Question 1

Which of the following is not a sign of thromboembolism?

Accepted Answer

Answer reason: Thromboembolism typically presents with redness, swelling, warmth, and pain due to impaired venous return and inflammation. Coolness is more characteristic of arterial occlusion rather than venous thromboembolism.

Question 2

This type of urinary incontinence may be seen after childbirth?

Accepted Answer

Answer reason: Stress incontinence commonly occurs after childbirth due to weakening or stretching of pelvic floor muscles and urethral support, leading to urine leakage with coughing, laughing, or physical activity.

Question 3

Which person is at greatest risk for developing Lyme's disease?

Accepted Answer

Answer reason: Landscapers are at greatest risk because frequent exposure to wooded and grassy environments increases the likelihood of tick bites, which can transmit Borrelia burgdorferi, leading to Lyme disease and its systemic manifestations.

Question 4

The sputum of a client remains positive for the tubercle bacillus even though the client has been taking Laniazid (isoniazid). The nurse recognizes that the client should have a negative sputum culture within?

Accepted Answer

Answer reason: With appropriate isoniazid therapy, sputum cultures for tuberculosis typically convert to negative within about 6 weeks as the bacterial load decreases. Persistent positivity beyond this period may indicate inadequate response or non-adherence.

Question 5

A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?

Accepted Answer

Answer reason: A client with a T6 spinal cord injury who develops severe hypertension and flushing is likely experiencing autonomic dysreflexia. The most common trigger is a distended bladder, so assessing and relieving bladder distention is the priority intervention after elevating the head of the bed.

Question 6

Which of the following advanced sign and symptom of ARDS?

Accepted Answer

Answer reason: In advanced ARDS, severe impairment of gas exchange leads to carbon dioxide retention, causing respiratory acidosis. Early stages often show respiratory alkalosis from tachypnea, but as fatigue and lung stiffness worsen, ventilation fails and acidosis develops.

Question 7

Dementia is defined as a..?

Accepted Answer

Answer reason: Dementia is characterized by a progressive decline in cognitive function, with memory loss being one of the primary and defining features due to degenerative changes in the brain.

Question 8

What are symptoms of increasing intracranial pressure (ICP) in infants?

Accepted Answer

Answer reason: Irritability is an early sign of increased intracranial pressure in infants because rising pressure affects brain tissue and causes discomfort and neurological irritability before more obvious symptoms develop.

Question 9

When assessing an individual with spontaneous pneumothorax, what symptoms should the nursing staff expect?

Accepted Answer

Answer reason: Spontaneous pneumothorax causes sudden collapse of part or all of a lung, leading to sharp unilateral chest pain due to pleural irritation and loss of lung expansion on the affected side.

Question 10

Kussmaul breathing is associated with?

Accepted Answer

Answer reason: Kussmaul breathing is a deep, rapid respiratory pattern seen in diabetic ketoacidosis as the body attempts to compensate for severe metabolic acidosis by blowing off excess CO₂.

Question 11

A patient with diabetes mellitus type 2 is sweating, dizzy, and confused. What is the priority nursing action?

Accepted Answer

Answer reason: Sweating, dizziness, and confusion are signs of hypoglycemia. The nurse’s priority action is to verify the patient’s blood glucose level before any intervention, ensuring accurate and safe management. Administering insulin or orange juice without confirmation could worsen the situation.

Question 12

What would the nurse expect the admission assessment to reveal in a client with glomerulonephritis?

Accepted Answer

Answer reason: Glomerulonephritis reduces GFR and causes sodium and water retention, leading to edema and elevated blood pressure; hypertension is a classic finding. The other options are nonspecific or atypical.

Question 13

What is a life-threatening complication of Guillain-Barré syndrome (GBS)?

Accepted Answer

Answer reason: GBS can progress to paralysis of the diaphragm and intercostal muscles, leading to acute respiratory failure, which is the most life‑threatening complication.

Question 14

A child with Tetralogy of Fallot visits the clinic several weeks before the planned surgery. The nurse should give priority attention to?

