The charge nurse is having trouble finding nurses who will accept responsibility for the
"difficult" patient and family who have been on the unit for 2 months. Once the assignment is
determined for the next shift, the next action of the nurse might be to:
A. Hold a family meeting and demand that their behavior change at once
B. Call the nursing supervisor and have the patient transferred to another unit
C. Arrange to have a nursing care conference and discuss possible solutions
D. Put a note by the charge nurse station to always assign this patient to the float or PRN nurse -
ANSWER-C. Arrange to have a nursing care conference and discuss possible solutions
Communication, collaboration, and a consistent plan are what's needed. If this had been done
earlier, the situation this shift might have been avoided.
Three days after undergoing elective hip replacement, a patient has HR 125, RR 36, BP 164/84;
is diaphoretic; has dilated pupils; is anxious; denies pain; and appears to be having tactile
hallucinations. Despite frequent reorientation from the nurse, the patient continues to try to
climb out of bed. Which of the following ordered might be appropriate?
A. Lorazepam (Ativan)
B. Soft wrist restraints
C. Methadone
D. Leaving the TV or radio on in the room for background noise - ANSWER-A. Lorazepam
(Ativan)
The timing and assessment indicate the patient might be in alcohol withdrawal or heading into
DT's. Of the 4 choices, prescribing a benzo would be the most appropriate.
,A patient with a documented history of schizophrenia is admitted with DKA. A priority of the
admitting nurse would be to:
A. Review all per admission medications
B. Contact the patient's counselor
C. Hold all psychiatric medications pending glucose regulation
D. ask the patient if he is hearing voices - ANSWER-A. Review all per admission medications
Is a priority for patient admissions
A nurse walks into the family waiting room and discovers a physical altercation between two
visitors has just begun. The nurse should:
A. Get between the 2 individuals and tell them their behavior is inappropriate
B. ask the largest man in the waiting room to break it up
C. Pull the fire alarm by the door
D. Call security - ANSWER-D. Call security
Think safety first, for yourself and everyone else. Our security colleagues are trained to handle
these situations
The wife of a patient recently admitted because of a single vehicle crash tells the nurse "I'm
afraid he was trying to kill himself." A priority for the nurse would be to:
A. Identify if the patient has a history of depression
B. Ask the patient directly about suicidal intent with the wife in the room
C. Obtain an order for a psych consult
D. Ensure the suicide assessment is completed in the electronic health record - ANSWER-D.
Ensure the suicide assessment is completed in the electronic health record
,This screen/ assessment tool guides the health care team in determining a treatment plan
Which of the following actions by the nurse might decrease a patient's self-esteem?
A. Discussing the negative consequences of the patient's condition
B. Requiring the patient to participate in all treatments
C. Providing opportunities to discuss issues important to the patient
D. Indicating his or her acceptance of the patient's condition - ANSWER-B. Requiring the patient
to participate in all treatments
The 2 key words being requiring and all. We can't require an adult to do anything. When we
start thinking we can, we are behaving paternalistically.
A 22 year old patient has been declared brain dead. The parents decide to discontinue feeding
and donate their child's organs. In response to the parents' request, the most appropriate
action by the nurse would be to:
A. Contact the organ procurement agency
B. Convene a multidisciplinary care conference
C. Tell the parents that the condition precludes organ donation
D. Discontinue the feeding per their request - ANSWER-A. Contact the organ procurement
agency
We collaborate with this agency to be the primary communicator with potential donor families
A patient in the ICU is confused about time and place, despite frequent reorientation. For the
patient's safety, the nurse would initially:
A. Put a vest restraint on the patient
B. Ask the family member to stay with the patient
C. Administer a mild sedative
, D. Increase the frequency of observation of the patient - ANSWER-D. Increase the frequency of
observation of the patient
The confusion doesn't appear to be a safety issue, so frequent monitoring is the best plan
Six members of a trauma patient's family arrive at the ICU asking questions about their loved
one's condition. The nurse's most appropriate initial response would be to:
A. Ensure that the Chaplin is available
B. Include the family in patient care
C. Offer the family a tour of the ICU
D. Identify a family spokesperson - ANSWER-D. Identify a family spokesperson
One of the most important needs of families is accurate and regular information
A patient has been waiting in the ICU for 2 months for a heart transplant. A family member
angrily tells the nurse, "this is hopeless!" The nurse's actions should be based on the knowledge
that:
A. Expressions of frustration are normal and usually require no nursing intervention
B. Since expressions of hopelessness may be harmful to the patient, the family member should
be encouraged to keep those statements out of the patient care area
C. The integrity of the family system is crucial in the transplant process
D. Encouraging discussion of negative emotions can impede their resolution - ANSWER-C. The
integrity of the family system is crucial in the transplant process
Expressions of frustration need to be discussed and the family unit is the "patient"
"difficult" patient and family who have been on the unit for 2 months. Once the assignment is
determined for the next shift, the next action of the nurse might be to:
A. Hold a family meeting and demand that their behavior change at once
B. Call the nursing supervisor and have the patient transferred to another unit
C. Arrange to have a nursing care conference and discuss possible solutions
D. Put a note by the charge nurse station to always assign this patient to the float or PRN nurse -
ANSWER-C. Arrange to have a nursing care conference and discuss possible solutions
Communication, collaboration, and a consistent plan are what's needed. If this had been done
earlier, the situation this shift might have been avoided.
