Question 1

Which is the highest priority nursing diagnosis for a college student who is living away from home for the first time?

Accepted Answer

A)  Sleep deprivation related to noisy dormitory environment 
B)  Risk-prone health behavior related to weekend binge drinking 
C)  Relocation stress syndrome related to moving away from home 
D)  Risk for loneliness related to being away from family and old friends 
A)  Sleep deprivation related to noisy dormitory environment 
B)  Risk-prone health behavior related to weekend binge drinking 
C)  Relocation stress syndrome related to moving away from home 
D)  Risk for loneliness related to being away from family and old friends

Question 2

A patient smokes in the hospital bathroom and starts a fire.Which is the nurse's first response?

Accepted Answer

A)  Remove the patient to a safe area. 
B)  Close the door to contain the fire. 
C)  Call the operator to activate the fire alarm. 
D)  Utilize a fire extinguisher to put out the fire. 
A)  Remove the patient to a safe area. 
B)  Close the door to contain the fire. 
C)  Call the operator to activate the fire alarm. 
D)  Utilize a fire extinguisher to put out the fire.

Question 3

The patient is aggressively attempting to pull out IV lines and hurt staff members.Which is the first action of the nurse?

Accepted Answer

A)  Conduct a thorough mental status assessment. 
B)  Contact the health care provider to obtain an order for restraints. 
C)  Place the patient in soft restraints to prevent injury. 
D)  Document the patient's actions in the medical record. 
A)  Conduct a thorough mental status assessment. 
B)  Contact the health care provider to obtain an order for restraints. 
C)  Place the patient in soft restraints to prevent injury. 
D)  Document the patient's actions in the medical record.

Question 4

The patient's electricity has been shut off after failure to pay the utility bills.Which actions by the patient pose health hazards?

Accepted Answer

A)  The gas oven is used to warm the kitchen. 
B)  Extra layers of warm clothing are worn. 
C)  Food is smelled to determine if it is edible. 
D)  Dry ice is used to keep milk and eggs cold. 
E)  Lit taper candles are placed around the house. 
A)  The gas oven is used to warm the kitchen. 
B)  Extra layers of warm clothing are worn. 
C)  Food is smelled to determine if it is edible. 
D)  Dry ice is used to keep milk and eggs cold. 
E)  Lit taper candles are placed around the house.

Question 5

Which nursing diagnosis is the highest priority for a sexually active adolescent?

Accepted Answer

A)  Risk for infection related to participation in unprotected sexual activity 
B)  Disturbed body image related to depersonalization and fear of rejection 
C)  Spiritual distress related to inability to integrate sexuality with church teaching 
D)  Risk for compromised human dignity related to loss of respect from peer group 
A)  Risk for infection related to participation in unprotected sexual activity 
B)  Disturbed body image related to depersonalization and fear of rejection 
C)  Spiritual distress related to inability to integrate sexuality with church teaching 
D)  Risk for compromised human dignity related to loss of respect from peer group

Question 6

The nurse is caring for a patient who has ongoing headaches,nausea,dizziness,and fatigue since the weather turned cold and snowy.Which assessment question is most important to ask the patient?

Accepted Answer

A)  "Has your furnace been inspected lately?" 
B)  "Have you checked your roof for any leaks?" 
C)  "When was the last time your house was painted?" 
D)  "When did you change your smoke detector batteries?" 
A)  "Has your furnace been inspected lately?" 
B)  "Have you checked your roof for any leaks?" 
C)  "When was the last time your house was painted?" 
D)  "When did you change your smoke detector batteries?"

Question 7

Which patient care need may be delegated to the nursing assistant?

Accepted Answer

A)  Providing discharge teaching about fall precautions in the home 
B)  Responding to the patient's bed alarm as the patient attempts to get up 
C)  Performing a mental status assessment to check for confusion or delirium 
D)  Obtaining a consult for physical therapy for strengthening/balance exercises 
A)  Providing discharge teaching about fall precautions in the home 
B)  Responding to the patient's bed alarm as the patient attempts to get up 
C)  Performing a mental status assessment to check for confusion or delirium 
D)  Obtaining a consult for physical therapy for strengthening/balance exercises

Question 8

Which is the appropriate disposal method for used insulin syringes at home?

Accepted Answer

A)  Engage the safety cap over the needle and place it in the recycle bin. 
B)  Remove the needle from the syringe and then flush it down the toilet. 
C)  Place the used syringes in a sharps container that is mailed back for destruction. 
D)  Place the used needles in a plastic can that is placed in the center of the trash bin. 
A)  Engage the safety cap over the needle and place it in the recycle bin. 
B)  Remove the needle from the syringe and then flush it down the toilet. 
C)  Place the used syringes in a sharps container that is mailed back for destruction. 
D)  Place the used needles in a plastic can that is placed in the center of the trash bin.

Question 9

Which intrinsic assessment finding could lead a patient to fall?

Accepted Answer

A)  The patient has orthostatic hypotension and faints when standing too quickly. 
B)  The patient's room is located at the end of the hall far from the nursing station. 
C)  The patient's roommate sometimes spills the contents of a urinal on the floor. 
D)  The patient's room is crowed with walkers,wheelchairs,and bedside commodes. 
A)  The patient has orthostatic hypotension and faints when standing too quickly. 
B)  The patient's room is located at the end of the hall far from the nursing station. 
C)  The patient's roommate sometimes spills the contents of a urinal on the floor. 
D)  The patient's room is crowed with walkers,wheelchairs,and bedside commodes.

Exam 30: Safety

Which is the highest priority nursing diagnosis for a college student who is living away from home for the first time?

A patient smokes in the hospital bathroom and starts a fire.Which is the nurse's first response?

The patient is aggressively attempting to pull out IV lines and hurt staff members.Which is the first action of the nurse?

The patient's electricity has been shut off after failure to pay the utility bills.Which actions by the patient pose health hazards?

Which nursing diagnosis is the highest priority for a sexually active adolescent?

The nurse is caring for a patient who has ongoing headaches,nausea,dizziness,and fatigue since the weather turned cold and snowy.Which assessment question is most important to ask the patient?

Which patient care need may be delegated to the nursing assistant?

Which is the appropriate disposal method for used insulin syringes at home?

Which intrinsic assessment finding could lead a patient to fall?

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