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NMC CBT Mock Test 15:

1. The physician has ordered a thyroid scan to confirm the diagnosis of a goiter. Before the procedure, the nurse should:

• Assess the client for allergies.
• Bolus the client with IV fluid.
• Tell the client he will be asleep.
• Insert a urinary catheter.

2. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

• Impaired physical mobility related to decreased endurance
• Hypothermia r/t decreased metabolic rate
• Disturbed thought processes r/t interstitial edema
• Decreased cardiac output r/t bradycardia

3. The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?

• A tracheotomy set
• A padded tongue blade
• An endotracheal tube
• An airway

4. Which of the following cannot be seen in a depressed client?

• Inactivity
• Sad facial expression
• Slow monotonous speech
• Increased energy

5. Which of the following situations on a psychiatric unit are an example of a trusting a patient-nurse relationship?

• The patient tells the nurse that he feels suicidal
• The nurse offers to contact the doctor if the patient has a headache
• The nurse gives the patient his daily medication right on schedule
• The nurse enforce rules strictly on the unit

6. When should adult patients in acute hospital settings have observations taken?

• When they are admitted or initially assessed. A plan should be clearly documented which identifies which observations should be taken & how frequently subsequent observations should be done
• When they are admitted & then once daily unless they deteriorate
• As indicated by the doctor
• Temperature should be taken daily, respirations at night, pulse & blood pressure 4 hourly

7. On a psychiatric unit, the preferred milieu environment is BEST describe as:

• Fostering a therapeutic social, cultural, and physical environment.
• Providing an environment that will support the patient in his or her therapeutic needs
• Fostering a sense of well-being and independence in the patient
• Providing an environment that is safe for the patient to express feelings

8. What does AVPU mean?

• alert verbalization pain unconscious
• awake voice pain unconscious
• alert voice pain unresponsive
• awake verbalization pain unconscious

9. Who should do the assessment in a patient with dysphagia

• Neurologic physiotherapist
• Speech therapist
• Occupation therapist

10. Which of the following population group is at risk of developing cardiovascular disease?

• Obese, male, diabetic, hypertensive, sedentary lifestyle
• female, forty, fertile
• smoker, diabetic and alcoholic
• drug user, male, hypertensive

11. The nurse is preparing the move an adult who has right sided paralysis from the bed into a wheel chair. Which statement best describe action for the nurse to take?

• Position the wheelchair on the left side of the bed.
• Keep the head of the bed elevated 10 degrees.
• Protect the patients left arm with a sling during transfer.
• Bend at the waist while helping the client into a standing position

12. In the News observation system, what is AVUP?

• A replacement for GCS
• An assessment for confusion
• Assessment for the level of consciousness

13. After the suicide of her best friend Linda feels a sense of guilt, shame and anger because she had not answered the phone when her friend called shortly before her death. Which of the following statements is the most accurate when talking about Linda’s feelings?

• Linda’s feelings are normal and are a form of perceived loss
• Linda’s feelings are normal and are a form of situational loss.
• Linda’s feelings are not normal and are a form of situational loss.
• Linda’s feelings are not normal and are a form of physical loss

14. A patient suffered from CVA and is now affected with dysphagia. What should not be an intervention to this type of patient?

• Place the patient in a sitting position / upright during and after eating.
• Water or clear liquids should be given.
• Instruct the patient to use a straw to drink liquids.
• Review the patient's ability to swallow, and note the extent of facial paralysis.

15. When is the time to take the vital signs of the patients? Select which does not apply:

• At least once every 12 hours, unless specified otherwise by senior staff.
• When they are admitted or initially assessed.
• On transfer to a ward setting from critical care or transfer from one ward to another.
• Every four hours

16. The wife of a client with PTSD (post-traumatic stress disorder) communicate to the nurse that she is having trouble dealing with her husband's condition at home. Which of the following suggestions made by the nurse is CORRECT?

