D) Downward Diagonal What is the most informal type of communication? Grapevine What is incongruent communication? When the thoughts, ideas, and information exchanged do not have the same meaning for both the sender and the receiver of the message Verbal and nonverbal communication may not match If verbal and nonverbal messages are incongruent, the receiver will believe which type of message? The nonverbal message What is the most reliable communication mode? Nonverbal True or False: Communication has the greatest likelihood of being accurately interpreted when it's face to face True What type of communication always requires that verbal and nonverbal messages be congruent? Assertive What type of communication allows people to express themselves in direct, honest, and appropriate ways that do not infringe on another person's rights. Assertive - goal oriented decreases stress What are the four types of communication? Assertive Passive Aggressive Passive aggressive What type of communication occurs when a person suffers in silence, although he or she may feel strongly about the issue? Passive What type of communication involves expressing oneself in a direct and often hostile manner that infringes on another person's rights? Aggressive - generally oriented to "winning at all costs" What type of communication involves limited verbal behavior with incongruent nonverbal behavior? Passive aggressive The average person spends ___% of his or her time listening, but only one-third of all messages are retained. 70 What does GRRRRR stand for? greeting respectful listening review recommend request reward When may GRRRRR be helpful? Helpful in organizations where disruptive behavior, toxic environments, and power struggles interfere with listening. A longitudinal electronic record of patient health information produced by encounters in one or more care settings EHR Which nurse is most likely to get bullied? A) international nurse B) new grad C) older nurse D) new nurse to unit B) new grad What is the competing method of conflict resolution? One party pursues what it wants regardless of the cost to others. Used when a quick, unpopular decision has to be made What is the accommodating method of conflict resolution? One party sacrifices his or her beliefs and wants to allow the other party to win What is the smoothing method of conflict resolution? An individual attempts to reduce the emotional component of the conflict True or False: Concentrate on understanding and not on agreement. True A critical goal in ____________ is that both parties perceive that they have won something that they want Negotiation Greatest challenge in consensus building is _____ Time When does communication have the greatest likelihood of being accurately interpreted? A) More than one mode is used B) Face-to-face communication is used C) Written communication is used D) The sender repeats the message using the same mode A) More than one mode is used Which behaviors would be associated with a group in the "norming" stage? A) Group members actively attempt to impress each other with their credentials B) Group members establish short- and long-term goals for the group to accomplish C) Group members achieve stated goals D) The group terminates and celebrates its accomplishments B) Group members establish short- and long-term goals for the group to accomplish What location of the SBAR charting tool states the patient's problem? A) Situation B) Background C) Assessment D) Recommendation C) Assessment What is the traditional form of communication in organizations that helps to coordinate activities in various levels of the hierarchy? A) Upward B) Downward C) Horizontal D) Diagonal B) Downward Which behavior by a team member is demonstrated through cynicism and a nonchalance attitude about the group's work? A) Blocker B) Playboy C) Dominator D) Recognition seeker B) Playboy A nurse sits at the foot of a patient's bed during an admission interview. This positioning supports the proxemics concept of which psychological comfort zone? A) Intimate relationships B) Personal interactions C) Social exchange D) Public distance D A charge nurse assists a group of personnel to resolve their conflict, with the outcome being that the two opposing goals were discarded and new goals were adopted. What is this an example of? A) Smoothing of conflict by the leader B) Facilitating collaboration among personnel C) A majority rule approach D) A good lesson in compromising B) Facilitating collaboration among personnel What did the interactionist theorists of the 1970s believe about organizational conflict? A) It should be dealt with immediately B) It should be encouraged C) It was an indication of poor management D) It should be avoided B) It should be encouraged What term is used when two or more people have conflict about values or goals? A) Intergroup conflict B) Common control C) Intrapersonal conflict D) Interpersonal conflict D) Interpersonal conflict Which statement is true concerning perceived conflict? A) It develops during the first stage of the conflict process B) It is sometimes referred to as antecedent conflict C) It occurs if the conflict is intellectualized D) It occurs when the conflict is emotionalized C) It occurs if the conflict is intellectualized What is the most important criterion for success for health-care providers collaborate on patient care? A) Having mutual respect for one another's knowledge and expertise B) Having the skills to negotiate successfully C) Liking each other enough to want to collaborate D) Being willing to cooperate with each other A) Having mutual respect for one another's knowledge and expertise A registered nurse reports to the nurse-manager that the team's nursing assistant regularly fails to complete assigned tasks. The nurse-manager