13. After receiving report on four patients with dementia, which patient would the nurse assess first?

38. A patient with a T6 spinal cord injury is being discharged home. Which instructions would the nurse include to prevent autonomic dysreflexia? (Select all that apply.)

29. A patient receiving IV tPA for ischemic stroke suddenly develops a severe headache and blood pressure rises to 200/120 mm Hg. What is the nurse’s priority action?

23. A patient with suspected bacterial meningitis has orders for blood cultures, lumbar puncture, IV ceftriaxone, and IV dexamethasone. Which sequence would the nurse follow?

54. A patient has a burn on the anterior chest and both entire arms. Using the Rule of Nines, the nurse calculates the total body surface area burned as:

94. A 90-kg burn patient with 35% TBSA requires Parkland formula resuscitation. What is the IV rate for the first 8 hours?

39. A patient with a new C3 spinal cord injury suddenly develops shallow, labored respirations and decreasing oxygen saturation. What is the nurse’s priority action?

12. A patient scores 0 on the three-word recall portion of the Mini-Cog exam but draws the clock correctly with all numbers and hands at the requested time. How does the nurse interpret the result?

11. A patient with advanced dementia suddenly begins crying and pushing staff away during morning care. Which action would the nurse take first?

15. A patient opens eyes only to painful stimulation, makes incomprehensible sounds, and exhibits flexion withdrawal from pain. The nurse calculates the Glasgow Coma Scale score as: