Name: Score:
86 Multiple choice questions
Term 1 of 86
Charlie Raymond Scenario 2
Mr. Raymond is found walking down the hallway without a mask. He is confused to person,
place, and time.
Help patient search for his glasses
Identify yourself verbally when entering and leaving the room
Do not rely on gestures or non-verbal communication
Use indirect lighting to avoid glare
Inform Mr. Goodman that his girlfriend called about his status.
Explain HIPAA policy to the girlfriend
Do not give out any information without consent from the patient
Direct Mr. Raymond back to his room and place his O2 cannula
Assess Mr. Raymond's A&O x4 and pulse oximetry
Give Mr. Raymond a mask
Nursing concern/diagnosis of acute anxiety
Nursing concern/diagnosis of patient safety related to domestic abuse
Term 2 of 86
Donald Lyles Scenario 4
Mr. Lyles falls while evacuating the room in the hallway
Obtain vital signs
Notify HCP of fall
Assess for obvious injury
Verify patient identity
Use unexpired glucometer strips
Hand imprint on the arm
Multiple bruises to the back
Activate fire alarm
Contain the fire
Assist patient in leaving the room
,Term 3 of 86
Preston Wright Scenario 5
The nurse is having difficulty communicating the discharge instructions with Mr. Wright's wife.
Mrs. Wright is Korean and speaks very little English. What are appropriate actions to take in
communicating with Mrs. Wright?
Inform Mr. Goodman that his girlfriend called about his status.
Explain HIPAA policy to the girlfriend
Do not give out any information without consent from the patient
Contact social services
Provide therapeutic communication and emotional support to the patient
Reassess patients pain every time PRN medication is due
Use an interrupter/ family member if available
Access telephone language line
Use a communication board, if available
Speak to Mrs. Wright in a normal tone and cadence
Observe the degree of chest wall movement while counting the rate and palpate the
chest wall excursion
Observe the complete respiratory cycle
Auscultate the lungs
,Term 4 of 86
Roger Clinton Scenario 1
Mr. Clinton is awaiting the pathology report. He is experiencing pain and a scratchy throat
postoperatively. The dressing is intact with minimal pinkish drainage.
Use a temporal or tympanic thermometer, if available
Take an axillary temperature with the blue electronic thermometer (red for rectal)
Contact Provider for an anxiolytic medication
Reassess wound site
Initiate alternative distractions for pain / anxiety interventions
Listen to patient's concern
Rate patient's pain on a scale of 1-10
Assess his airway
Determine if drainage is increasing
Inspect toes on cast site for temperature, blanching, and pulses
Offer distraction (TV, book, etc.)
Reposition patient to a more comfortable position
Term 5 of 86
Karen Cole Scenario 2
The patient's systolic blood pressure (BP) is 30 mmHg lower in the left arm than it is in the right.
Have a nursing colleague verify BP readings
Have the patient rest in the same position and repeat BP assessment in 15 minutes
Notify Healthcare Provider of findings
Reduce external stimuli
Sit at the patient's eye level and ensure they can see your lip movement and facial
expression
Speak slowly in a normal tone of voice
Sit quietly with the patient allowing them enough time to respond
Notify HCP of suspected abuse
Report suspicion of abuse to adult protective services
Have nursing personnel in the room when family visit
Wait 2-5 minutes and re-take patient's pulse ox
Ensure O2 tubing is in place and unobstructed
Ensure patient is in a semi-recumbent position and at rest
, Term 6 of 86
Tim Jones Scenario 4
The nurse is concerned that the patient may be abused in several ways. The nurse assumes that
the prescription medication is being diverted to the son. After going through the patients
medications, it is noted that the patient's Tylenol number 3 is missing. When asking who cares
for him daily, Mr. Jones notes that his son takes care of his finances and filling his medications.
The patient's son and grandson live with him; when the grandson comes into the room, the
patient grimaces. Determine the types of abuse.
Contact provider for an anxiolytic medication
reassess wound site
initiate alternative distractions for pain / anxiety interventions
Psychological abuse
Medication abuse
Financial abuse
Contact social services
Provide therapeutic communication and emotional support to the patient
Reassess patients pain every time PRN medication is due
Assess patient's ability to perform activities of daily living over the last 6 weeks
Determine onset of confusion
Administer a mini-mental state exam
86 Multiple choice questions
Term 1 of 86
Charlie Raymond Scenario 2
Mr. Raymond is found walking down the hallway without a mask. He is confused to person,
place, and time.
