A 19-year-old college student is brought to the emergency department with a severe headache he describes as, "Like nothing I've ever had before." His temperature is 40 C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem?

A) Head injury
B) Cluster headache
C) Migraine headache
D) Meningeal inflammation

Which of the following statements are true regarding professional standards of nursing assessment? Select all that apply.

A) Assessment is a professional nursing responsibility.
B) Assessment helps the nurse identify problems and assign priorities for patient care.
C) Assessment helps the nurse formulate the medical diagnosis.
D) Only patients complaining of pain need to be assessed for pain.
E) Parts of nursing assessments can be delegated according to state practice acts and agency policies.

Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions?

A) Nurses are responsible for breaking silences.
B) Patients withdraw if silences are prolonged.
C) Silence can provide meaningful moments for reflection.
D) Silence helps patients know that what they said is understood.

After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference?

A) The patient's reactions toward the nurse seem realistic and appropriate.
B) The patient states, "Talking to you feels like talking to my parents."
C) The nurse feels unusually happy when the patient's mood begins to lift.
D) The nurse develops a trusting relationship with the patient.

The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse's action?

A) Inadequate blood flow leads to decreased tissue ischemia.
B) Patients with limited caloric intake develop thicker skin.
C) Pressure reduces circulation to affected tissue.
D) Verbalization of skin care needs is decreased.

The nurse manager is concerned with the safety of the staff as they transfer patients.Facility policy reinforces the principles of appropriate body mechanics,which include which of the following? (Select all that apply.)

A) A wide base of support increases stability
B) A higher center of gravity increases stability
C) Facing the direction of movement prevents abnormal twisting of the spine
D) Pivoting requires less work than lifting
E) Manually lift the patient in sections
F) Dividing balanced activity between arms and the legs