1. An elderly patient with Parkinson’s disease is admitted post-hip fracture. The nurse notes the EHR’s AI-driven fall risk algorithm assigns a "low risk" score despite gait instability and PRN sedative use. Which action aligns with safe technology integration?
Answer: A
Clinical judgment must supersede algorithmic outputs when discrepancies exist. Option A upholds nursing autonomy by layering evidence-based precautions (e.g., non-slip socks, hourly checks) despite the flawed "low risk" rating, complying with joint commission standards. Option B risks misusing override functions without validation. Option C assumes data error rather than algorithm limitation. Option D neglects comprehensive interventions for high fall-risk patients with neuro-mobility deficits. Parkinson’s and sedatives necessitate tailored precautions beyond AI scoring.
2. A nurse receives a telephone order for "haloperidol 2 mg IM now" for an elderly patient with UTI-induced delirium attempting to pull out their IV. The patient has a history of Parkinson's disease and takes carbidopa-levodopa. Which action takes priority?
Answer: D
Haloperidol is contraindicated in Parkinson's as it worsens symptoms. Option A risks severe neurological deterioration. Options B and C suggest alternatives but benzodiazepines may worsen delirium in elderly patients. Option D directly addresses the contraindication, prioritizing patient safety over immediate behavioral control per geriatric psychopharmacology guidelines.
3. An RN delegates post-fall neurological checks every 15 minutes to a UAP for a patient on anticoagulants who hit their head. The UAP reports unchanged vital signs but omits that the patient vomited once. The patient later has a brain bleed. What delegation failure contributed to this?
Answer: B
Vomiting is a critical neuro indicator requiring immediate RN notification post-head injury with anticoagulants. Option B identifies the failure to define reportable symptoms despite known bleed risk. Option A is inherent—UAPs can't perform neuro assessments. Option C/D are important but don't address the omission of symptom reporting parameters. The RN retains liability for not providing clear "report if" criteria for delegated monitoring.
4. A 58-year-old with metastatic breast cancer reports 8/10 lumbar pain. She describes it as constant and unchanged for 5 months despite oxycodone. Today, she notes new right-leg weakness. Her pain scale is 8/10 at rest. Which assessment approach is most appropriate?
Answer: B
New neurological symptoms (leg weakness) in chronic pain suggest acute complications like spinal cord compression, requiring urgent evaluation. Option B addresses this by prioritizing neurological assessment and provider notification per oncology guidelines. Option A ignores the acute red flag. Option C delays evaluation for a non-pain-responsive emergency. Option D addresses chronic pain management but neglects the acute neurological change. The constant pain duration (5 months) and new motor deficit are key discriminators.
5. A nurse on a medical-surgical unit delegates vital sign monitoring for a postoperative diabetic patient with hypertension to an unlicensed assistive personnel (UAP). The UAP reports a BP of 190/100 mmHg and pulse 110 but does not notify the nurse. The patient later experiences a stroke. Which element must be established to prove nursing negligence?
Answer: C
Negligence requires duty, breach, causation, and damages. The nurse had a duty to supervise delegated tasks per NCSBN guidelines. Option C correctly identifies failure to supervise as the breach. Option A is incorrect because the nurse didn't personally administer meds. Option B focuses on the UAP's history, not the nurse's supervisory duty. Option D addresses system issues, but the nurse remains responsible for delegated tasks. The cues (postoperative diabetic with hypertension and unreported abnormal vitals) create urgency requiring nurse intervention.
6. A nurse cares for a comatose stroke patient whose advance directive prohibits life support. The spouse presents a handwritten note dated yesterday stating, "I changed my mind—want full treatment." What action is warranted?
Answer: C
Advance directives can only be modified by competent patients; surrogates cannot alter written directives. Option C maintains legal/ethical compliance. Option A inappropriately questions the directive's validity without evidence of revocation. Option B accepts an invalid modification. Option D pathologizes normal grief. Nurses must recognize that directives remain effective until formally revoked by the patient per Uniform Health Care Decisions Act standards.
7. On postoperative day 2, a hip replacement patient with mild cognitive impairment exhibits acute confusion, incoherent speech, and fluctuating attention. Which tool should the nurse prioritize to assess this change?
Answer: B
CAM detects delirium through acute onset, inattention, disorganized thinking, and altered consciousness—matching this patient's postoperative confusion and cognitive fluctuations. MMSE and MoCA screen for dementia, not acute delirium. GDS identifies depression, which doesn't explain acute symptoms. Hospital Elder Life Program guidelines prioritize CAM for rapid delirium identification in postoperative older adults to guide immediate interventions.
8. An elderly patient with Alzheimer’s has Aldrete 9 post-cataract surgery but is agitated and pulling at IV. Pre-procedure cognition was baseline (oriented x1). What disposition aligns with Aldrete guidelines?
