NUR 204 EXAM 1: CRAVEN QUESTIONS
AND VERIFIED CORRECT ANSWERS
GRADED A+ [LATEST 2026-2027] 100%
GUARANTEED PASS
RATIONALE: For a patient managing deficits following a stroke, neurologic and musculoskeletal
system assessments would be a priority. Cardiovascular assessment is not indicated because the
cardiovascular capacity is not directly impacted by this diagnosis. Skin assessment may provide
important clues to the patient's history of accidents or injuries but would not indicate new risk
following a stroke. Respiratory assessment is needed to ensure that the patient's breathing has
not been impacted by the stroke and to assess for choking or aspiration that may occur due to
the stroke.
17. A nurse is evaluating outcome criteria for a patient following a stroke who is at risk for
aspiration. Which of the following would be appropriate goals for this patient? SATA
a. The patient will tuck chin for more effective swallow when drinking thin liquids.
b. The patient will avoid drinking liquids related to increased risk for aspiration.
c. The patient will have no signs or symptoms of aspiration (e.g., coughing).
d. The patient will place food on right side to avoid vision cut. - CORRECT ANSWER-ANSWER: A,
C
RATIONALE: Appropriate goals for this stroke patient are to identify high-risk settings (e.g.,
drinking thin liquids) and to demonstrate appropriate safety habits (chin tuck). Avoiding
drinking liquids is not appropriate at this stage. Compensation for a vision cut is not related to
risk for aspiration.
,17. Restraints should be used for patient safety in which of the following situations? SATA
a. The patient is attempting to remove mechanical ventilator tubing.
b. The patient is at risk for falling due to impaired neurologic status.
c. The patient is confused, is impulsive, and wants to leave the hospital unit.
d. The patient is combative with staff members.
e. The patient is picking at his oxygen tubing but is easily redirected. - CORRECT ANSWER-
ANSWER: A, D
RATIONALE: Restraints are only clinically justified in selected instances to prevent irreparable
harm associated with pulling out therapeutic devices or when endangering self or others. Risk
for falls does not indicate restraint use because restraints have not been shown to reduce fall or
injury rates and may actually increase incidence of unintended negative consequences.
Impulsive behavior and confusion are not indicators for restraints because restraints may
increase agitation and injury. Patients who are easily redirected should be managed without
restraints as long as possible. Redirection can be an effective alternative therapy to restraints.
17. In the event of a fire, what is the most important thing that a nurse needs to do?
a. Give patients wet washcloths to breathe through to reduce smoke inhalation
b. Close windows and doors and turn off oxygen
c. Determine which patients are in immediate danger
d. Evacuate bedridden patients - CORRECT ANSWER-ANSWER: C
RATIONALE: Determining which patients are in immediate danger is the priority for nurses in
case of a fire (assessment of the situation). Giving patients wet washcloths, closing windows,
and evacuating patients are all interventions that should be done once assessment of risk is
complete.
,17. A conscious patient's respiratory function is currently being supported by a mechanical
ventilator. Although the patient has been sedated to facilitate the process, blood pressure and
heart rate still remain slightly elevated. What is the expected outcome on the patient's well-
being of having the nurse sit and hold the patient's hand until a family member comes to spend
the night?
a. The nurse's presence will distract the patient until the family member arrives.
b. A sense of safety and security will help reduce stress and moderate the vital signs.
c. The patient will remember this action with fondness and view the nurse as being a true
advocate.
d. This act of caring will help the patient be more prepared when faced with other medical
interventions. - CORRECT ANSWER-ANSWER: B
RATIONALE: Safety and security are basic human needs, second in priority in Maslow's hierarchy
only to physiologic needs. Safety not only prevents harm and injury but also allows people to
feel secure in their actions. A sense of safety reduces stress, which promotes general health
and, in this case, causes a reduction in blood pressure and heart rate. Although the nurse's
presence may serve as a distraction and proof of the nurse's attention to the patient's needs,
the physical effects are most important to the patient's well-being. This action could better
prepare the patient for future interventions but is secondary to a general sense of well-being.
