Nausea
Which nursing intervention best supports patient coping during ongoing nausea?
A. Limiting environmental stimuli
B. Encouraging deep breathing and comfort items
C. Maintaining strict bed rest
D. Restricting family presence
Encouraging deep breathing and comfort items
Which vital signs most strongly indicate an acute stress response?
A. HR 72, BP 118/70
B. HR 105, BP 162/90
C. SpO₂ 95%
D. Temp 37°C
B. HR 105, BP 162/90
A child experiencing anxiety is hospitalized after an injury. Which nursing action is most appropriate?
A. Focus solely on physiologic stabilization
B. Encourage parental presence and consistent guidance
C. Avoid discussing emotions
D. Administer benzodiazepines as first-line therapy
Encourage parental presence and consistent guidance
Before administering ketorolac, which assessment is most important?
A. Pain severity
B. History of GI bleeding
C. Level of consciousness
D. Oxygen saturation
B. History of GI bleeding
A patient begins actively vomiting while lying flat in bed. What is the priority nursing intervention?
A. Provide oral fluids
B. Administer antiemetics
C. Position the patient upright and suction as needed
D. Assess bowel sounds
C. Position the patient upright and suction as needed
The nurse is administering ondansetron (Zofran) to a patient with nausea. Which statement demonstrates correct nursing understanding?
A. “This medication is only given rectally.”
B. “The typical dose ranges from 4–8 mg.”
C. “It should only be used after vomiting occurs.”
D. “This medication primarily treats motion sickness.”
B. “The typical dose ranges from 4–8 mg.”
Which physiologic response is most directly caused by sympathetic nervous system activation during stress?
A. Decreased blood glucose
B. Constricted pupils
C. Increased skeletal muscle tension
D. Decreased ventilation
C. Increased skeletal muscle tension
Why must benzodiazepines be tapered rather than abruptly stopped?
A. Risk of renal failure
B. Risk of acute withdrawal
C. Risk of serotonin syndrome
D. Risk of rebound hypertension
B. Risk of acute withdrawal
A nurse assumes a patient with a history of substance use disorder is exaggerating pain. Which action best reflects appropriate pain assessment?
A. Delay analgesics until objective signs are present
B. Use behavioral signs only
C. Ask the patient to rate pain and assume pain presence based on condition
D. Provide nonpharmacologic interventions only
Ask the patient to rate pain and assume pain presence based on condition
A patient has not vomited for 6 hours and is tolerating oral fluids. What is the most appropriate next nursing action?
A. Resume a regular diet
B. Advance to a soft bland diet
C. Discontinue intake and output monitoring
D. Administer IV fluids only
B. Advance to a soft bland diet
Which adverse effect should the nurse monitor for when a patient is receiving second-line antiemetics such as promethazine or metoclopramide?
A. Hypertension
B.Hyperglycemia
C. CNS depression
D. Renal failure
C. CNS depression
Why does the nurse assess how a patient interprets a stressful event?
A. Stress responses are identical for all patients
B. Cognitive appraisal influences coping effectiveness
C. Stress is primarily a physiologic response
D. Coping strategies are random
Cognitive appraisal influences coping effectiveness
Which nursing behavior is most likely to reduce re-traumatization?
A. Limiting patient questions
B. Completing procedures efficiently
C. Offering choices whenever possible
D. Redirecting emotional responses
Offering choices whenever possible
Which finding requires the most immediate nursing intervention for a patient receiving IV hydromorphone?
A. Nausea
B. Constipation
C. Respiratory rate of 8/min
D. Pain score of 6/10
C. Respiratory rate of 8/min
Which assessment finding would prompt the nurse to investigate a possible GI bleed?
A. Green-tinged emesis
B. Projectile vomiting
C. Coffee-ground appearance of vomit
D. Nausea triggered by motion
Coffee-ground appearance of vomit
Which statement by a patient indicates need for further teaching?
A. “I’ll avoid strong smells that trigger my nausea.”
B. “I should take frequent small sips of liquids.”
C. “Cold carbonated drinks help prevent nausea.”
D. “I’ll advance my diet slowly after vomiting stops.”
. “Cold carbonated drinks help prevent nausea.”
Which nursing action best prevents a serious complication of benzodiazepine therapy?
A. Encouraging PRN use only
B. Gradually tapering the medication
C. Combining with other sedatives
D. Limiting patient education
Gradually tapering the medication
Which intervention best supports physiologic regulation during anxiety?
A. Providing detailed medical explanations only
B. Encouraging mindful breathing
C. Limiting patient movement
D. Avoiding discussion of stressors
Encouraging mindful breathing
A patient on chronic opioids reports severe pain after surgery despite standard dosing. Which nursing interpretation is most accurate?
A. The patient is drug-seeking
B. The patient may require higher doses due to opioid deficit
C. Opioids are ineffective for surgical pain
D. The patient should receive nonpharmacologic therapy only
B. The patient may require higher doses due to opioid deficit
A patient with severe vomiting is ordered laboratory testing. Which test directly evaluates the most immediate life-threatening complication?
A. White blood cell count
B. Hemoglobin and hematocrit
C. Potassium level
D. Stool culture
C. Potassium level
Which patient would require the greatest caution when administering second-line antiemetics?
A. Patient with motion sickness
B. Patient experiencing vertigo
C. Patient with decreased level of alertness
D. Patient with pregnancy-related nausea
C. Patient with decreased level of alertness
Which patient statement most clearly reflects stress related to hospitalization?
A. “Does the cafeteria have good food?”
B. “How long has my doctor been practicing?”
C. “How would I take care of my partner if they amputate my leg?”
D. “What time are visiting hours?”
How would I take care of my partner if they amputate my leg?”
Which nursing action is most important when administering lorazepam for anxiety?
A. Encourage long-term daily use
B. Monitor for CNS depression
C. Administer abruptly discontinued doses
D. Teach immediate symptom relief without monitoring
Monitor for CNS depression
A nurse prepares to administer oral morphine. Which statement reflects correct nursing knowledge?
A. Oral and IV morphine doses are equivalent
B. Oral morphine requires a higher dose than IV
C. IV morphine lasts longer than oral
D. Oral morphine has greater risk of respiratory depression
B. Oral morphine requires a higher dose than IV
PO morphine dose is 3× IV dose due to first-pass metabolism.
A patient with ongoing vomiting suddenly develops tachycardia, delayed capillary refill, and decreased urine output. Which conclusion should the nurse make?
A. Antiemetic therapy is ineffective
B. The patient is developing hypovolemic shock
C. The patient has a mechanical bowel obstruction
D. The patient requires abdominal imaging
The patient is developing hypovolemic shock