and Correct Answers
A 44-year-old male patient has been exposed to a severe amount of radiation
after a leak in a reactor plant. When planning this patient's care, the nurse
should implement what action? - ANSWERThe patient should be carefully
protected from infection.
A nurse suspects a client who has Alzheimer's disease in unconsciously telling
untrue stories to protect the client's self-esteem. This nurse correctly identifies
this behavior as: - ANSWERConfabulation
A patient diagnosed with alcoholism is admitted to a substance abuse unit
complaining of decreased exercise tolerance, lower extremity edema,
arrhythmias, and dyspnea. Which nursing intervention would be most
appropriate for this patient? - ANSWERAdminister digoxin (Lanoxin) and
furosemide (Lasix)
, A patient diagnosed with borderline personality disorder coyly requests
diazepam (valium). When the physician refuses, the client becomes angry and
demands to see another physician. What defense mechanism is the patient/client
using? - ANSWERSplitting
A patient has been admitted to your unit with a GI ulcer. The patient/client is
NPO and has a nasogastric tube in place connected to low suction. What for of
shock should you monitor this patient for? - ANSWERHypovolemic shock
A patient has been brought to the emergency department with multiple trauma
after a MVA. After immediate threats to life have been corrrected in a patient
with multiple trauma, which action would the nurse perform? -
ANSWERPerform a rapid physical assessment
A patient is admitted to the hospital with a head injury resulting from an
automobile accident. On admission the patient/clients vital signs are
temperature 98.6 F (37 C), blood pressure 128/68, pulse 110, and respirations
26. One hour after admission, the nurse notes the presence of the Cushing's triad
when the patient's vital signs are - ANSWERBlood pressure 156/60, pulse 60,
respirations 14
A patient who has undergone an implantable cardioverter defibrillator (ICD)
procedure asks the nurse about the purpose of this device. What would be the
nurse's best response? - ANSWERTo detect and treat ventricular fibrillation and
ventricular tachycardia