Answer: C
Aldrete assesses recovery from anesthesia/sedation, not behavioral issues. Agitation may reflect dementia baseline or emergence delirium but doesn't alter physiological readiness if scores are met. Option A: Restraints are inappropriate without exhaustion of alternatives. Option B: Prolonged PACU stay isn't required for non-physiological issues. Option D: Agitation alone doesn't indicate psychiatric emergency. Behavioral management can occur on the receiving unit.
9. A nurse admits a frail elderly patient with delirium, polypharmacy, and fluctuating vital signs. The unit uses charting by exception. Which action best ensures accurate documentation?
Answer: D
Complex patients with labile conditions (discriminating cues: delirium, polypharmacy, vital sign instability) require more than minimal CBE. Daily summaries capture trends without hourly narratives, balancing efficiency and safety. Option A risks missing subtle changes in high-risk patients. Option B is inefficient for stable intervals. Option C lacks synthesis of trends. CMSRN guidelines support modified CBE with periodic summaries for unstable patients to highlight patterns while reducing documentation burden.
10. After implementing a new delirium screening protocol, a unit notes inconsistent documentation. To improve adherence, which strategy aligns best with EBP sustainability principles?
Answer: C
Sustainability requires addressing human factors in workflow integration. Option C provides active mentorship, which reinforces skills and problem-solves barriers, aligning with implementation science. Option A (data feedback) raises awareness but doesn't build skills. Option B (job aids) supports recall but not application. Option D (reminders) is passive and may cause alert fatigue. The documentation inconsistency cue indicates a need for engagement-based strategies per EBP change models.
11. A diabetic patient with delirium tremens is thrashing in bed, yelling about spiders. His IV line dislodges, and he has a history of osteoporosis. Vital signs show tachycardia and hypertension. Which action best balances safety and restraint minimization?
Answer: D
One-on-one observation allows continuous monitoring without physical restrictions, addressing safety (dislodged IV) while accommodating sensory sensitivity (cue: visual hallucinations). Side rails (A) increase fall/injury risk in osteoporosis patients. Vest restraints (C) may escalate agitation in withdrawal syndromes. Lorazepam (B) is appropriate but shouldn't replace environmental modifications first per CMS guidelines. Reduced lighting targets hallucination triggers while observation prevents harm.
12. An 82-year-old with heart failure, GERD, and chronic constipation develops new confusion. Medications include furosemide, digoxin, omeprazole, and diphenhydramine nightly. Which intervention aligns with deprescribing goals for polypharmacy-related delirium?
Answer: D
Anticholinergics like diphenhydramine are high-risk for delirium in elderly patients per Beers Criteria. Option D correctly targets this while offering non-pharmacological alternatives. Furosemide (A) requires monitoring but isn't the primary deliriogen. Digoxin (B) has neurotoxic potential but levels must be checked before discontinuation. Omeprazole substitution (C) doesn't address the anticholinergic culprit. The cues (new confusion, nightly diphenhydramine) prioritize eliminating unnecessary CNS-active drugs before adjusting essential medications.
13. When preparing to lift a 300-pound postoperative patient with an abdominal incision, which ergonomic principle is most critical for injury prevention?
Answer: A
Proper bed height maintains spinal neutral alignment during transfers per NIOSH guidelines. Option A prevents back strain when combined with assistive devices. Option B still risks injury without mechanical aids. Option C compromises patient stability. Option D helps but height adjustment is foundational for biomechanical safety with obese patients.
14. A post-stroke patient with left-sided neglect and dysphagia has a safety plan including bed alarms and pureed diets. Which event during multidisciplinary evaluation signals the greatest safety process failure?
Answer: B
Inaccessible call light (cue: communication barrier) with neglect (cue: inability to problem-solve) directly undermines the bed alarm safety net. Coughing (A) is expected in dysphagia management. Balance issues (C) and dressing difficulty (D) are known deficits requiring therapy. AMSN safety standards mandate evaluating accessibility of rescue systems; tangled equipment creates immediate risk. Distractors represent ongoing clinical challenges, while option B indicates a correctable system error compromising the safety plan's integrity.
15. During night shift, a sundowning patient with Parkinson's tries to climb over bed rails. He has orthostatic hypotension and recurrent hallucinations. Which intervention aligns with restraint-free care?
Answer: A
Environmental adaptations (low bed/mats) reduce fall injury while the rocking chair offers safe mobility (cue: sundowning restlessness). Net beds (C) and Posey vests (D) are restrictive devices violating CMS restraint definitions. Quetiapine (B) risks worsening orthostasis (cue: hypotension). The Joint Commission requires modifying environments before pharmacological/restrictive interventions for delirium.
