Question 1

A client with Crohn’s disease is experiencing an exacerbation. Which instruction would be a priority in planning his care?

Accepted Answer

Answer reason: Minimizing GI workload through bowel rest (often with diet modification and, if severe, enteral/TPN support per orders) is a core immediate nursing focus. Weight gain is a longer-term outcome and is not addressed first during an active flare. Rectal bleeding can occur but is more characteristic of ulcerative colitis, and the priority intervention for a Crohn’s flare is controlling inflammatory activity and gut stimulation rather than treating bleeding as the main problem unless there is hemodynamic instability.

Question 2

A client has a cervical spine injury at the level of C5. Which condition should the nurse anticipate during the acute phase?

Accepted Answer

Answer reason: At C5, diaphragmatic function may be partially preserved (phrenic nerve C3–C5), but ventilation is often inadequate early due to reduced chest wall expansion and ineffective cough/airway clearance. In the acute phase, edema and evolving cord dysfunction can worsen breathing, so anticipating ventilatory support is a key safety priority. The other options are more consistent with brainstem/cranial nerve injury (corneal reflex), severe intracranial pathology (decerebrate posturing), or cerebral hemisphere stroke (unilateral body movement).

Question 3

A client who has been experiencing a chronic illness develops pneumonia. The nurse is aware that the factor most likely contributing to the client’s development of pneumonia is?

Accepted Answer

Answer reason: Impaired immune function is a major risk factor for pneumonia, and chronic illness commonly contributes to inadequate intake and increased metabolic demands that worsen nutritional status. Protein-calorie malnutrition reduces antibody production, weakens cell-mediated immunity, and decreases respiratory muscle strength and cough effectiveness, all of which promote lower-respiratory infection. Dehydration can thicken secretions but is generally a less central driver of infection than global immune suppression. Group living increases exposure risk, but the question emphasizes chronic illness–related susceptibility, which is most directly explained by poor nutrition.

Question 4

A client has been diagnosed with thoracic kyphoscoliosis. The nurse is aware that this will have what effect on the client’s lungs?

Accepted Answer

Answer reason: This limits the ability of the lungs to expand fully on inspiration, producing a restrictive ventilatory pattern with reduced vital capacity and total lung capacity. The primary problem is impaired expansion rather than airway obstruction, which is characteristic of obstructive diseases like COPD. Reduced chest expansion can also contribute to hypoventilation and V/Q mismatch, especially in severe curvature.

Question 5

A client with a pulmonary embolism is experiencing chest pain and apprehension. What is the priority intervention by the nurse?

Accepted Answer

Answer reason: Rapid pain control is an immediate physiologic priority because it supports effective breathing, reduces tachycardia, and helps stabilize the client while definitive therapies (e.g., oxygen, anticoagulation) are initiated. Nonpharmacologic methods and emotional support can be helpful but are secondary when the client is in acute distress. Left-side positioning is not a targeted intervention for PE-related pain/anxiety and does not address the immediate physiologic stressor.

Question 6

A client with a massive pulmonary embolism is scheduled to have arterial blood gas analysis performed. The nurse expects the analysis will identify?

Accepted Answer

Answer reason: A pulmonary embolism causes acute ventilation-perfusion mismatch with impaired perfusion of ventilated alveoli, producing hypoxemia. The usual immediate compensatory response is tachypnea/hyperventilation driven by hypoxemia and anxiety, which lowers PaCO2. A decreased PaCO2 raises pH, creating an acute respiratory alkalosis pattern on ABG. Respiratory acidosis would be more consistent with hypoventilation (e.g., severe COPD exacerbation), not the typical early PE response.

Question 7

Which change would the nurse expect after administering oxygen to an infant with uncorrected tetralogy of Fallot?

Accepted Answer

Answer reason: Because shunted blood bypasses the lungs, oxygen will not reliably eliminate cyanosis, so complete resolution of bluish discoloration is not expected. A cardiac murmur from outflow obstruction/structural defects will not disappear with oxygen therapy. Finger clubbing is a chronic change from long-standing hypoxemia and would not improve acutely after giving oxygen.

Question 8

The nurse is caring for an infant suspected of having esophageal atresia and tracheoesophageal fistula. Which sign would the nurse initially observe?

Accepted Answer

Answer reason: This is a typical early observable finding alongside feeding-related choking/coughing and copious secretions (not listed). Decreased oral secretions is the opposite of what is expected because saliva pools above the atresia. A scaphoid abdomen is more consistent with conditions such as congenital diaphragmatic hernia rather than TEF with distal fistula.

Question 9

The nurse is evaluating the effectiveness of nutritional therapy for a child with celiac disease. What is the most important assessment?