Help patient search for his glasses
Identify yourself verbally when entering and leaving the room
Do not rely on gestures or non-verbal communication
Use indirect lighting to avoid glare
Inform Mr. Goodman that his girlfriend called about his status.
Explain HIPAA policy to the girlfriend
Do not give out any information without consent from the patient
Direct Mr. Raymond back to his room and place his O2 cannula
Assess Mr. Raymond's A&O x4 and pulse oximetry
Give Mr. Raymond a mask
Nursing concern/diagnosis of acute anxiety
Nursing concern/diagnosis of patient safety related to domestic abuse
Term 2 of 86
Donald Lyles Scenario 4
Mr. Lyles falls while evacuating the room in the hallway
Obtain vital signs
Notify HCP of fall
Assess for obvious injury
Verify patient identity
Use unexpired glucometer strips
Hand imprint on the arm
Multiple bruises to the back
Activate fire alarm
Contain the fire
Assist patient in leaving the room
,Term 3 of 86
Preston Wright Scenario 5
The nurse is having difficulty communicating the discharge instructions with Mr. Wright's wife.
Mrs. Wright is Korean and speaks very little English. What are appropriate actions to take in
communicating with Mrs. Wright?
Inform Mr. Goodman that his girlfriend called about his status.
Explain HIPAA policy to the girlfriend
Do not give out any information without consent from the patient
Contact social services
Provide therapeutic communication and emotional support to the patient
Reassess patients pain every time PRN medication is due
Use an interrupter/ family member if available
Access telephone language line
Use a communication board, if available
Speak to Mrs. Wright in a normal tone and cadence
Observe the degree of chest wall movement while counting the rate and palpate the
chest wall excursion
Observe the complete respiratory cycle
Auscultate the lungs
,Term 4 of 86
Roger Clinton Scenario 1
Mr. Clinton is awaiting the pathology report. He is experiencing pain and a scratchy throat
postoperatively. The dressing is intact with minimal pinkish drainage.
Use a temporal or tympanic thermometer, if available
Take an axillary temperature with the blue electronic thermometer (red for rectal)
Contact Provider for an anxiolytic medication
Reassess wound site
Initiate alternative distractions for pain / anxiety interventions
Listen to patient's concern
Rate patient's pain on a scale of 1-10
Assess his airway
Determine if drainage is increasing
Inspect toes on cast site for temperature, blanching, and pulses
Offer distraction (TV, book, etc.)
Reposition patient to a more comfortable position
Term 5 of 86
Karen Cole Scenario 2
The patient's systolic blood pressure (BP) is 30 mmHg lower in the left arm than it is in the right.
Have a nursing colleague verify BP readings
Have the patient rest in the same position and repeat BP assessment in 15 minutes
Notify Healthcare Provider of findings
Reduce external stimuli
Sit at the patient's eye level and ensure they can see your lip movement and facial
expression
Speak slowly in a normal tone of voice
Sit quietly with the patient allowing them enough time to respond
Notify HCP of suspected abuse
Report suspicion of abuse to adult protective services
Have nursing personnel in the room when family visit
Wait 2-5 minutes and re-take patient's pulse ox
Ensure O2 tubing is in place and unobstructed
Ensure patient is in a semi-recumbent position and at rest
, Term 6 of 86
Tim Jones Scenario 4
The nurse is concerned that the patient may be abused in several ways. The nurse assumes that
the prescription medication is being diverted to the son. After going through the patients
medications, it is noted that the patient's Tylenol number 3 is missing. When asking who cares
for him daily, Mr. Jones notes that his son takes care of his finances and filling his medications.
The patient's son and grandson live with him; when the grandson comes into the room, the
patient grimaces. Determine the types of abuse.
Contact provider for an anxiolytic medication
reassess wound site
initiate alternative distractions for pain / anxiety interventions
Psychological abuse
Medication abuse
Financial abuse
Contact social services
Provide therapeutic communication and emotional support to the patient
Reassess patients pain every time PRN medication is due
Assess patient's ability to perform activities of daily living over the last 6 weeks
Determine onset of confusion
Administer a mini-mental state exam
