Correct Answer: D

Rationale: The correct answer is D because initiating the alcohol withdrawal protocol shows an understanding of managing a patient at risk for alcohol withdrawal syndrome. This protocol involves carefully monitoring the patient's symptoms, providing appropriate medications, and ensuring a safe environment. Option A is incorrect as it downplays the seriousness of alcohol withdrawal. Option B is incorrect as there are assessment tools available for identifying alcohol withdrawal. Option C is incorrect as pain management should be tailored to the individual's needs, not necessarily lessened due to alcohol withdrawal risk.

Correct Answer: A

Rationale: The correct answer is A, absence of a corneal reflex, because in brain death, all brainstem reflexes, including the corneal reflex, are absent. This indicates complete loss of brain function.
Choice B, unequal reactive pupils, is incorrect as it suggests some level of brainstem function.
Choice C, withdrawal from painful stimuli, is also incorrect as it is a spinal reflex and can occur even in the absence of brain function.
Choice D, core temperature of 100.8° F, is irrelevant to assessing brain death.

Correct Answer: D

Rationale: The correct answer is D because a patient with a history of fluid overload due to heart failure is at the greatest risk of developing acute kidney injury. Heart failure can lead to decreased kidney perfusion causing acute kidney injury. In this scenario, the patient's fluid overload exacerbates the situation, further compromising kidney function.


Choice A is incorrect as aminoglycosides can cause kidney injury but the duration of 6 days is less concerning compared to chronic fluid overload from heart failure in choice D.
Choice B is incorrect because controlled hypertension does not directly increase the risk of acute kidney injury.
Choice C is incorrect as the patient being discharged 2 weeks earlier after aminoglycoside therapy does not necessarily indicate a higher risk compared to chronic fluid overload.

Correct Answer: C

Rationale: The correct answer is C: Assessment. In the SBAR communication model, the nurse's information about the patient's history and vital signs falls under the Assessment component. This is because the nurse is providing a detailed evaluation of the patient's current condition based on objective data such as urine output, heart rate, blood pressure, and other key indicators. The nurse is analyzing the situation and forming a judgment that the patient is hypovolemic, indicating a fluid deficit. This assessment is crucial for informing further actions or interventions, such as increasing fluids or providing a fluid challenge.

Summary of other choices:
A: Situation - This choice would refer to a brief summary of the current situation without detailed analysis or interpretation.
B: Background - This choice would involve providing relevant background information about the patient, such as medical history or recent procedures, but not the current assessment of the patient's condition.
D: Recommendation - This choice would involve suggesting a course of action or treatment based on the assessment, which comes after

Correct Answer: C

Rationale: The correct answer is C: True collaboration. In this scenario, the physician consults with the nurse to understand the situation and collaborates on the best course of action for the patient's care. This demonstrates effective teamwork, communication, and mutual respect between healthcare professionals, which are key components of a healthy work environment.


Choice A (Skilled communication) is not the best answer because while communication between the physician and nurse is important, the focus in this scenario is more on collaboration and teamwork.


Choice B (Appropriate staffing) is not the best answer as the scenario does not specifically address staffing levels but rather the interaction and collaboration between the physician and nurse.


Choice D (Recognizing signs of imminent stroke and paging the physician) is incorrect as it is unrelated to the scenario described, which is about the physician and nurse collaborating on patient care.