Accepted Answer

Answer reason: Effective nutritional therapy (gluten-free diet) should rapidly improve GI absorption, making normalization of stool characteristics one of the most direct and sensitive indicators of response. Vital signs are usually nonspecific and may remain normal despite ongoing malabsorption. Intake/output and BUN/creatinine reflect hydration and renal function rather than mucosal healing and fat/carbohydrate absorption, so they are less targeted measures of dietary effectiveness.

Question 10

The nurse observes a neonate who is having excessive salivation and drooling, accompanied by coughing, choking, and sneezing. The nurse suspects the neonate has which condition?

Accepted Answer

Answer reason: With esophageal atresia, oral secretions cannot pass into the stomach and pool in the upper pouch, leading to drooling and respiratory symptoms when secretions spill into the airway. A coexisting tracheoesophageal fistula allows abnormal communication between trachea and esophagus, worsening choking/coughing with feeds and increasing aspiration risk. Cleft lip/palate primarily causes feeding difficulty and nasal regurgitation, but does not typically cause persistent copious frothy secretions with choking at baseline like this presentation. Gastroschisis presents with abdominal wall defect and exposed bowel, not airway/secretions symptoms.

Question 11

When assessing an infant diagnosed with pyloric stenosis, the nurse would determine that which of the following is a normal finding?

Accepted Answer

Answer reason: This increased peristaltic activity commonly presents with audible or hyperactive bowel sounds, along with visible peristaltic waves and nonbilious projectile vomiting. Decreased bowel sounds would be more consistent with ileus or significant hypoperfusion rather than an obstructive process with increased peristalsis. A heart murmur is not a typical finding directly associated with this gastrointestinal condition, and respiratory effort is generally unaffected unless there is severe metabolic disturbance or aspiration.

Question 12

A mother of a recently admitted child asks the nurse about the bluish black lines along her child’s gums. The nurse would respond that the bluish black lines indicate which of the following types of poisoning?

Accepted Answer

Answer reason: This sign supports systemic lead toxicity rather than an acute ingestion syndrome. Acetaminophen toxicity is primarily hepatic and does not produce characteristic gum discoloration. Salicylate poisoning typically presents with tinnitus, hyperventilation, and acid–base disturbances, not gingival lines.

Question 13

The nurse is reviewing orders for the assigned clients. A nebulizer treatment has been ordered for a child with croup. What is the best time for the nurse to administer the treatment?

Accepted Answer

Answer reason: Administering aerosol therapy when the child is calm/asleep supports better tolerance of the mask and more effective delivery of the medication. Giving it during playtime commonly increases resistance and distress, which can exacerbate stridor. Administering immediately after eating is less ideal because coughing and distress during treatment can increase the risk of emesis/aspiration and reduce cooperation.

Question 14

The nurse is caring for a client with atelectasis. What is the most important nursing intervention for the nurse to provide?

Accepted Answer

Answer reason: Atelectasis decreases alveolar ventilation and creates ventilation-perfusion mismatch, so the immediate priority is improving oxygenation to prevent hypoxemia. Oxygen therapy is a rapid, stabilizing intervention that addresses the most time-sensitive physiologic problem while other measures are initiated. Chest physiotherapy can help re-expand areas of collapse or mobilize secretions but is not the first priority if oxygenation is compromised. ABGs are an assessment that may quantify severity, but they do not correct the impaired gas exchange, and increasing IV fluids is not a primary treatment for alveolar collapse.

Question 15

The client diagnosed with lung cancer has developed metastasis to the brain. Which problem would be priority for this client?

Accepted Answer

Answer reason: The priority in NCLEX-style questions follows ABCs (airway, breathing, circulation), so breathing/oxygenation problems take precedence over psychosocial needs and comfort. Lung cancer can directly compromise ventilation and oxygenation via airway obstruction, tumor burden, pleural effusion, or pneumonia, creating immediate risk of hypoxemia and respiratory failure. Brain metastases can also worsen respiratory status indirectly by decreasing level of consciousness and protective reflexes, increasing aspiration risk. Anticipatory grieving, nutrition, and comfort are important but are not as immediately life-threatening as inadequate gas exchange.

Question 16

The nurse cares for a client who sustained serious injuries from a motor vehicle accident. In assessing client needs, the nurse knows that a client’s response to stressors depends on individual differences such as?

Accepted Answer

Answer reason: Stress responses are influenced by inherent biopsychosocial factors that affect perception, appraisal, and physiologic reactivity to trauma. Biological sex and gender-related differences can influence neuroendocrine and autonomic responses, coping styles, and vulnerability to anxiety or post-traumatic stress symptoms, making it a true individual-difference variable. The other choices are primarily environmental or situational logistics and are not established determinants of an individual’s stress-response pattern in the way personal characteristics are. In planning care, recognizing individual characteristics helps tailor communication, coping support, and monitoring for stress-related complications.

