Question 1
Which assessment data should the RN collect first from the patient brought to the Emergency Department with
confusion and a decreased level
... [Show More] of consciousness?
History of drug or alcohol abuse.
Current medications.
Onset of symptoms
Family medical history.
Question 2
The registered nurse uses the Glasgow Coma Scale to assess a patient with an acute brain injury and notes a
score of four (4). Which intervention is a priority for this patient?
Improve extremity range of motion.
Prevent injury.
Promote skin integrity.
Maintain the airway.
Question 3
An RN is caring for a patient with Multiple Sclerosis, who is experiencing weakness in their extremities.
Which of the following would be an appropriate expected outcome for the nursing diagnosis Impaired physical
mobility? The patient will:
Ambulate without shortness of breath
Use assistive devices safely.
Participate in strenuous exercise as tolerated.
Take a hot bath daily to limit spasticity.
Question 4
Which assessment indicates to the RN that the prescribed acetylcholinesterase inhibitor is effective for the
patient diagnosed with myasthenia gravis? The patient:
Denies nausea when eating.
Feeds self independently.
Blinks eyes without tearing.
Reports no muscle pain.
Question 5
Which information should the RN include in the teaching plan for the patient with a new diagnosis of
myasthenia gravis? Select all that apply.
Avoid soft foods in gravy or sauces.
Schedule rest periods throughout the day.
Sit upright during meals.
Take medications on a regular schedule.
Use scatter rugs on bare floor
Question 6
Which outcome indicates to the RN that patient teaching has been effective for the patient diagnosed with
Parkinson’s disease?
Ambulates with a walker.
Sits in an upright position for meals.
Communicates only by writing.
Takes frequent naps during the day.
Question 7
Which intervention should the RN implement for that patient with Parkinson’s disease and a nursing diagnosis
of Impaired physical mobility?
Use a walker at all times.
Concentrate on walking erect.
Take small shuffling steps.
Walk slowly with arms at sides.
Question 8
During medication reconciliation for a patient diagnosed with Parkinson’s disease and narrow angle glaucoma,
the registered nurse notes an order for benzotropine mesylate (Cogentin). What is the most appropriate
intervention for the registered nurse to take?
Maintain the patient on bedrest.
Administer the medication as soon as possible.
Collaborate with the physical therapist.
Contact the health care provider about the order.
Question 9
Which intervention should the RN implement to help the patient diagnosed with amylotrophic lateral sclerosis
(ALS) preserve their autonomy in decision making?
Provide the patient with information about the ALS Society.
Initiate a referral to a social worker for hospice care.
Obtain consent for the placement of an enteral feeding tube.
Encourage the patient to complete an advanced directive.
Question 10
What information is essential for the registered nurse to include when teaching the family of a patient with
Huntington’s Disease?
It is important to maintain a positive outlook.
The medications will help cure the disease.
Personality changes and dementia are part of the disease.
Confusion and writhing movements are temporary.
Question 11
Which nursing intervention is the priority when providing care for a patient experiencing status epilepticus?
Time the length of the seizure.
Contact the heath care provider.
Maintain the airway.
Administer medication IV stat.
Question 12
Which statement made by the patient with a new prescription for phenytoin indicates to the RN that more
teaching is needed?
“My spouse will have to drive me to my next doctor’s appointment.”
“I need to take this medication on an empty stomach.”
“My urine may turn reddish brown in color.”
“I will use a soft bristle toothbrush.”
Question 13
Which information should the RN include when discharging a pediatric patient with a fiberglass forearm cast?
Select all that apply.
Blow cool air down the cast if itching occurs.
Ask the child to wiggle their fingers every 4 hours.
Do not use magic markers for autographs.
Elevate the arm on a pillow for the first day.
Swimming is allowed with a fiberglass cast.
Question 14
Which intervention by the unlicensed assistive personnel (UAP) caring for the patient with right hemiparesis
requires the RN to intervene?
The UAP places a hand under the right axilla to move the patient up in bed.
The UAP positions the patient supine with the head turned to one side.
The UAP places a gait belt around the patient’s waist prior to ambulating.
The UAP praises the patient for performing ADLs independently.
Question 15
Which assessment is a priority for the RN to perform while the patient diagnosed with an ischemic stroke is
receiving tissue plasminogen activator (t-PA) ?
Skin turgor.
Blood pressure.
Signs of active bleeding.
Urine output. [Show Less]