responds that it is the nurse's responsibility to talk with the nursing assistant about this problem. The manager is engaged in what aspect of conflict? A) Conflict avoidance B) Conflict smoothing C) Encouraging competitive conflict D) Facilitating conflict resolution D) Facilitating conflict resolution What is "Consensus" in negotiation referring to? A) One party wins at the expense of another B) The willingness by all parties to accept agreed-on conditions C) The most rapid conflict resolution strategies D) An unanimous decision has been reached B) The willingness by all parties to accept agreed-on conditions The nurse-manager is negotiating for the funds necessary to purchase several new isolettes for the facility's newborn nursery. The Chief Financial Officer (CFO) states, "I've always been curious about that piece of equipment; how does it actually work?" What negotiation action has the CFO engaged in? A) Collaborating B) Smoothing C) A diversionary tactic D) Appropriate fact finding C) A diversionary tactic The nurse-manager facilitates a conflict that involves the delineation of staff job descriptions. What is this an example of? A) Responsibility charting B) Smoothing conflict C) Alternate dispute resolution D) Mediation counseling A) Responsibility charting What are the least common sources of organizational conflict? A) Communication problems B) Organizational structure C) Individual behavior within the organization D) Self-scheduling D) Self-scheduling What is the name given to the first stage in the conflict process? A) Latent B) Perceived C) Felt D) Manifest A) Latent What is the function of an ombudsperson? A) Providing expert testimony in conflict cases B) Mediating disputes between an organization and its employees C) Educating individuals involved in a grievance situation of their rights D) Monitoring the implementation of the terms of a conflict's compromise C) Educating individuals involved in a grievance situation of their rights A nurse-manager is engaged in a negotiation with staff representatives when the discussion becomes controlled by a particularly aggressive member. Which action will the nurse-manager take to assure that the process is successful? A) Asks that the aggressive individual recognize the rights of all the other members B) States, "I need to have time to think over all that we have discussed." C) Halts any discussion until new representatives can be appointed D) Shares with the members that aggressiveness negatively impacts the negotiations B) States, "I need to have time to think over all that we have discussed." Which personal characteristics will best help meet the psychological needs of conflict negotiation? A) Perseverance and assertiveness B) Calmness and self-assuredness C) Compassion and reflectiveness D) Organization and preparedness B) Calmness and self-assuredness Mrs. Thorne has a subarachnoid hemorrhage (SAH) which may be a result of bleeding from a cerebral aneurysm. You know that SAH resulting from a cerebral aneurysm is characterized by: arterial bleeding into the subarachnoid space Which of the following describes the correct procedure for testing for Kernig's sign? Passively flex one of the patient's legs at the hip and knee and then extend her knee while observing for pain or resistance You note that Mrs. Thorne arrived from the Emergency Department (ED) with a peripheral IV line through which dextrose 5% in water is slowly infusing at 75 mL per hour. Which of the following is indicated? Question the infusion solution After subarachnoid hemorrhage (SAH) due to bleeding from a cerebral aneurysm, patients like Mrs. Thorne are at high risk for complications. Besides rebleeding, complications include: hydrocephalus, cerebral vasospasm, seizures Mrs. Thorne requires frequent neurological assessment for signs of increased intracranial pressure (ICP). In assessing Mrs. Thorne for indications of increased ICP, which of the following assessments is most important? Level of consciousness You know that the Glasgow Coma Scale (GCS) is used to grade level of consciousness based on assessment of: eye opening ability, motor responses, verbal responses Which of the following clinical signs and symptoms would you expect in a patient with a total Glasgow Coma Scale (GCS) score of 15? spontaneous opening of the eyes, alert and oriented behavior, appropriate response to commands You dim the lights around Mrs. Thorne and examine her eyes, comparing pupil size bilaterally. Pupil size is similar at 4 mm. This finding is: normal You also check pupil response to light. Brisk consensual pupil __________ in response to light is observed, which is normal. constriction Intracranial pressure (ICP) monitoring is initiated with Mrs. Thorne. She has an intraventricular catheter and ICP monitor in place. An initial ICP reading of 20 mm Hg is obtained. An ICP reading of 20 mm Hg is: high At the time Mrs. Thorne's initial ICP reading of 20 mm Hg was obtained, her BP was 150/90. Her CPP at that time was: 90 mm Hg In caring for Mrs. Thorne, you use interventions aimed at preventing/controlling increases in intracranial pressure (ICP). These include: maintaining head of bed elevation, avoiding neck flexion, spacing patient care activities, maintaining a relaxed physical and emotional environment Mrs. Thorne has many needs. You take time to work on her plan of care. Which of the following are relevant for Mrs. Thorne? Self-Care Deficit Syndrome, Deficient Knowledge, Risk for Impaired Skin Integrity, Risk for Injury, Decreased Intracranial Adaptive Capacity. "Triple H" therapy is commonly used to treat cerebral vasospasm, with the aim of preventing stroke. You know that "triple H" therapy involves use of: Hypertension, Hypervolemia, Hemodilution Which complication would the nurse assess in both