ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 5
The nurse is caring for four patients on the progressive car e unit. Which patient is at greatest risk for developing delirium?
Correct Answer: C
Rationale: The correct answer is C, the 86-year-old postoperative from colonic resection. This patient is at the greatest risk for delirium due to being elderly, having undergone surgery, and having a history of being from a nursing home. These factors contribute to an increased susceptibility to delirium. A: The 36-year-old with alcohol withdrawal may be at risk for delirium tremens, but the older age of the patient in choice C places them at higher risk. B: The 54-year-old with an elevated creatinine level postoperative is at risk for complications, but age and history of nursing home placement increase the risk for delirium in choice C. D: The 95-year-old with community-acquired pneumonia is at risk for delirium, but the combination of age, surgery, and nursing home history in choice C presents a greater risk.
Question 2 of 5
The nurse is caring for a critically ill patient who can speak. The nurse notices that the patient is demonstrating behaviors indicative of anxiety but is silent. What nursing strategy would give the nurse the most information about the patients feelings?
Correct Answer: B
Rationale: The correct answer is B because asking the patient to share his or her internal dialogue can provide direct insight into the patient's thoughts and feelings, allowing the nurse to address specific anxieties. This approach promotes open communication and understanding. Choice A focuses on providing information but may not directly address the patient's feelings. Choice C is unrelated to addressing the patient's anxiety. Choice D addresses pain control, which is important but not directly related to exploring the patient's emotions. Therefore, option B is the most effective strategy for gaining insight into the patient's feelings in this scenario.
Question 3 of 5
When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87�F (30.6�C), which assessment indicates that the nurse should discontinue active rewarming?
Correct Answer: D
Rationale: The correct answer is D. When rewarming a hypothermic patient, the goal is to gradually increase their core temperature. A core temperature of 94�F (34.4�C) is still below the normal range, but it indicates that the rewarming process is working. Shivering (A) is a normal response to rewarming. A decrease in blood pressure (B) may be expected due to peripheral vasodilation during rewarming. Developing atrial fibrillation (C) may be a concern but does not necessarily indicate that rewarming should be discontinued. Therefore, choice D is correct as it signifies progress in the rewarming process.
Question 4 of 5
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?
Correct Answer: A
Rationale: Step 1: Symptoms of weight loss, racing heart rate, and difficulty sleeping are common in hyperthyroidism. Step 2: Presence of moist skin, fine hair, prominent eyes, lid retraction, and staring expression are classic signs of Grave's disease, a type of hyperthyroidism. Step 3: Grave's disease is an autoimmune disorder where the thyroid gland is overactive, leading to excessive production of thyroid hormones. Step 4: Excess thyroid hormones increase metabolic rate, causing weight loss, racing heart rate, and insomnia. Step 5: Therefore, the findings described in the question are consistent with Grave's disease.
Question 5 of 5
The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse sh ould provide instruction?
Correct Answer: B
Rationale: Step 1: Influenza can lead to pneumonia as a complication, so getting an annual flu shot can reduce the risk of pneumonia. Step 2: Providing education on the importance of prevention aligns with discharge teaching goals. Step 3: Option A is incorrect as the pneumococcal vaccine doesn't guarantee immunity from all causes of pneumonia. Step 4: Option C is incorrect as cold or drafty places do not directly cause pneumonia. Step 5: Option D is incorrect as having pneumonia once does not confer permanent immunity.
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