1. A newly diagnosed patient with Alzheimer disease is admitted to the hospital. The nurse first line of action will be to?

Answer:

• Introduce patient to his roommate.
• Give patient toothpaste and toothbrush.
• Give the patient finger food.
• Assess the patient’s level of orientation during the admission process.

Correct answer D.

2.A 33years old female comes to the recovery room following a tympanoplasty of the right ear. The nurse should?

Answer:

• Position the patient flat in bed with affected ear up.
• Position patient supine in bed with affected ear lateral.
• Position patient on the left side with affected ear downward.
• Allow patient to choose comfortable position.

Correct answer A.

Rationale: Flat in bed for 12 hours with affected ear up prevent disgorgement of graft.

.

Rationale: Umbilical hernia usually closes spontaneously by the age of 3years to 4 years old.

3.A 68years old woman diagnosed with Alzheimer disease is being discharged. The nurse teaches her daughter how to care for her mother at home. Which statement if made by her daughter will be an indication that she understands how to care for her mother at home?

Answer:

• I will just let her do her own thing.
• I thought that God is perfect and he made this stupid mistake.
• It is important to establish a routine for daily activities.
• None of the above.

Correct answer C.

Rationale: Consistent environment and routine helps with memory.

Alzheimer disease (senile dementia) chronic, progressive degenerative disease resulting in cerebral atrophy. Signs and symptoms are changes in memory, confusion, disorientation, change in personality. Most common after the age of 65years. Nursing Responsibilities: Reorient as needed, speak slowly. Clocks and calendars in the room. Bed in low position with side rail up.

4.The nurse is assisting an elderly client’s family to cope with the stress of caring for the client at home. The nurse knows that when client has dementia. Which of the following is most likely to increase the family’s stress?

Answer:

• The client wandering.
• The client poor appetite.
• The client’s inability to recognize and communicate with the family.
• None of the above.

Correct answer C.

Rationale: It is always very emotional for families when their love one cannot recognize them and sees them as strangers.

5.The nurse prepares an adult client for instillation of ear drops. The nurse should use which of the following methods to administer the ear drops?

Answer:

• Warm the solution. Drop the medication along the side of the ear canal.
• Let patient drop.
• None of the above.
• All of the above.

Correct answer A.

Rationale: prevents acoustic nerve reflex and dizziness. This method will not damage the tympanic membrane.

6.A 42years old woman is admitted to the hospital for surgical repair of a retinal tear of the right eye.While waiting for surgery which of the following nursing interventions should receive the highest priority?

Answer:

• Place patch on the right eye. Position him on the right side, and increase sensory stimuli.
• Patch is not needed. Only facemask.
• Patient should be sitting in upright position.
• Let him decide.

Correct answer A.

7.A 52years man is admitted to the hospital for treatment of severe diverticulitis. Because he has not responded well to medical treatment .Surgical treatment with a colostomy is scheduled. The nurse plan to teach the patient ostomy self care.Which of the following will the nurse recognize to have the greatest influence on the success of the teaching?

Answer:

• Patient acceptance of the colostomy and the ability to manage it well at home.
• The vow not to look at the bag or touch it.
• Patient vomited each time that colostomy is mentioned.

Correct answer A.

Rationale: Prove proper education on how to manage the colostomy. Clean stoma and surrounding skin with moisten cloth. Do not use soap or cleanser because it will cause problem and keep barrier from sticking.

8.The nurse performs discharge teaching with a woman who has been treated for a duodenal ulcer. The patient is to continue taking ranitidine (Zantac)and aluminum hydroxide

(Amphojel.OTC) at home. The patient asks the nurse what she should do if she experience epigastric discomfort between meals. Which of the following suggestion, if provided by the nurse should be most appropriate?

Answer:

• Take additional Amphojel.OTC antacid, take 4 to 6 tablets a day as ordered by your doctor.
• Call your doctor.
• Good back to emergency room.
• It is going to go away.

Correct answer A.

9.A client is diagnosed with bipolar disorder and is manic physic with combative behavior. An initial nursing priority is to?

Answer:

• Administer and monitor sedative and mood stability medication.
• Do allow patient to escape.
• All of the above.
• None of the above.

Correct answer A.

10.A young adult client describes her fears about taking the elevator to the 15th floor of her office building. She states feeling anxious, dizzy her heart races and she is short of breath. This information gained during the nursing assessment reveals that the client is probably experiencing?

Answer:

• Hallucination.
• Phobic disorder.
• Delusions.
• All of the above.

Correct answer B.

11.What is Code Orange?

Answer:

• Adult medical emergency.
• Pediatric Medical Emergency.
• Infant abduction.
• Hazardous material spill.

Correct answer is D.A,B and C wrong.

Rationale: Code Orange is for Hazardous material spill. Adult Medical Emergency is code blue.Pediatric Medical emergency is Code White. Infant Abduction is Code Pink.

12.When do you call Rapid Response Team?

Answer:

• When patient is in respiratory distress, change in vital signs ,respiration less than 8 or greater then 28bpm.
• Change in oxygen saturation of less than 90 even with supplemental oxygen, on-reactive or fixed pupil and decrease in level of consciousness.(neurological). Chest pain.
• Decrease in urine output of less than 100 in 8hours.Heart rate greater than 130 or less than 40.Change in color of patient.
• None of the above is correct.
• All of the above is correct.

Correct answer E.