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?
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/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