What is the priority need for a patient diagnosed with severe, late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering ● Maintenance of nutrition and hydration A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse’s comments and asks, “What do you mean? What are they going to do?” Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient’s level of anxiety? a. Mild b. Moderate c. Severe d. Panic A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for a. coma. b. seizures. c. hypotonia. d. respiratory depression. While performing an assessment, the nurse says to a patient, “While growing up, most of us heard some half-truths about sexual matters that continue to puzzle us as adults. Do any come to your mind now?” The purpose of this question is to a. identifies areas of sexual dysfunction for treatment. b. determines possible homosexual urges. c. introduces the topic of masturbation.

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