Multiple Choice and Conceptual Actual
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1. What changes are noted in Ann Rails’ assessment profile?
A. Educational – Decreased; Pain – Normal
B. Educational – Increased; Fall Risk – Increased; Health Change – Increased; Pain
– Increased
C. Sensorium – Decreased; Psychological – Altered
D. Health Change – Normal; Pain – Decreased
2. Which nursing diagnoses are most appropriate for Ann Rails?
A. Risk for infection, Impaired gas exchange, Anxiety
B. Acute pain, Impaired comfort, Impaired mobility, Disturbed sensory
perception, Risk for falls, Risk for peripheral neurovascular dysfunction
C. Ineffective airway clearance, Risk for shock
D. Chronic pain, Activity intolerance
3. Scenario #1: Which actions are part of appropriate nursing interventions for
Ann Rails?
,A. Use therapeutic communication, Educate the patient, Evaluate learning, Place
call light, Document
B. Assess lung sounds, Administer oxygen, Call family
C. Provide medication education only
D. Reassess and discharge
4. Scenario #2: Which steps should the nurse take in sequence?
A. Notify physician, then wash hands
B. Wash and glove hands → Assess → Provide comfort → Notify doctor →
Document
C. Document first, then assess
D. Wait for physician’s order
5. Scenario #3: How should the nurse respond to patient concerns?
A. Ignore minor concerns
B. Provide reassurance only
C. Listen to patient → Reassure → Notify lead nurse/doctor → Contact Social
Services → Document
D. Immediately transfer the patient
6. Scenario #4: What is the correct immediate nursing action?
A. Begin chest compressions
B. Wash and glove hands → Perform visual assessment → Do not disturb →
Verify call light → Document
C. Call for help before assessing
D. Remove equipment
7. Scenario #5: What education should the nurse provide regarding bowel care?
,A. Encourage medication only
B. Assess bowel sounds → Encourage fluids, fiber, ambulation → Evaluate
understanding → Attain fluid/fiber diet → Document
C. Restrict fluids
D. Provide laxative immediately
1. What changes are noted in Arthur Thomason’s assessment profile?
A. Educational – Increased; Health Change – Increased; LOC – Increased; Pain –
Increased; Psychological Needs – Increased; Safety – Increased
B. LOC – Decreased; Pain – Decreased
C. No significant changes
D. Sensorium – Normal; Pain – Normal
2. Which nursing diagnoses are most appropriate for Arthur Thomason?
A. Acute pain, Impaired mobility, Fall risk
B. Impaired comfort, Impaired gas exchange, Ineffective airway clearance, Risk
for shock, Anxiety/Fear, Risk for failure to thrive
C. Impaired swallowing, Constipation
D. Ineffective coping, Fluid overload
3. Scenario #1: What is the priority action for Arthur Thomason?
A. Call family
B. Assess patient → Replace O₂ → Use therapeutic communication → Notify
physician and charge nurse
C. Document first
D. Provide oral fluids
4. Scenario #2: When assisting the physician, what should the nurse do?
, A. Stay silent during exam
B. Remind and assist the physician, explain to the patient, obtain recent results,
reassure patient
C. Observe only
D. Provide discharge teaching
5. Scenario #3: What is the correct emergency response sequence?
A. Call rapid response before assessing
B. Tap patient → Elevate HOB → Call rapid response → Start secondary
assessment/intervention → Remain with patient
C. Leave to get crash cart
D. Notify housekeeping
6. Scenario #4: What should the nurse do during emergency intubation?
A. Provide verbal report → Assist with intubation → Assume assigned role →
Obtain patient record → Provide ongoing information
B. Step out of the room
C. Call pharmacy
D. Observe only
7. Scenario #5: What is the appropriate communication with Arthur Thomason’s
family?
A. Avoid discussing his condition
B. Explain his condition clearly → Reassure them he’s receiving care → Have
them remain with you → Escort them → Call his physician
C. Refer them to social worker only
D. Delay discussion until after procedure