clients who have Parkinson disease and clients who have myasthenia gravis? a. cogwheel gait b. impaired cognition c. difficulty swallowing d. nonintention tremors c. difficulty swallowing Which explanation would the nurse provide to a client about TIAs? a. Temporary episodes of neurological dysfunction b.Intermittent attacks caused by multiple small clots c.Ischemic attacks that result in progressive neurological deterioration d.Exacerbations of neurological dysfunction alternating with remissions a. Temporary episodes of neurological dysfunction Which goal is a priority for a client who is unconscious after a cerebrovascular accident? a. promoting elimination b. maintaining the airway c. optimizing fluid volume d. preserving skin integrity b. maintaining the airway While caring for a client who sustained a severe head injury in a motor vehicle accident, the nurse observes that the client is constantly passing urine and is dehydrated. What does the nurse suspect as the cause for the client's condition? a. decreased secretion of aldosterone b. decreased secretion of antidiuretic hormone c. decreased secretion of parathyroid hormone d. decreased secretion of atrial natriuretic peptide b. decreased secretion of antidiuretic hormone When assessing LOCs, which one of the four clients would the nurse identify as having the lowest neurological function? a. eye movement: spontaneous; motor response: localizes pain; verbal response: inappropriate words b. eye movement: opens on pain; motor response: flaccid; verbal response: incomprehensible sounds c. eye movement: spontaneous; motor response: normal flexion; verbal response: oriented d. eye movement: opens on sound; motor response: abnormal extension; verbal response: confused conversation b. eye movement: opens on pain; motor response: flaccid; verbal response: incomprehensible sounds Which assessment would be the priority for the nurse to complete for the client that has GBS with rapidly ascending paralysis? a. monitoring urinary output b. assessing nutritional status c. monitoring respiratory status d. assessing communication needs c. monitoring respiratory status A client asks the nurse what causes the sudden loss of vision common in persons with MS. Which factor would the nurse include in the explanation? a. virus-induced iritis b. intracranial pressure c. closed-angle glaucoma d. optic nerve inflammation d. optic nerve inflammation A client with GBS has been hospitalized for 3 days. Which assessment data would the nurse plan to monitor frequently for this client? a. localized seizures b. skin desquamation c. hyperactive reflexes d. ascending weakness d. ascending weakness Which clinical indicators should the nurse consider evidence of increasing ICP? SATA. a. vomiting b. irritability c. hypotension d. increased respirations e. decreased LOC a. vomiting b. irritability e. decreased LOC Which is the priority nursing intervention for a client admitted to the hospital with a cerebrovascular accident? a. changing position every 2 hrs b. keeping a serial record of the pulse c. performing ROM exercises d. monitoring for increased ICP d. monitoring for increased ICP Which clinical finding would the nurse expect when assessing a client who has cardiogenic shock? SATA. a. pallor b. agitation c. tachycardia d. narrow pulse pressure e. decreased respirations a. pallor b. agitation c. tachycardia d. narrow pulse pressure How would the nurse describe cardiogenic shock when a family member of a patient asks for more info about the condition? a. an irreversible phenomenon b. a failure of the circulatory pump c. usually a fleeting reaction to tissue injury d. generally caused by decreased blood volume b. a failure of the circulatory pump Which statement reflects understanding of sepsis screening requirements by the nurse a. Blood cultures are required to diagnosis sepsis and begin sepsis protocols. b. An oral temperature of 96.4°F (35.8°C) is not an indicator of sepsis. c. A primary health care provider's prescription is required to screen for sepsis. d. Sepsis mortality is affected greatly by treatments performed in the first 6 hours d. Sepsis mortality is affected greatly by treatments performed in the first 6 hours Which change in the client's lab results indicates the client is experiencing septic shock? a. BG of 80 b. an increased serum lactate level c. an increased neutrophil level d. a WBC of 5000 b. an increased serum lactate level A client receiving a blood transfusion reports itching and difficulty breathing. The heart rate has increased, and the blood pressure is falling. Which type of shock would the nurse suspect? A) Septic shock B) Cardiogenic shock C) Neurogenic shock D) Anaphylactic shock D) Anaphylactic shock Which type of collaborative action would the nurse anticipate the need to rapidly implement when caring for a client who has a BP of 80/60 and HR of 120 after a MVA? a. increasing circulating blood volume b. administer arterial vasopressors c. stimulate increased HR d. correct electrolyte disturbances a. increasing circulating blood volume Which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm? 1. Obstructive 2. Neurogenic 3. Cardiogenic 4. Hypovolemic 4. Hypovolemic A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? a. respirations of 10 b. urine output of 30 mL/hr c. lethargy d. restlessness d. restlessness Which complication will the nurse anticipate when caring for a client in late hypovolemic shock? a. hypokalemia b. metabolic acidosis c respiratory alkalosis d. decreased Pco2 levels b. metabolic acidosis When a client is admitted to the ED with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? SATA. a. bradycardia b. hypotension c. spastic paralysis d. urinary retention e. increased pulse pressure a. bradycardia b. hypotension d. urinary retention