Cognition

Which tool does the nurse use to assess pain in the 4-year-old patient who sustained minor injuries on the playground? 

The patient is in a coma following evacuation of an acute subdural hematoma. Which intervention does the nurse utilize to increase the patient's level of consciousness? 

The nurse is performing a psychosocial assessment on an 84-year-old male in a hospice. The patient says, “I have had a good life. My children are grown and successful, and I was a successful businessman.” How does the nurse document this patient’s psychosocial development?

The nurse is assigned to care for a 27-year-old male who presented with acute onset personality changes and neuropsychiatric symptoms. Upon entering the patient’s room, the nurse notices the patient is staring at the ceiling and muttering. Which action by the nurse is most appropriate?

The nurse is caring for a 32-year-old patient admitted for neuropsychiatric evaluation. The patient says to the nurse, “Can’t you hear them? The voices are telling me to end it. I’m so scared.” Which response by the nurse is most appropriate?

A nurse is assigned to care for a 28-year-old patient with seizures and neuropsychiatric symptoms secondary to cocaine abuse. The patient is combative and prone to hurting himself despite a 24-hour bedside sitter, so the provider writes for physical restraints. Which options are included in this order? Select all that apply.

Following an assault by an unknown assailant, the patient is diagnosed with post-traumatic stress disorder. Which intervention must be implemented first for this patient? 

The patient who is scheduled for an elective surgery in 2 hours asks the nurse, “What time do the maids typically come to clean the hotel room?” Further questioning reveals the patient believes the hospital in the United States is a hotel in Paris, France, and the year is 20 years prior. The nurse notes that the patient signed a consent form for the procedure just minutes ago. Which action does the nurse take first?

Which patient is appropriate to assign to a licensed practical/vocational nurse (LPN/LVN)?

The patient is rushed into the emergency department by a family member who states the patient is having a stroke. Which action does the nurse take first?

After receiving report, which patient does the nurse see first?

The nurse learns the patient has a plan to kill as many people as possible by stabbing or shooting them. Which intervention by the nurse is most important?

Which exercise is appropriate for the patient who has a Glasgow Coma Scale of 4?

Which patient is at risk for failure to progress past the Industry vs. Inferiority stage of Erik Erikson’s developmental stages?

The patient presents to the emergency department after having a metal beam fall on his head at a work site. He was wearing a helmet which broke with the impact. He was unconscious at the scene but is awake now, and his initial assessment is completely benign. Which finding upon reassessment 30 minutes later is most concerning?

The patient tells the nurse “I drink three cups of black coffee a day. Is that okay?” Which response by the nurse is best?

The patient with acute psychosis tells the nurse he is going to leave this earth soon and go live in a house with the little green men on Mars. Which is the best response to this statement?

The patient with advanced dementia accuses the nurse of trying to poison him with his scheduled medications. Which nursing intervention is most appropriate?

The patient with a history of psychiatric disorders tells the nurse that her neighbor is working with Mr. Dawsom at the World Financial Organization to bring the world under their control, and that she is the only one who knows about it. Which response by the nurse is best?

The patient is brought to the emergency department following a serious motor vehicular accident (MVA). List the assessments the nurse performs in order from highest to lowest priority.

The emergency department nurse is assessing the unconscious patient following a fall from the ladder while he was doing home improvement work. Which assessment is performed first?

The nurse is involved in a motor vehicular accident in which a minor injury from the seatbelt was sustained. Which action does the nurse take first in helping the other victims?

The provider orders physical restraints for a patient in alcohol withdrawal who is delirious, combative, and a fall risk. Which statement is true regarding use of physical restraints for this patient?

The patient with neurosyphilis who has attempted to stab the nurse with scissors, pulled out several IVs, and is a fall risk is placed in wrist restraints per physician order. How frequently does the nurse assess the patient’s skin integrity?

Which explanation of the mechanism of action of the cutaneous stimulation method in reducing pain is correct?

An 84-year-old patient being treated for a chronic obstructive pulmonary disorder (COPD) exacerbation starts to become disoriented after the evening meal and will not stay in bed. Which intervention does the nurse take first?

Which characteristic is considered to be a positive symptom of schizophrenia?

The patient is being treated for obsessive-compulsive disorder with medication and behavioral therapy. At a follow-up visit, the patient reports near complete resolution of symptoms. The nurse anticipates discussing which treatment plan?  

