Audrey is a veteran who served in Afghanistan. She finds it very difficult to drive through a parking ramp because she perceives that "There are people hiding behind the pillars! They have guns! Be careful." Audrey is most likely experiencing which of the following?

Auditory hallucinations

Free-floating anxiety

Flashbacks

Delusions of grandeur

Answer and Explanation

The Correct Answer is C

Choice A reason: Auditory hallucinations involve hearing voices or sounds that are not present, which does not match Audrey's experience of visual perceptions.

Choice B reason: Free-floating anxiety is a general feeling of unease that is not tied to a specific situation, whereas Audrey's anxiety is triggered by a specific scenario reminiscent of past trauma.

Choice C reason: Flashbacks are vivid, often distressing, memories of past traumatic events that feel as though they are happening in the present. Audrey's experience is indicative of flashbacks related to her military service.

Choice D reason: Delusions of grandeur involve beliefs of inflated worth, power, or identity, which is not described in Audrey's situation.

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Correct Answer is A

Explanation

Choice A reason: A urine output of 18 mL/hr is significantly lower than the normal range (typically around 0.5-1 mL/kg/hr), indicating possible renal hypoperfusion, an early sign of shock.

Choice B reason: While blood pressure is an important indicator, it may not drop until later stages of shock.

Choice C reason: Lethargy can be a sign of shock, but it is a more subjective and later symptom compared to the objective measure of urine output.

Choice D reason: An elevated pulse is a compensatory mechanism in shock, but it is not as specific an early indicator as a decrease in urine output.

A. Providing the patient with a pillow to brace the incision B. Instructing the patient to perform deep coughing every 30 minutes C. Having the patient sit up and lean forward D. Giving pain medication prior to coughing

Correct Answer is B

Explanation

Choice A reason: Providing a pillow to brace the incision is a recommended practice to support the incision during coughing or movement.

Choice B reason: Instructing the patient to perform deep coughing every 30 minutes is a standard postoperative care practice to prevent atelectasis.

Choice C reason: Having the patient sit up and lean forward can help with breathing and comfort after surgery.

Choice D reason: Giving pain medication prior to coughing is actually a recommended practice to reduce pain and facilitate effective coughing.

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Audrey is a veteran who served in Afghanistan. She finds it very difficult to drive through a parking ramp because she perceives that "There are people hiding behind the pillars! They have guns! Be careful." Audrey is most likely experiencing which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 52-year-old male patient with a bowel obstruction. Which of these signs would be the earliest indicator to the nurse that the patient is developing symptoms of shock?

Correct Answer is A

Explanation

The nurse is assisting in the care of a patient after open-heart surgery. Which action by the other nurse would warrant intervention?

Correct Answer is B

Explanation

Lisa is a 22-year-old woman who experiences episodes of extreme muscle rigidity. She sometimes repeats a word or phrase over and over. Attempts to move her are met with increased muscle resistance. What is she exhibiting?

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder (OCD) regarding brushing his teeth. The client brushes his tongue several times a day and has developed several ulcerations. Which of the following interventions should the nurse identify as a priority?

The nurse is assisting a coworker in preparing a patient for surgery. Which statement by the coworker should warrant intervention by the nurse?

The nurse is providing care for a patient after an above-the-knee amputation due to diabetes complications. Which nursing care is essential for promoting ambulation?

A nurse is caring for a client who has paranoid delusions and believes the hospital food is being poisoned by the staff. Which meal presentation should the nurse consider to be an effective method of encouraging nutritional intake?

The sudden bursting open of the wound's edges is known as: