RN101
Home of the Registered Nurses (RN) and
Licensed Practical Nurses (LPN)

SITUATION I

A new male orderly is assisting you today for a female patient with right-sided paralysis who needs assistance with eating due to impaired swallowing and complains of frequent heartburn. While waiting for the meal to arrive, you put the patient in sitting position, assesses her gag reflex, washes her hands and you put on her eyeglasses before you left the patient’s room.see answer

 

Question 1:

What instruction will you ask the orderly to do in order to alleviate the patient's complaint?

1. _____________________________________________________________________________________________________________________________.

 

You notice that the orderly praises the patient for attempting to perform ADL's independently uses a gait belt around the patient's waist prior to ambulation places the patient on the back of the patient's head to the side and places his hand under the patient's axilla to help her move up in bed.

 

Question 2:

What action by the orderly requires for you to intervene?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION II

You are providing care for a patient with an acute hemorrhagic stroke. The patient’s husband has been reading a lot about strokes and asks why his wife did not receive alteplase (tPA).see answer

 

Question 1:

What is your best response?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION III

A patient with Parkinson’s disease who has impaired physical mobility is taking care of by a new orderly. You observe the orderly performing all of these actions:see answer

1. Ambulate the patient back to the bathroom and back to the bed.

2. Reminds the patient not to look at his feet when he is walking.

3. Performs the patient's complete bath and oral care.

4. Set up the patient tray and encourage the patient to eat.

 

Question 1:

For which action by the orderly must you intervene and why?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION IV

A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures.see answer

 

Question 1:

Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? 

Take patient vital signs; Perform neurologic checks; Document the onset time and nature of seizure activity; Administer phenytoin (Dilantin) 200 mg PO daily; Teach the patient the need for good oral hygiene; Develop a discharge plan, physician visits, and referral to the epilepsy foundation.

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

 

SITUATION V

Mrs. A is a 31-year-old who lives with her partner and three young children. She has had severe epileptic seizures which are more often this year. Her physician prescribed phenytoin (Dilantin). Today, you are preparing the patient for discharge who will be picked up by her husband.see answer

 

Question 1:

Identify three (3) instructions you should include about her phenytoin (Dilantin) before they leave, apart from signs and symptoms of phenytoin toxicity?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

3. _____________________________________________________________________________________________________________________________.

 

SITUATION VI

Mr. C, age 26, has been hospitalized on your unit since this morning following a vehicular accident. The patient suffered an arm fracture with a suspected C5 compression fracture. The patient is conscious and oriented.see answer

 

MEDICAL HISTORY                                                                                        MEDICAL ORDER

Retrograde amnesia post-accident                                                           Cervical collar at all times

Loss of consciousness for 2 minutes                                                        Vital and neurological signs every hour    

GCS score 14/15 in ER

CT scan revealed a C5 compression fracture

On arm cast

 

At 12:00 pm Mr. C is resting in his bed in a supine position. Suddenly, he feels nauseous. Vital signs were taken as follows: BP: 125/80 mmHg, P- 72/min, R-16/min reg., T-37.8˚ C. You decided to place him in a lateral position.

 

Question 1:

Identify two (2) precautions you must do or how will you place the patient in a lateral position?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

 

At 14:00, you noticed that the patient has flushed skin, diaphoretic, and with a blood pressure of 162/96 mmHg. Mr. C also reports a severe pounding headache.

 

Question 2:

What do you suspect is happening to the patient?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION VII

A new female patient with moderate Alzheimer's disease is exhibiting symptoms of confusion.see answer

 

Question 1:

You should do the following appropriate interventions, except: (Encircle your answer)

1. Furnish the patient room with pictures of her family and familiar positions

2. Remove hazardous items

3. Orient the patient to the environment

4. Place the patient in a secluded area where she can be alone and would facilitate independence

5. Call the patient by name, identify yourself and wait for a response

 

Question 2:

Justify your answer in question number one.

1. _____________________________________________________________________________________________________________________________.

 

SITUATION VIII

An elderly woman's husband died. When her brother arrives for the funeral, he notices her short-term memory problems and occasional disorientation. A few weeks later, she calls him to say that her husband just died. She says, "I didn't know he was so sick. Why did he die now?" She also complains of not sleeping, urinary frequency and burning, and seeing rats in the kitchen. You're a home care nurse who  is sent to evaluate her situation and finds the woman reclusive and passive but pleasant. You call the woman's primary care physician to discuss the client's situation and background and give your assessment and recommendations.see answer

 

Question 1:

You conclude that the patient is experiencing what?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

 

SITUATION IX

You are attempting to draw blood from a woman with a diagnosis of delirium who was admitted last evening. The client yells out, "Stop! Leave me alone! What are you trying to do to me?! What's happening to me?"see answer

 

Question 1:

What will be your most appropriate response? 

1. _____________________________________________________________________________________________________________________________.

 

Later in the day, she tries to get out of the locked unit. He yells, "Unlock this door! I've got to go see my doctor. I just can't miss my monthly Friday appointment." 

 

Question 2:

What will be your appropriate response?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION X

Nursing staff is trying to provide for the safety of an elderly female client with moderate dementia. She is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries.see answer 

 

Question 1:

What are your interventions for this patient?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

 

SITUATION XI

During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore."see answer 

 

Question 1:

What will you suggest to the patient's daughter?

1. _____________________________________________________________________________________________________________________________.

2. _____________________________________________________________________________________________________________________________.

3. _____________________________________________________________________________________________________________________________.

 

SITUATION XII

While assessing a patient diagnosed with dementia, you note that patient uses vulgar language.see answer

 

Question 1:

What should you do?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION XIII

An 89-year-old female patient with dementia is admitted to the Alzheimer’s unit in a home care facility. This patient insists on carrying a purse at all times.see answer

 

Question 1:

What nursing approach is best when managing the care of this patient who insists on carrying her purse at all times?

1. _____________________________________________________________________________________________________________________________.

 

Question 2:

The patient repeatedly asks, “Where is my mother?”. What response would be best to prevent patient’s frustration and agitation?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION XIV

The patient with Parkinson’s disease takes levodopa/carbidopa (Sinemet) capsule three times a day.see answer

 

Question 1:

You observe that the patient has difficulty swallowing the capsule of medication, what action is best for you to take?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION XV

A newly admitted patient who has suffered a right-sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia.see answer

 

Question 1:

Early in the care of the patient, the nurse should place objects on which side of the patient?

1. _____________________________________________________________________________________________________________________________.

 

SITUATION XVI

A family member of a patient with possible Alzheimer's disease asks the nurse the purpose of the Mini-Mental State Examination (MMSE). What response by the nurse is appropriate?see answer

1. _____________________________________________________________________________________________________________________________.

 

SITUATION XVII

You work as a CLSC nurse for a home health patient with Alzheimer's disease (AD) and mild dementia  who has a new prescription for donepezil (Aricept).see answer 

 

Question 1:

What nursing action will be most effective in ensuring compliance with the medication?

1. _____________________________________________________________________________________________________________________________.