Medical Tests Medical Tests Certifications CEN Questions & Answers

• Question 111:

  You are caring for a patient who is becoming more aggressive. He is pacing and agitated. His speech is becoming rapid and his affect belligerent. What should the nurse's first priority be?

  A. Provide safety for the patient and other patients on the unit.

  B. Offer the patient a less stimulated area to calm down and gain control.

  C. Provide the patients on the unit with a sense of comfort and safety.

  D. Assist the staff in caring for the patient in controlled environment.

  Correct Answer: A

  Safety to the patient and other patients on the unit should be the nurse's first priority. The patient is showing behavior that is escalating and most likely will hurt himself or some one else if the staff does not step in immediately. Use Maslow's hierarchy of needs to prioritize which is the most immediate priority.

• Question 112:

  Which of the following assessments by the nurse would indicate a possible manifestation of dementia?

  A. Presence of personal hygienic care

  B. Improvement in sleeping

  C. Absence of sundown syndrome

  D. Confabulation

  Correct Answer: D

  Confabulation is when a patient fabricates events or experiences to fill in the gaps in memory. This is common with dementia patients. Dementia varies from the development of mild cognitive symptoms to more severe alterations in neurological functions. These more severe alterations can become life-threatening.

• Question 113:

  You are caring for a patient who came into the emergency department in a severe state of anxiety following a care accident. What would be appropriate nursing intervention for the patient?

  A. Remain with the patient.

  B. Put the patient in a quiet room.

  C. Teach the patient to deep breathe.

  D. Encourage the patient to talk about their feelings.

  Correct Answer: A

  Remain with the patient to prevent the patient from becoming overwhelmed and feeling abandoned. The primary focus of the nurse would be to put the patient at ease. It would not be possible to teach the patient to deep breathe or get them to talk until the anxiety has decreased. It would be okay to place the patient in a quiet room as long as you remain with them.

• Question 114:

  Which of the following symptoms would require the nurses immediate attention if the patient had bipolar affective disorder?

  A. Outlandish behaviors and inappropriate dress

  B. Grandiose delusions of being a royal descendent of King Arthur

  C. Nonstop physical activity and poor nutritional intake

  D. Constant, incessant talking that includes sexual innuendoes and teasing the staff

  Correct Answer: C

  The nurse would need to give her immediate attention to the bipolar patient with nonstop physical activity and poor nutritional intake. The patient with bipolar affective disorder has moments of mania, which are characterized by euphoria, hyperactivity, excitement and excessive energy. These patients would have a difficult time completing a single train of thought. The behavior of the patient represents a problem and needs to be addressed immediately before it escalates.

• Question 115:

  You are caring for a patient who has been involuntarily admitted to the hospital because of violent behavior. The patient is demanding to leave the hospital. The nurse understands that keeping the patient will lead to:

  A. Charges of imprisonment

  B. Charges of assault

  C. Charges of slander

  D. No charges because the nurse's actions are reasonable.

  Correct Answer: D

  No charges will be filed against the nurse, because the actions of the nurse are reasonable. False imprisonment is an act with intent to confine a person to a specific area. This could be charged against the nurse if the patient had been voluntarily admitted to the hospital.

• Question 116:

  Your patient has been involuntarily admitted the hospital. He has been scheduled for electroconvulsive therapy. The nurse knows that:

  A. Informed consent is not necessary.

  B. The family will need to sign informed consent.

  C. The patient will need to sign informed consent.

  D. The physician will need to sign informed consent.

  Correct Answer: C

  The patient will still need to sign the informed consent for the therapy. The patient is still considered legally competent until declared otherwise. Patients who are admitted involuntarily do not lose their right to informed consent unless they are declared incompetent; then the consent falls to the next of kin.

• Question 117:

  You are caring for a patient who has been admitted to the hospital involuntarily. You know based on this admission that the patient:

  A. Is a harm to himself or others

  B. Is requesting admission

  C. Has agreed to admission

  D. Has provided a written request for admission

  Correct Answer: A

  The patient has been involuntarily admitted to the hospital because he presents a threat to himself or others. In this situation the patient has not consented to admission. The patient will probably be upset about the admission and will request to leave repeatedly.

• Question 118:

  You are caring for a patient who demands to be released from the hospital immediately. The patient was admitted voluntary for an anxiety disorder. What actions should the nurse take next?

  A. Tell the patient that discharge is not possible at this time.

  B. Call the patient's family.

  C. Notify the physician.

  D. Persuade the patient to stay.

  Correct Answer: C

  The nurse would need to notify the physician that the patient is requesting discharge. The patient came into the hospital voluntary and has the right to request discharge. The physician will need to evaluate the patient and determine if the patient can be discharged or should be converted to an involuntary admission.

• Question 119:

  You are caring for a patient who is being admitted to the psychiatric unit. Which of the following would present the most concern to the nurse?

  A. Presence of bruises on the patients body

  B. Reports by the patient that they can't eat or sleep

  C. Reports by the patient of suicidal thoughts

  D. Significant other's disapproval of treatment

  Correct Answer: C

  The nurse would be most concerned if the patient reports suicidal thoughts. When the patient reports suicidal thoughts, the physician should be notified. The nurse should plan to have the patient under complete supervision until further notice, for the protection of the patient.

• Question 120:

  You are caring for a patient who has been sexually assaulted. The patient has become quiet and calm. What defense mechanism does this indicate to the nurse?

  A. Denial

  B. Projection

  C. Rationalization

  D. Intellectualization

  Correct Answer: A

  The defense mechanism that the patient is displaying is denial. Denial is a way for the patient to refuse to admit to a painful. The other three defense mechanisms do not apply in this situation.