Question 17

The nurse is performing a physical assessment on a client. The physical assessment is positive for Kernig's sign, Brudzinski's sign, and nuchal rigidity. Which condition is associated with these symptoms?

Accepted Answer

Answer reason: Kernig’s sign, Brudzinski’s sign, and nuchal rigidity are classic meningeal irritation findings and point to inflammation of the meninges. This constellation is most strongly associated with acute meningitis and should prompt urgent evaluation because of the risk for rapid neurologic deterioration and sepsis (especially with bacterial causes). Ear, throat, or sinus infections can be antecedent sources but do not typically produce objective meningeal signs on exam. The presence of these signs helps distinguish a primary CNS meningeal process from uncomplicated otitis media, pharyngitis, or sinusitis.

Question 18

A client is involved in a horseback riding accident. The client complains of right upper quadrant pain and radiation to the right shoulder. With which injury is this most compatible?

Accepted Answer

Answer reason: Right upper quadrant trauma can irritate the diaphragm via blood or inflammation under the right hemidiaphragm, producing referred pain to the right shoulder through the phrenic nerve (C3–C5) (Kehr-type pain). In blunt trauma such as a horseback riding accident, the liver is a common injured solid organ located in the RUQ, making this symptom pattern highly compatible. A splenic injury more typically presents with left upper quadrant pain and referred pain to the left shoulder. Pancreatic injury tends to cause epigastric pain radiating to the back rather than the right shoulder.

Question 19

A client with heart failure says he sleeps with two pillows because he experiences difficulty breathing when lying flat. The nurse would documents this as which condition?

Accepted Answer

Answer reason: Needing extra pillows to sleep is a hallmark way patients compensate for this positional dyspnea. This differs from paroxysmal nocturnal dyspnea, which is a sudden awakening from sleep with severe shortness of breath after being supine for a period of time. Bradypnea refers only to a slow respiratory rate, and dyspnea on exertion occurs with activity rather than with recumbency.

Question 20

The nurse assesses that the 8-hour—old infant’s axillary temperature is 97°F (361°C). Which intervention should the nurse implement first?

Accepted Answer

Answer reason: Newborns have limited thermoregulation and can rapidly develop cold stress, which increases oxygen consumption and can precipitate hypoglycemia and metabolic acidosis. The priority nursing action is to stabilize temperature with an external heat source and neutral thermal environment. A radiant warmer provides controlled rewarming while allowing ongoing assessment and minimizing additional heat loss from handling. Documentation and notifying the provider are appropriate after immediate warming measures are initiated, and feeding is not the first step because hypothermia can impair feeding effectiveness and does not correct heat loss quickly.

Question 21

The nurse assesses that the newly admitted pediatric client has tachycardia, edema, dyspnea, orthopnea, and crackles. The nurse should plan interventions to treat which possible condition?

Accepted Answer

Answer reason: Tachycardia is a common compensatory response to maintain cardiac output when stroke volume is reduced. Edema can occur with overall volume overload and may accompany progressive heart failure, but the most discriminating findings here are the respiratory symptoms and crackles indicating pulmonary edema. Right-sided failure more typically presents with systemic venous congestion (hepatomegaly, ascites, peripheral edema) without prominent crackles, while rheumatic fever and Kawasaki disease have characteristic inflammatory/mucocutaneous features not described.

Question 22

The adolescent who had a T10 complete SCI reports leaking of urine at fairly regular intervals. The nurse should plan interventions for which type of incontinence?

Accepted Answer

Answer reason: This leads to involuntary leakage when the bladder reaches a threshold volume, often occurring at somewhat predictable, regular intervals. A T10 complete SCI fits this pattern (spastic/reflex neurogenic bladder), so nursing interventions should focus on scheduled bladder emptying programs (e.g., intermittent catheterization) and trigger management. Stress incontinence is due to pelvic floor/urethral sphincter weakness, and urge incontinence is typically from detrusor overactivity with intact neural pathways and strong urgency—both less consistent with a complete T10 lesion.

Question 23

If medical treatment for cardiomyopathy fails, the nurse should prepare the client for which of the following procedures?

Accepted Answer

Answer reason: This procedure is the definitive option for irreversible, progressive pump failure when medications no longer maintain adequate perfusion and quality of life. Cardiac catheterization is primarily diagnostic and would not treat refractory cardiomyopathy by itself, and CABG targets ischemic coronary disease rather than primary myocardial dysfunction. An IABP can provide short-term hemodynamic support as a bridge, but it is not a definitive long-term solution for failed cardiomyopathy management.

Question 24

A client is being admitted with acute gastritis. The nurse knows the immediate collaborative treatment plan will include which of the following?