Accepted Answer

Answer reason: Tetralogy of Fallot causes chronic right-to-left shunting with hypoxemia. The priority is assessing oxygenation to detect and prevent complications such as acidosis, decreased pulmonary blood flow, polycythemia, and neurologic effects—higher priority than infection, nutrition, or development at this visit.

Question 15

A fifteen-year-old client has been placed in a Milwaukee brace. Which one of the following statements from the client indicates the need for additional teaching?

Accepted Answer

Answer reason: The Milwaukee brace for scoliosis is typically worn for several years, not six months, until skeletal maturity.

Question 16

The nursing care plan for a client with decreased adrenal function should include?

Accepted Answer

Answer reason: Adrenal insufficiency requires minimizing physiological stress and exposure to pathogens; limiting visitors helps reduce stress and infection risk. Activity should be conserved, reverse isolation is unnecessary, and constipation prevention is not a priority (GI symptoms often include diarrhea).

Question 17

A baby girl is born prematurely to a mother with polyhydramnios. The baby is diagnosed with esophageal atresia with tracheoesophageal fistula. What assessment finding would the nurse likely note?

Accepted Answer

Answer reason: The hallmark signs of esophageal atresia with tracheoesophageal fistula (TEF) are excessive frothy saliva, drooling, choking, and coughing, especially during feeding, due to the esophagus ending in a blind pouch.

Question 18

On discharge, a patient diagnosed with acute glomerulonephritis should be taught the following topics?

Accepted Answer

Answer reason: Patients with acute glomerulonephritis require education on sodium and fluid restriction to control edema and hypertension, daily weight and blood pressure monitoring to assess fluid status, and recognition of uremic symptoms to be reported promptly. Therefore, all listed topics should be taught.

Question 19

A client with acute asthma has been admitted to the hospital. The client's pulse oximeter reading is 89%. Which of the following nursing diagnoses would be most appropriate for this client based on this assessment data?

Accepted Answer

Answer reason: An SpO2 of 89% reflects hypoxemia. In acute asthma, bronchoconstriction and mucosal edema impair ventilation and oxygenation; thus, the priority diagnosis is impaired gas exchange. The other options are not directly supported by the given assessment data.

Question 20

A client is admitted with an acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has?

Accepted Answer

Answer reason: Acute adrenal (Addisonian) crisis causes a severe glucocorticoid/mineralocorticoid deficiency, leading to volume depletion and hypotension. The pulse is typically tachycardic, the skin is cool and clammy, and urine output is decreased.

Question 21

An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by saying?

Accepted Answer

Answer reason: Hyponatremia (serum sodium

Question 22

The nurse is caring for a client with laryngeal cancer. Which finding, ascertained in the health history, would not be common for this diagnosis?

Accepted Answer

Answer reason: Laryngeal cancer primarily affects the upper respiratory and digestive tracts, producing local symptoms such as hoarseness, dysphagia, and halitosis. Diarrhea is unrelated to this localized disease process, making it an atypical finding.

Question 23

A client is admitted to the emergency room with partial-thickness burns on his right arm and full-thickness burns on his trunk. According to the Rule of Nines, the nurse calculates that the total body surface area (TBSA) involved is?

Accepted Answer

Answer reason: Rule of Nines for adults: each arm = 9%; entire trunk (anterior 18% + posterior 18%) = 36%. Right arm (9%) + trunk (36%) = 45% TBSA.

Question 24

A client has signs of increased intracranial pressure. Which of the following is an early indicator of deterioration in the client's condition?

Accepted Answer

Answer reason: Decreased consciousness is an early sign of cerebral hypoxia and pressure on the reticular activating system.

Question 25

The nurse is caring for a client admitted with congestive heart failure. Which finding would the nurse expect if the failure were on the right side of the heart?

Accepted Answer

Answer reason: Right-sided heart failure leads to systemic venous congestion, manifesting as jugular distention and peripheral edema.

Question 26

The school nurse assessed and referred a 14-year-old with scoliosis. An 18° curvature of the spine was diagnosed. Which treatment plan would the nurse expect?

Accepted Answer

Answer reason: Adolescent idiopathic scoliosis with a Cobb angle 45–50°. Electrical stimulation is not standard care.

Question 27

A patient admitted to the hospital with a myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?

