AACN
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 - Answers -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 - Answers -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 - Answers -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 - Answers -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 -
Answers -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 - Answers -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 - Answers -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 - Answers -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 - Answers -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 - Answers -
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"
A patient is admitted in DKA. Since admission, the patient's glucose levels have been in
the 400-400 range, and regular insulin has been administered on a sliding scale. Given
these findings, the most appropriate nursing intervention is to:
A. Consult with the physician about changing the regimen to regular insulin via
continuous drip
B. Arrange for nutritional consult to enhance adherence to an ADA diet
C. Consult with the physician about increasing the maximum dose age of regular insulin
on the sliding scale
D. Request an evaluation by a diabetic educator - Answers -A. Consult with the
physician about changing the regimen to regular insulin via continuous drip
The nurse would collaborate with the provider to ensure best practice is being used
A Russian patient who does not speak or understand English has just undergone an
aortic valve replacement. The nurse notices he is increasingly restless and splinting his
chest with both hands. An effective means of communication with this patient would be:
A. Using a letter board
B. Contacting the patient's family
C. Touch and gestures
D. Using "yes" or "no" questions - Answers -C. Touch and gestures
, The patient is probably trying to express pain, which we would want to assess and treat
promptly. Pain has some universal gestures
The daughter of a mechanically ventilated patient is being taught how to suction. When
developing a teaching plan, the nurse must first:
A. Obtain written information about the procedure
B. Determine a schedule for demonstrating the technique
C. Assess the knowledge and skills the daughter needs to learn
D. Encourage the daughter to observe the procedure on other patients - Answers -C.
Assess the knowledge and skills the daughter needs to learn
Adult learning principles dictate that knowledge assessment comes first
When caring for a 15 year old patient, the nurse would:
A. Address worries about the future
B. Use games as a teaching strategy
C. Encourage the patient to talk about life experiances
D. Allow the patient's peers to visit - Answers -D. Allow the patient's peers to visit
This question is about Erikson's stages of growth and development. At 15, the peer
group is the primary motivator
A patient with receptive aphasia and dementia is eligible for a clinical trial. How could
the nurse ensure that informed consent is obtained ethically?
A. Involve the patient's legal guardian in the consent process
B. Ensure that the investigator is aware of the patient's condition
C. Inform the institutional board about the potential risk to the patient
D. Obtain a copy of the consent form to place in the patient's chart - Answers -A. Involve
the patient's legal guardian in the consent process
If a patient is unable to "consent" they can't be enrolled in a study (despite the fact that
the stem of the question does not state whether this patient has a legal guardian)
A patient who is in the critical care unit with sepsis has a known history of PTSD
secondary to a physical assault, including rape 6 months prior to admission. Which os
the following is a recommended strategy for the nurse to utilize in the care of this
patient?
A. Administer benzodiazepines for anxiety
B. Limit family visitation
C. Insist on having a discussion about the assault
D. Provide the opportunity for the patient to record her daily activities whole critically ill -
Answers -D. Provide the opportunity for the patient to record her daily activities whole
critically ill
Providing a process that encourages the patient/ her family to record daily activities
prevents the anxiety that is associated with memory gaps during a critical illness
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 - Answers -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 - Answers -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 - Answers -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 - Answers -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 -
Answers -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 - Answers -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 - Answers -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 - Answers -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 - Answers -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 - Answers -
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"
A patient is admitted in DKA. Since admission, the patient's glucose levels have been in
the 400-400 range, and regular insulin has been administered on a sliding scale. Given
these findings, the most appropriate nursing intervention is to:
A. Consult with the physician about changing the regimen to regular insulin via
continuous drip
B. Arrange for nutritional consult to enhance adherence to an ADA diet
C. Consult with the physician about increasing the maximum dose age of regular insulin
on the sliding scale
D. Request an evaluation by a diabetic educator - Answers -A. Consult with the
physician about changing the regimen to regular insulin via continuous drip
The nurse would collaborate with the provider to ensure best practice is being used
A Russian patient who does not speak or understand English has just undergone an
aortic valve replacement. The nurse notices he is increasingly restless and splinting his
chest with both hands. An effective means of communication with this patient would be:
A. Using a letter board
B. Contacting the patient's family
C. Touch and gestures
D. Using "yes" or "no" questions - Answers -C. Touch and gestures
, The patient is probably trying to express pain, which we would want to assess and treat
promptly. Pain has some universal gestures
The daughter of a mechanically ventilated patient is being taught how to suction. When
developing a teaching plan, the nurse must first:
A. Obtain written information about the procedure
B. Determine a schedule for demonstrating the technique
C. Assess the knowledge and skills the daughter needs to learn
D. Encourage the daughter to observe the procedure on other patients - Answers -C.
Assess the knowledge and skills the daughter needs to learn
Adult learning principles dictate that knowledge assessment comes first
When caring for a 15 year old patient, the nurse would:
A. Address worries about the future
B. Use games as a teaching strategy
C. Encourage the patient to talk about life experiances
D. Allow the patient's peers to visit - Answers -D. Allow the patient's peers to visit
This question is about Erikson's stages of growth and development. At 15, the peer
group is the primary motivator
A patient with receptive aphasia and dementia is eligible for a clinical trial. How could
the nurse ensure that informed consent is obtained ethically?
A. Involve the patient's legal guardian in the consent process
B. Ensure that the investigator is aware of the patient's condition
C. Inform the institutional board about the potential risk to the patient
D. Obtain a copy of the consent form to place in the patient's chart - Answers -A. Involve
the patient's legal guardian in the consent process
If a patient is unable to "consent" they can't be enrolled in a study (despite the fact that
the stem of the question does not state whether this patient has a legal guardian)
A patient who is in the critical care unit with sepsis has a known history of PTSD
secondary to a physical assault, including rape 6 months prior to admission. Which os
the following is a recommended strategy for the nurse to utilize in the care of this
patient?
A. Administer benzodiazepines for anxiety
B. Limit family visitation
C. Insist on having a discussion about the assault
D. Provide the opportunity for the patient to record her daily activities whole critically ill -
Answers -D. Provide the opportunity for the patient to record her daily activities whole
critically ill
Providing a process that encourages the patient/ her family to record daily activities
prevents the anxiety that is associated with memory gaps during a critical illness