17. Which statement made by a parent of an 8-month-old demonstrates an understanding of a
necessary safety measure specifically directed toward the child as a result of developmentally
associated behaviors?
a. "Since she has started crawling, we are careful about keeping small objects out of her reach."
b. "We never leave her alone in the bathtub since she is always trying to turn the faucets on."
c. "He loves stairs; we have gates at the top and bottom of every set of steps in the house."
d. "He is always trying to pull the pets' tails, so we can't leave him alone with the pets." -
CORRECT ANSWER-ANSWER: A
, RATIONALE: Because they lack musculoskeletal and neurologic maturity, newborns and infants
are susceptible to choking. As babies gain function, they learn and explore by pulling objects to
themselves and placing things in their mouths, increasing their risk of choking. All the other
options are behaviors and risks associated with the older toddler.
24. A nurse is providing oral care to an elderly patient with dentures who is receiving nothing by
mouth (NPO status) . Which of the following is an appropriate action?
a. Brush dentures and remaining teeth in mouth using toothbrush or swab.
b. Position the patient in Trendelenburg or side-lying position.
c. Place your finger in the mouth of the unconscious patient to open the mouth.
d. Provide oral care daily and as needed to prevent nosocomial pneumonia. - CORRECT
ANSWER-ANSWER: D
RATIONALE: Oral care should be done daily and as needed to manage oral mucosa integrity and
secretions. Dentures should be removed and brushed or soaked in special cleanser. Failure to
remove dentures may lead to bacterial or fungal colonization between the palate and dentures.
The patient should be positioned in the high Fowler's or side-lying position; Trendelenburg
refers to supine with head lower than feet. Never place fingers in the unconscious patient's
mouth because the patient may respond to oral stimulus by biting down.
24. The nurse is caring for a patient with hemiplegia following a severe cerebrovascular
accident. In order to promote independence in self-care, which of the following actions would
be appropriate? SATA
a. Place basin and washcloth on patient's nonaffected side.
b. Assist the patient to bedside commode for toileting.
c. Perform oral care daily. - CORRECT ANSWER-ANSWER: A, B, D
AND VERIFIED CORRECT ANSWERS
GRADED A+ [LATEST 2026-2027] 100%
GUARANTEED PASS
RATIONALE: For a patient managing deficits following a stroke, neurologic and musculoskeletal
system assessments would be a priority. Cardiovascular assessment is not indicated because the
cardiovascular capacity is not directly impacted by this diagnosis. Skin assessment may provide
important clues to the patient's history of accidents or injuries but would not indicate new risk
following a stroke. Respiratory assessment is needed to ensure that the patient's breathing has
not been impacted by the stroke and to assess for choking or aspiration that may occur due to
the stroke.
17. A nurse is evaluating outcome criteria for a patient following a stroke who is at risk for
aspiration. Which of the following would be appropriate goals for this patient? SATA
a. The patient will tuck chin for more effective swallow when drinking thin liquids.
b. The patient will avoid drinking liquids related to increased risk for aspiration.
c. The patient will have no signs or symptoms of aspiration (e.g., coughing).
d. The patient will place food on right side to avoid vision cut. - CORRECT ANSWER-ANSWER: A,
C
RATIONALE: Appropriate goals for this stroke patient are to identify high-risk settings (e.g.,
drinking thin liquids) and to demonstrate appropriate safety habits (chin tuck). Avoiding
drinking liquids is not appropriate at this stage. Compensation for a vision cut is not related to
risk for aspiration.
,17. Restraints should be used for patient safety in which of the following situations? SATA
a. The patient is attempting to remove mechanical ventilator tubing.
b. The patient is at risk for falling due to impaired neurologic status.
c. The patient is confused, is impulsive, and wants to leave the hospital unit.
d. The patient is combative with staff members.
e. The patient is picking at his oxygen tubing but is easily redirected. - CORRECT ANSWER-
ANSWER: A, D
RATIONALE: Restraints are only clinically justified in selected instances to prevent irreparable
harm associated with pulling out therapeutic devices or when endangering self or others. Risk
for falls does not indicate restraint use because restraints have not been shown to reduce fall or
injury rates and may actually increase incidence of unintended negative consequences.