Accepted Answer

Answer reason: Severe pulmonary edema causes acute hypoxemia and dyspnea with a sensation of suffocation or air hunger; tachypnea and tachycardia are typical, not slow respirations or bradycardia. Stridor reflects upper airway obstruction, not pulmonary edema.

Question 28

A client with a spinal cord injury at the C6 level complains of a pounding headache, and his blood pressure is 180/120. The nurse should?

Accepted Answer

Answer reason: The client is experiencing autonomic dysreflexia, commonly triggered by bladder distention; the first action is to remove the stimulus such as a blocked catheter.

Question 29

Which of the following is not directly related to pheochromocytoma?

Accepted Answer

Answer reason: Pheochromocytoma causes excessive catecholamine release leading to hypertension, not hypotension. Pallor, sweating, and headaches are typical signs.

Question 30

A client receiving vent-assisted mode of ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should?

Accepted Answer

Answer reason: Cluster breathing suggests worsening neurologic status (pons/brainstem dysfunction) after intracranial bleeding. This is an urgent change that requires prompt provider notification rather than independent ventilator setting changes.

Question 31

What is the most common type of congenital atresia?

Accepted Answer

Answer reason: The most common form of tracheoesophageal atresia is Type C, in which the upper (proximal) esophagus ends blindly and the lower (distal) segment forms a fistula with the trachea. This results in regurgitation of feeds and risk of aspiration.

Question 32

Identify the correct statement regarding acute respiratory distress syndrome (ARDS)?

Accepted Answer

Answer reason: ARDS results from increased alveolar-capillary permeability, causing protein-rich fluid to fill alveoli and impair gas exchange, leading to severe hypoxemia.

Question 33

Vaish was diagnosed with minimal change nephrotic syndrome. Which of the following signs and symptoms are characteristics of the said disorder?

Accepted Answer

Answer reason: Minimal change nephrotic syndrome primarily presents with massive proteinuria, hypoalbuminemia, edema, and poor appetite, without hypertension or hematuria. It is the most common nephrotic syndrome in children.

Question 34

Which of the following characteristics defines nephrotic syndrome?

Accepted Answer

Answer reason: Nephrotic syndrome is characterized by massive proteinuria (>3.5 g/day), hypoalbuminemia, and lipiduria, often evidenced by fatty casts or “Maltese crosses” in the urine sediment.

Question 35

In a child with malnutrition, the first line of management would be?

Accepted Answer

Answer reason: In severe acute malnutrition, immediate priorities are to prevent/treat hypoglycemia and hypothermia before other issues. Thus the first-line step is prevention of hypoglycemia.

Question 36

The client with hemophilia A is experiencing hemarthrosis. Which intervention should the nurse recommend to the client?

Accepted Answer

Answer reason: Acute hemarthrosis is managed with RICE; cold/ice for 24–48 hours helps limit bleeding and swelling. Avoid aspirin (impairs platelets), avoid active ROM during acute bleed, and avoid dependent positioning which increases blood flow to the joint.

Question 37

When planning nursing care for a 5 year old with acute post streptococcal glomerulonephritis, what should the nurse emphasize that the child and family maintain?

Accepted Answer

Answer reason: In acute post‑streptococcal glomerulonephritis, high‑protein diets are avoided if azotemia is present, prolonged prescribed bed rest is not required, and routine daily penicillin is not indicated once the infection has resolved. Preventing exposure to infections during recovery is appropriate, making isolation from infected children the best emphasis.

Question 38

What are the management options of a patient that de complications of tonsillitis?

Accepted Answer

Answer reason: Complicated tonsillitis (e.g., peritonsillar abscess) requires securing the airway, IV antibiotics for severe infection, and incision and drainage if an abscess is present—hence all of the above.

Question 39

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?

Accepted Answer

Answer reason: Homonymous hemianopsia causes loss of half the visual field. Teaching the client to turn the head and scan compensates for the deficit. The other statements are incorrect: do not discourage eyeglasses, avoid approaching or placing objects in the impaired field initially.

Question 40

The nurse caring for a client with myasthenias gravis recognizes which of the following as the priority nursing diagnosis?