• Do not touch or speak to your husband during an active flashback. Wait until it is finished to give him support."
• Discourage your husband from exercising, as this will worsen his condition
• Encourage your husband to avoid regular contact with outside family members
• Keep your cupboards free of high-sugar and high-fat foods

17. The nurse restrains a client in a client in a locked room for 3 hours until the client acknowledge wo started a fight in the group room last evening. The nurse’s behaviour constitutes;

• False imprisonment
• Duty of care
• Standard of care practice
• Contract of care

18. Glasgow Coma score (GCS) is made up of 3 component parts and these are:

• eye opening response/motor response/verbal response
• eye opening response/verbal response/pupil reaction to light
• eye opening response/motor response/pupil reaction to light
• eye opening response/limb power/verbal response

19. Which sign or symptom is a key indication of progressive arterial insufficiency?

• Oedema
• Hyperpigmentation of the skin
• Pain
• Cyanosis

20. You are caring for a patient who has had a recent head injury and you have been asked to carry out neurological observations every 15 minutes. You assess and find that his pupils are unequal and one is not reactive to light. You are no longer able to rouse him. What are your actions?

• Continue with your neurological assessment, calculate your Glasgow Coma Scale (GCS) and document clearly.
• This is a medical emergency. Basic airway, breathing and circulation should be attended to urgently and senior help should be sought.
• Refer to the neurology team.
• Break down the patient's Glasgow Coma Scale as follows: best verbal response V = XX, best motor response M = XX and eye opening E = XX. Use this when you hand over.

21. A patient with antisocial personality disorder enters the private meeting room of a nurse unit as a nurse is meeting with a different patient. Which of the following statements by the nurse is BEST?

• I’m sorry, but HIPPA says that you can’t be her. Do you mind leaving?
• You may sit with us as long as you are quiet
• I need you to leave us alone
• Please leave and I will speak with you when I am done

22. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?

• Obtain a crash cart.
• Check the calcium level.
• Assess the dressing for drainage.
• Assess the blood pressure for hypertension.

23. You are monitoring a patient in the ICU when suddenly his consciousness drops and the size of one his pupil becomes smaller what should you do?

• Call the doctor
• Refer to neurology team
• Continue to monitor patient using GCS and record
• Consider this as an emergency and prioritize ABC

24. A 17-year old patient who was involved in an orthopaedic accident is observed not eating the meals that she previously ordered and refuses to take a bath even if she is already in recovery stage. As a nurse what do you think is the best explanation for her reaction to the accident that happened to her?

• Supression
• Undoing
• Regression
• Repression

25. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

• Feet
• Neck
• Hands
• Sacrum

26. Which of the following is NOT a symptom of impacted earwax?

• Dizziness
• Dull hearing
• Reflux cough
• Sneezing

27. Common cause of airway obstruction in an unconscious patient

• Oropharyngeal tumor
• Laryngeal cyst
• Obstruction of foreign body
• Tongue falling back

28. A patient suffered from stroke and is unable to read and write. This is called

• Dysphasia
• Dysphagia
• Partial aphasia
• Aphasia

29. The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

• Atrial flutter
• A sinus rhythm
• Ventricular tachycardia
• Atrial fibrillation

30. After two weeks of receiving lithium therapy, a patient in the psychiatric unit becomes depressed. Which of the following evaluations of the patient’s behavior by the nurse would be MOST accurate?

• The treatment plan is not effective; the patient requires a larger dose of lithium.
• This is a normal response to lithium therapy; the patient should continue with the current treatment plan.
• This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior.

31. What is an indication that a suicidal patient has an impending suicide plan:

• She/he is cheerful and seems to have a happy disposition
• talk or write about death, dying or suicide
• threaten to hurt or kill themselves
• actively look for ways to kill themselves, such as stockpiling tablets

32. A patient with a history of schizophrenia is admitted to the acute psychiatric care unit. He mutters to himself as the nurse attempts to take a history and yells. “I don’t want to answer any more questions! There are too many voices in this room!” Which of the following assessment questions should the nurse as NEXT?

• Are the voices telling you to do things?
• Do you feel as though you want to harm yourself or anyone else?
• Who else is talking in this room? It’s just you and me
• I don’t hear any other voices

33. When caring for clients with psychiatric diagnoses, the nurse recalls that the purpose of psychiatric diagnoses or psychiatric labelling to:

• Identify those individuals in need of more specialized care.
• Identity those individuals who are at risk for harming others
• Define the nursing care for individuals with similar diagnoses
• Enable the client's treatment team to plan appropriate and comprehensive care

34. Risk for health issues in a person with mental health issues

• Increased than in normal people
• Slightly decreased than in normal people
• Very low as compared to normal people
• Risk is same in people with and without mental illness

35. The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to: Proximal third section of the small intestines

• Apply the new tie before removing the old one.
• Have a helper present.
• Hold the tracheotomy with the nondominant hand while removing the oldtie.
• Ask the doctor to suture the tracheostomy in place.

