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During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse's initial action is to
- A. continue the hourly neurologic assessments.
- B. inform the neurosurgeon of the patient's status.
- C. prepare the patient for emergency surgery.
- D. recheck the patient's neurologic status in 15 minutes.
Correct Answer: B
Rationale: Neurological changes could indicate worsening intracranial pressure, necessitating immediate physician notification.
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What is your priority intervention for this patient?
- A. Transportation arrangements to a safe house
- B. Referral to a counselor
- C. Advise about contacting the police
- D. Follow-up appointment for injuries
Correct Answer: A
Rationale: Ensuring the patient's safety by arranging transportation to a safe house is the top priority.
A nursing department in an acute care setting decides to redesign its nursing practice based on a theoretical framework. The feedback from patients, families, and staff reflects that caring is a key element. Which theorist best supports this concept?
- A. Erikson.
- B. Maslow.
- C. Rogers.
- D. Watson.
Correct Answer: D
Rationale: Jean Watson's theory emphasizes the importance of caring in nursing.
What evaluation would help Mr. Jones control his chest pain on inspiration?
- A. Evaluate the intensity and quality of his pain
- B. Explain the cause of his pain
- C. Encourage him to lie on his affected side
- D. Reassure him that the pain will subside
Correct Answer: C
Rationale: Lying on the affected side stabilizes the chest wall, reducing pain during inspiration.
The patient will be placed under moderate sedation to allow realignment of a fracture in the emergency department. When the family asks about this anesthesia, what should the nurse tell them?
- A. Includes inhalation agents
- B. Induces high levels of sedation
- C. Frequently used for traumatic injuries
- D. Patients remain responsive and breathe without assistance
Correct Answer: D
Rationale: Moderate sedation keeps patients responsive and maintains spontaneous breathing.
For care of a patient who has oral cancer, which task would be appropriate to delegate to the LPN/LVN?
- A. Assist the patient to brush and floss.
- B. Give antacids and sucralfate suspension as ordered.
- C. Recommend saliva substitutes.
- D. Explain when brushing and flossing are contraindicated.
Correct Answer: A
Rationale: Assisting with oral hygiene is within the scope of practice for LPNs/LVNs, while medication administration and patient education require higher-level training.