Accepted Answer

Answer reason: Myasthenia gravis causes bulbar and respiratory muscle weakness, making airway and breathing the highest priority; therefore ineffective airway clearance is the priority diagnosis over pain, injury risk, or mobility.

Question 41

When providing care for a client with pancreatitis, the nurse would anticipate which of the following orders?

Accepted Answer

Answer reason: Acute pancreatitis care focuses on resting the pancreas: NPO and gastric decompression with an NG tube to low intermittent suction. Forcing oral fluids is contraindicated, reverse Trendelenburg offers no benefit, and enteric isolation is unnecessary.

Question 42

The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?

Accepted Answer

Answer reason: Cardiogenic shock results from failure of the heart to pump effectively after myocardial infarction, leading to decreased cardiac output and tissue perfusion. Chest pain reflects ongoing myocardial ischemia and is a distinguishing sign of cardiogenic, not anaphylactic, shock. Anaphylactic shock instead presents with bronchospasm, urticaria, and hypotension related to histamine release rather than cardiac pump failure.

Question 43

After a fall resulting in a C6 fracture with spinal cord transection, which other findings should the nurse expect in a 36-year-old man?

Accepted Answer

Answer reason: At the C6 level, the diaphragm (C3–C5) remains functional, so the client can breathe diaphragmatically, though intercostals are weak. Tetraplegia occurs with some gross arm movement. Complete loss of respiratory function occurs with higher cervical injuries (above C3). Paraplegia is inconsistent with a C6 lesion, and bowel/bladder loss is nonspecific.

Question 44

Which nursing diagnosis is most appropriate for a client with iron deficiency anemia?

Accepted Answer

Answer reason: Iron deficiency anemia lowers hemoglobin and the blood’s oxygen-carrying capacity, leading to tissue hypoxia; airway patency and breathing pattern are not primarily impaired, and fluid volume is not necessarily deficient. Thus, impaired gas exchange is the most appropriate diagnosis.

Question 45

What is the primary treatment for patients diagnosed with occasional atrial premature complexes without underlying disease?

Accepted Answer

Answer reason: Occasional premature atrial complexes in otherwise healthy patients are usually benign and managed with reassurance and lifestyle changes such as reducing caffeine, alcohol, and stress; antiarrhythmics, pacemaker, or cardioversion are not indicated.

Question 46

What is the priority nursing diagnosis for a patient with Guillain-Barré Syndrome?

Accepted Answer

Answer reason: Guillain-Barré can rapidly progress to respiratory muscle weakness causing hypoventilation and hypoxia. By ABCs, airway/breathing take priority, making risk for impaired gas exchange the most urgent nursing diagnosis.

Question 47

Which complications should the nurse include when educating a patient diagnosed with aplastic anemia?

Accepted Answer

Answer reason: Aplastic anemia causes pancytopenia with severe neutropenia, making infection the most serious and common life‑threatening complication. Thromboembolism is not typical; while bleeding and hypoxia can occur, infection is the priority complication to emphasize.

Question 48

A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for?

Accepted Answer

Answer reason: Hepatic encephalopathy commonly presents with asterixis (flapping hand tremor) due to elevated ammonia affecting the CNS. Malaise, stomatitis, and weight loss are nonspecific and not key indicators of encephalopathy.

Question 49

What are the typical findings on assessment of a client with acute pancreatitis?

Accepted Answer

Answer reason: Acute pancreatitis triggers a systemic inflammatory response, often causing fever. Inflammation and stress hormone release impair insulin function, leading to hyperglycemia. Significant third-spacing of fluids and vomiting result in dehydration. Decreased amylase/lipase, melena, hyperactive bowel sounds, and steatorrhea are not typical of acute pancreatitis.

Question 50

A child who sustained a head injury from a fall is being monitored for increased intracranial pressure. Which nursing action is most appropriate to reduce intracranial pressure?

Accepted Answer

Answer reason: Elevating the head of the bed promotes venous drainage from the brain and helps reduce intracranial pressure. Coughing, deep breathing, flat positioning, and unrestricted fluids can increase intracranial pressure and are inappropriate in this situation.

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