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Question # 1
If your patient is acutely psychotic, which of the following independent nursing interventions
would not be appropriate?
A. Conveying calmness with one on one interaction
B. Recognizing and dealing with your own feelings to prevent escalation of thepatient’s anxiety level
C. Encourage client participation in group therapy
D. Listen and identify causes of their behavior
Question # 2
Which of the following syndromes associated with incomplete lesions of the spinal cord is a
result of damage to one-half of the spinal cord?
A. Brown-Séquard syndrome
B. posterior cord syndrome
C. central cord syndrome
D. cauda equina syndrome
Question # 3
A client receiving preoperative instructions asks questions repeatedly about when to stop
eating the night before the procedure. The nurse tries torefocus the client. The nurse notes
that the client is frequently startled by noises in the hall. Assessment reveals rapid speech,
trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to
feeling nervous and having trouble sleeping. Based on the assessment, the nurse
documents that the client has:
A. mild anxiety.
B. moderate anxiety.
C. severe anxiety.
D. a panic attack.
Question # 4
A 64 year-old Alzheimer’s patient has exhibited excessive cognitive decline resulting in
harmful behaviors. The physician orders restraints to be placed on the patient. Which of the
following is the appropriate procedure?
A. Secure the restraints to the bed rails on all extremities.
B. Notify the physician that restraints have been placed properly.
C. Communicate with the patient and family the need for restraints.
D. Position the head of the bed at a 45 degree angle.
Question # 5
A client was involved in a motor vehicle accident in which the seat belt was not worn. The
client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of
breath, and has a respiratory rate of 34/min. Which of the following assessment findings
should concern the nurse the most?
A. temperature of 102° F and a productive cough
B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg
C. trachea deviating to the right
D. barrel-chested appearance
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