The nurse learns in report the patient with schizophrenia has mainly exhibited negative symptoms. The nurse most expects to make which observation? 

Following electroconvulsive therapy, the patient with bipolar disorder tells the nurse he does not remember whether he arrived by bus or car. Which response by the nurse is appropriate? 

The nurse is assessing the patient with major depressive disorder. Which characteristic alerts the nurse that the patient may be planning to commit suicide? 

The patient with delusional disorder tells the nurse that he needs to see the Pope in Rome because he is a messenger of God. Which response by the nurse is most therapeutic?

The nurse prioritizes which intervention in caring for the patient with borderline personality disorder? 

The older adult patient is brought to the emergency department with sudden onset confusion, agitation, and hallucinations. The patient's past medical history is significant for type 2 diabetes managed with glyburide, anxiety managed with lorazepam, and insomnia managed with zolpidem. Upon assessment, the patient's heart rate and rhythm are regular, lungs are clear to auscultation, and bowel sounds are present. Vital signs are normal, with exception of a slightly elevated heart rate. Which is the most likely cause of the patient's symptoms?

The patient who recently lost her young child to acute lymphoblastic leukemia (ALL) tells the nurse that she is having trouble handling the grief and feels like she is to blame for her child’s death. Which response by the nurse is most appropriate? 

Which assessment is most consistent with disorganized schizophrenia? 

The unresponsive patient is brought via ambulance to the emergency department.  On physical assessment, the patient has a respiratory rate of 8 breaths per minute and pinpoint pupils. The nurse suspects which cause of the patient's condition?

A confused, minimally arousable patient is brought to the emergency department via ambulance. The patient is hypotensive and bradypneic. Paramedics report finding an empty bottle of diazepam next to the patient. The nurse prepares which therapy?

In the weeks after a stroke, which patient problem is of the highest priority?

The nurse is creating a tool to screen patients for depression and includes questions about which symptoms in the tool? Select all that apply.

The home health nurse is working with a patient who is a fall risk. During a home visit, the nurse sees the patient repeatedly using a step stool. Which intervention is the most appropriate?

The nurse is assessing the elderly patient in the long-term care facility. Which findings suggest urinary catheter-associated urinary tract infection (CAUTI)? Select all that apply.

A patient with longstanding alcohol abuse problems is admitted for COPD exacerbation. After reaching the floor, the patient becomes disoriented, anxious, tachycardic, diaphoretic, and tremulous. His oxygen saturation is 95% on 2 L supplemental oxygen via nasal cannula. Which intervention is most appropriate for this patient?

The elderly patient is brought to the ER by ambulance for confusion, slurred speech, and right-sided weakness. Vital signs, including body temperature and blood pressure, are normal. As the patient is waiting for an urgent head CT, the nurse performs which test first?

The nurse is assessing the patient’s ability to live independently. The patient ambulates with a cane but cannot manage stairs (lives in a one-level home). Due to advancing macular degeneration, the patient has forfeited her driving license. The patient has a daughter who is able to assist with transport to doctor appointments but cannot visit regularly. The macular degeneration is affecting the patient’s ability to tell the difference between her many pills. Which level of nursing care is appropriate for the patient?

There are four patients with hyperglycemia in the emergency department triage. One treatment room has become available. The patient with which additional symptom is moved into the available room first?

The patient is brought to the emergency department (ED) after falling down and being briefly unconsciousness. The patient’s wife is with him and tells the nurse in private, “He’s not been like himself. He’s verbally abusive, now, and mean. He was always the sweetest man I ever knew.” The nurse suspects testing will reveal a lesion in which lobe of the brain?

The nurse is assigned to the patient with a brain neoplasm who has been experiencing symptoms of depression. During shift report, the off-going nurse reports observing the patient in a trance-like state. The nurse suspects that the tumor is in which lobe of the brain?

The patient with a brain neoplasm is combative and cursing at the staff. The family reports that this is a drastic change in the patient's personality. The nurse suspects the tumor is in which lobe of the patient's brain?

The elderly patient with moderate Alzheimer’s disease was brought to the emergency department (ED) for rapidly worsening mental status, fever, and anorexia over the last 24 hours. Portable chest x-ray shows a consolidation in the left lower lobe.Which diagnosis is most accurate?