Three days after undergoing elective hip replacement, a patient has HR 125, RR 36, BP 164/84;
is diaphoretic; has dilated pupils; is anxious; denies pain; and appears to be having tactile
hallucinations. Despite frequent reorientation from the nurse, the patient continues to try to
climb out of bed. Which of the following ordered might be appropriate?
A. Lorazepam (Ativan)
B. Soft wrist restraints
C. Methadone
D. Leaving the TV or radio on in the room for background noise - ANSWER-A. Lorazepam
(Ativan)
The timing and assessment indicate the patient might be in alcohol withdrawal or heading into
DT's. Of the 4 choices, prescribing a benzo would be the most appropriate.
,A patient with a documented history of schizophrenia is admitted with DKA. A priority of the
admitting nurse would be to:
A. Review all per admission medications
B. Contact the patient's counselor
C. Hold all psychiatric medications pending glucose regulation
D. ask the patient if he is hearing voices - ANSWER-A. Review all per admission medications
Is a priority for patient admissions
A nurse walks into the family waiting room and discovers a physical altercation between two
visitors has just begun. The nurse should:
A. Get between the 2 individuals and tell them their behavior is inappropriate
B. ask the largest man in the waiting room to break it up
C. Pull the fire alarm by the door
D. Call security - ANSWER-D. Call security
Think safety first, for yourself and everyone else. Our security colleagues are trained to handle
these situations
The wife of a patient recently admitted because of a single vehicle crash tells the nurse "I'm
afraid he was trying to kill himself." A priority for the nurse would be to:
A. Identify if the patient has a history of depression
B. Ask the patient directly about suicidal intent with the wife in the room
C. Obtain an order for a psych consult
D. Ensure the suicide assessment is completed in the electronic health record - ANSWER-D.
Ensure the suicide assessment is completed in the electronic health record
,This screen/ assessment tool guides the health care team in determining a treatment plan
Which of the following actions by the nurse might decrease a patient's self-esteem?
A. Discussing the negative consequences of the patient's condition
B. Requiring the patient to participate in all treatments
C. Providing opportunities to discuss issues important to the patient
D. Indicating his or her acceptance of the patient's condition - ANSWER-B. Requiring the patient
to participate in all treatments
The 2 key words being requiring and all. We can't require an adult to do anything. When we
start thinking we can, we are behaving paternalistically.
A 22 year old patient has been declared brain dead. The parents decide to discontinue feeding
and donate their child's organs. In response to the parents' request, the most appropriate
action by the nurse would be to:
A. Contact the organ procurement agency
B. Convene a multidisciplinary care conference
C. Tell the parents that the condition precludes organ donation
D. Discontinue the feeding per their request - ANSWER-A. Contact the organ procurement
agency
We collaborate with this agency to be the primary communicator with potential donor families
A patient in the ICU is confused about time and place, despite frequent reorientation. For the
patient's safety, the nurse would initially:
A. Put a vest restraint on the patient
B. Ask the family member to stay with the patient
C. Administer a mild sedative
, D. Increase the frequency of observation of the patient - ANSWER-D. Increase the frequency of
observation of the patient
The confusion doesn't appear to be a safety issue, so frequent monitoring is the best plan
Six members of a trauma patient's family arrive at the ICU asking questions about their loved
one's condition. The nurse's most appropriate initial response would be to:
A. Ensure that the Chaplin is available
B. Include the family in patient care
C. Offer the family a tour of the ICU
D. Identify a family spokesperson - ANSWER-D. Identify a family spokesperson
One of the most important needs of families is accurate and regular information
A patient has been waiting in the ICU for 2 months for a heart transplant. A family member
angrily tells the nurse, "this is hopeless!" The nurse's actions should be based on the knowledge
that:
A. Expressions of frustration are normal and usually require no nursing intervention
B. Since expressions of hopelessness may be harmful to the patient, the family member should
be encouraged to keep those statements out of the patient care area
C. The integrity of the family system is crucial in the transplant process
D. Encouraging discussion of negative emotions can impede their resolution - ANSWER-C. The
integrity of the family system is crucial in the transplant process
Expressions of frustration need to be discussed and the family unit is the "patient"
