It is your turn to perform the role of charge nurse for your shift.  The night shift nurse reported that the patient in 28B who has Alzheimer’s disease (AD) had two episodes of wandering down the hall last night without assistance.  Which nursing action is the first priority in your role as charge nurse?

You received report from the night shift nurse that your patient with moderate dementia has shown increased restlessness, agitation and repetitiveness in the last few hours.  The initial action by the receiving nurse is to

A young male client with an arm wound caused by a metallic object questions why he needs to have “a shot” or “shots”. He has never had any tetanus treatment or prophylaxis. Which of the following is the most appropriate response?

Your patient’s thinking is intact but with apathy and frequently responds with “I don’t know.” He is noted to have selective disorientation resulting from impaired concentration and attention span.  These symptoms closely fit the clinical features of:

A client with GB in the acute phase is experiencing respiratory distress. Which of the following is most important to monitor?

Which of the following nursing interventions has the lowest priority for a patient with GB? 

A major goal of treatment for the patient with AD is which of the following?

A client involved in a traumatic fall has absence of independent respiratory function, but movement in the neck & above only. Where is the most likely location of the spinal cord lesion?

A 41-year-old female client with trigeminal neuralgia wishes to know why her severe pain is all over her face and radiates to the back of her skull. The nurse explains that the trigeminal nerve is involved and it has three branches. Which of the following is not a branch of this nerve?

A 55-year-old male client with GB in the acute phase has compromised nutritional intake. Which of the following is least likely?