Impulsive behavior and confusion are not indicators for restraints because restraints may
increase agitation and injury. Patients who are easily redirected should be managed without
restraints as long as possible. Redirection can be an effective alternative therapy to restraints.
17. In the event of a fire, what is the most important thing that a nurse needs to do?
a. Give patients wet washcloths to breathe through to reduce smoke inhalation
b. Close windows and doors and turn off oxygen
c. Determine which patients are in immediate danger
d. Evacuate bedridden patients - CORRECT ANSWER-ANSWER: C
RATIONALE: Determining which patients are in immediate danger is the priority for nurses in
case of a fire (assessment of the situation). Giving patients wet washcloths, closing windows,
and evacuating patients are all interventions that should be done once assessment of risk is
complete.
,17. A conscious patient's respiratory function is currently being supported by a mechanical
ventilator. Although the patient has been sedated to facilitate the process, blood pressure and
heart rate still remain slightly elevated. What is the expected outcome on the patient's well-
being of having the nurse sit and hold the patient's hand until a family member comes to spend
the night?
a. The nurse's presence will distract the patient until the family member arrives.
b. A sense of safety and security will help reduce stress and moderate the vital signs.
c. The patient will remember this action with fondness and view the nurse as being a true
advocate.
d. This act of caring will help the patient be more prepared when faced with other medical
interventions. - CORRECT ANSWER-ANSWER: B
RATIONALE: Safety and security are basic human needs, second in priority in Maslow's hierarchy
only to physiologic needs. Safety not only prevents harm and injury but also allows people to
feel secure in their actions. A sense of safety reduces stress, which promotes general health
and, in this case, causes a reduction in blood pressure and heart rate. Although the nurse's
presence may serve as a distraction and proof of the nurse's attention to the patient's needs,
the physical effects are most important to the patient's well-being. This action could better
prepare the patient for future interventions but is secondary to a general sense of well-being.
17. Which statement made by a parent of an 8-month-old demonstrates an understanding of a
necessary safety measure specifically directed toward the child as a result of developmentally
associated behaviors?
a. "Since she has started crawling, we are careful about keeping small objects out of her reach."
b. "We never leave her alone in the bathtub since she is always trying to turn the faucets on."
c. "He loves stairs; we have gates at the top and bottom of every set of steps in the house."
d. "He is always trying to pull the pets' tails, so we can't leave him alone with the pets." -
CORRECT ANSWER-ANSWER: A
, RATIONALE: Because they lack musculoskeletal and neurologic maturity, newborns and infants
are susceptible to choking. As babies gain function, they learn and explore by pulling objects to
themselves and placing things in their mouths, increasing their risk of choking. All the other
options are behaviors and risks associated with the older toddler.
24. A nurse is providing oral care to an elderly patient with dentures who is receiving nothing by
mouth (NPO status) . Which of the following is an appropriate action?
a. Brush dentures and remaining teeth in mouth using toothbrush or swab.
b. Position the patient in Trendelenburg or side-lying position.
c. Place your finger in the mouth of the unconscious patient to open the mouth.
d. Provide oral care daily and as needed to prevent nosocomial pneumonia. - CORRECT
ANSWER-ANSWER: D
RATIONALE: Oral care should be done daily and as needed to manage oral mucosa integrity and
secretions. Dentures should be removed and brushed or soaked in special cleanser. Failure to
remove dentures may lead to bacterial or fungal colonization between the palate and dentures.
The patient should be positioned in the high Fowler's or side-lying position; Trendelenburg
refers to supine with head lower than feet. Never place fingers in the unconscious patient's
mouth because the patient may respond to oral stimulus by biting down.
24. The nurse is caring for a patient with hemiplegia following a severe cerebrovascular
accident. In order to promote independence in self-care, which of the following actions would
be appropriate? SATA
a. Place basin and washcloth on patient's nonaffected side.
b. Assist the patient to bedside commode for toileting.
c. Perform oral care daily. - CORRECT ANSWER-ANSWER: A, B, D