36. When a patient is being monitored in the PACU, how frequently should blood pressure, pulse and respiratory rate be recorded?

• Every 5 minutes
• Every 15 minutes
• Once an hour
• Continuously

37. You are caring for a patient with a tracheostomy in situ who requires frequent suctioning. How long should you suction for?

• If you preoxygenate the patient, you can insert the catheter for 45 seconds.
• Never insert the catheter for longer than 10-15 seconds.
• Monitor the patient's oxygen saturations and suction for 30 seconds
• Suction for 50 seconds and send a specimen to the laboratory if the secretions are purulent

38. Which of the following is at a greater risk for developing coronary artery disease?

• Male, obese, sedentary lifestyle
• Female, obese, non sedentary lifestyle

39. Which of the following is a potential complication of putting an oropharyngeal airway adjunct:

• Retching, vomiting
• Bradycardia
• Obstruction
• Nasal injury

40. An adult has experienced a CVA that has resulted in right side weakness. The nurse is preparing to move the patients right side of the bed so that he may then be turned to his left side. The nurse knows that an important principle when moving the patient is?

• To keep the feet close together
• To bend from waist
• To move body weight when moving objects
• A twisting motion will save steps

41. Patient had CVA, who will assess swallowing capability?

• physiotherapy nurse
• psychotherapy nurse
• speech and language therapist
• neurologic nurse

42. Your patient has a bulky oesophageal tumour and is waiting for surgery. When he tries to eat, food gets stuck and gives him heartburn. What is the most likely route that will be chosen to provide him with the nutritional support he needs?

• Nasogastric tube feeding.
• Feeding via a percutaneous endoscopic gastrostomy (PEG).
• Feeding via a radiologically inserted gastrostomy (RIG).
• Continue oral food.

43. A patient got admitted to hospital with a head injury. Within 15 minutes, GCS was assessed and it was found to be 15. After initial assessment, a nurse should monitor neurological status

• Every 15 minutes
• 30 minutes
• 45 minutes
• 60 minutes

44. A client has been voluntary admitted to the hospital. The nurse knows that which of the following statements is inconsistent with this type of hospitalization

• The client retains all of his or her rights
• The client has a right to leave if not a danger to self or others
• The client can sign a written request for discharge
• The client cannot be released without medical advice.

45. Which of the following situations on a psychiatric unit are an example of trusting patient nurse relationship?

• The patient tells the nurse he feels suicidal
• The nurse offers to contact the doctor if the patient has a headache
• The nurse gives the patient his daily medications right on schedule
• The nurse enforces rules strictly on the unit

46. While changing tubing and cap change on a patient with central line on right subclavian what should the nurse do to prevent complication

• ask patient to breath normally
• ask patient to hold the breath and bear down
• inhale slowly

47. In doing neurological assessment, AVPU means:

• awake, voice, pain, unresponsive
• alert, voice, pain, unresponsive
• awake, verbalises, pain, unresponsive
• alert, verbalises, pain, unresponsive

48. All are risk factors of Coronary Artery Disease except:

• Obesity
• Smoking
• High Blood Pressure
• Female

49. A patient in your care knocks their head on the bedside locker when reaching down to pick up something they have dropped. What do you do?

• Let the patient’s relatives know so that they don’t make a complaint & write an incident report for yourself so you remember the details in case there are problems in the future
• Help the patient to a safe comfortable position, commence neurological observations & ask the patient’s doctor to come & review them, checking the injury isn’t serious, when this has taken place , write up what happened & any future care in the nursing notes
• Discuss the incident with the nurse in charge , & contact your union representative in case you get into trouble
• Help the patient to a safe comfortable position, take a set of observations & report the incident to the nurse in charge who may call a doctor. Complete an incident form. At an appropriate time , discuss the incident with the patient & if they wish , their relatives

50. A patient asking for LAMA, the medical team has concern about the mental capacity of the patient, what decision should be made?

• Call the police
• Let the patient go
• Encourage the patient to wait, by telling the need for treatment