Accepted Answer

Answer reason: Immediate collaborative actions commonly include stopping offending agents (e.g., NSAIDs, alcohol), treating infectious causes if suspected, and initiating acid suppression/antiemetics with hydration as needed. Stress reduction can be helpful but is not the immediate primary treatment focus for acute inflammation. Gastric resection is not a standard treatment for uncomplicated acute gastritis, and enteral tube feedings are generally not first-line because they can worsen symptoms and are reserved for specific nutritional indications.

Question 25

A client with cirrhosis complains that his skin always feels itchy. The nurse recognizes that the itching is a result of which abnormality associated with cirrhosis?

Accepted Answer

Answer reason: Reduced bile flow/processing leads to retention of bile salts and other pruritogens that stimulate cutaneous nerve endings, producing persistent itching. Prolonged PT reflects impaired hepatic synthesis of clotting factors and is more associated with bleeding risk than pruritus. Low protein (albumin) contributes to edema/ascites, and elevated AST indicates hepatocellular injury, neither being the primary cause of generalized itching.

Question 26

A nurse is assessing a child with growth hormone deficiency. The nurse documents the assessment data as?

Accepted Answer

Answer reason: Growth hormone is essential for linear bone growth and normal body composition, so deficiency primarily presents as slowed growth velocity and short stature. With reduced GH, children often have increased adiposity and relatively higher weight-for-height despite poor height gain. This pattern distinguishes GH deficiency from many chronic systemic illnesses, which more commonly cause poor weight gain before or along with impaired height. Therefore the best documentation reflects increased weight relative to a decreased (or stunted) height trajectory.

Question 27

The parents of a 4-year-old child diagnosed with cerebral palsy and resultant thoracic scoliosis ask the nurse what caused the scoliosis. What is the best response by the nurse?

Accepted Answer

Answer reason: Reduced tone in trunk and paraspinal muscles allows the spine to drift and rotate over time, especially with growth and prolonged asymmetrical positioning, leading to scoliosis. Intellectual disability does not cause structural spinal curvature, and autonomic dysreflexia is a complication of high spinal cord injury rather than cerebral palsy. Kyphosis describes a different spinal-plane deformity and is not the underlying cause of scoliosis in this context.

Question 28

Which instruction should a nurse give the parents of a 2-year-old child who wakes in the night with a barking cough?

Accepted Answer

Answer reason: A sudden nighttime barking cough in a 2-year-old is most consistent with croup, where upper-airway inflammation/edema leads to stridor and characteristic cough. Cool or humidified air can reduce airway dryness and soothe the inflamed laryngeal/tracheal mucosa, often improving symptoms at home while keeping the child calm. A warm, dry environment can worsen airway irritation and coughing. Calling an ambulance or starting rescue breathing is reserved for signs of severe respiratory distress (cyanosis, lethargy, severe retractions, inability to speak/cry), which are not described in the stem.

Question 29

Which nursing diagnosis is the priority for an infant with neonatal chronic lung disease (bronchopulmonary dysplasia)?

Accepted Answer

Answer reason: In priority frameworks (ABCs), problems affecting oxygenation and ventilation take precedence over nutrition and fluid balance concerns. This diagnosis directly targets the life-sustaining problem most likely to cause acute deterioration (hypoxemia, hypercapnia, increased work of breathing). Nutrition and fluid risks are common in chronic lung disease due to increased metabolic demand and diuretic use, but they are secondary once oxygenation is stabilized.

Question 30

A nurse is caring for a client who complains of fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. The nurse immediately puts the client in isolation. The nurses suspects that the client is suffering from which condition?

Accepted Answer

Answer reason: This symptom cluster (weight loss, afternoon fevers, night sweats, chronic cough, and hemoptysis) is classic for active pulmonary infection with a high risk of airborne transmission. Immediate isolation aligns with the need for airborne precautions because the organism can remain suspended in air and spread via droplet nuclei. Pneumonia more commonly presents with acute fever, pleuritic chest pain, and productive sputum without the chronic constitutional symptoms. Bronchitis typically causes cough and sputum but does not usually cause hemoptysis with profound systemic symptoms and does not warrant airborne isolation as an initial step.

Question 31

A client is diagnosed with second-degree burns. The nurse expects the physician to order?

Accepted Answer

Answer reason: Immediate first aid for partial-thickness burns aims to stop the thermal injury, reduce pain, and protect viable tissue without causing additional damage. Cool (not cold) water or cool moist saline dressings help dissipate heat and provide comfort while minimizing further tissue destruction. Ice is avoided because intense vasoconstriction can worsen tissue ischemia and deepen the burn. Betadine and hydrogen peroxide are generally avoided on fresh burns because they can be cytotoxic to healing tissue and increase irritation rather than promote optimal wound healing.

Question 32

A client presents to the clinic and is diagnosed with a genital chlamydial infection. Which symptom would the nurse anticipate being reported by this client?

Accepted Answer

Answer reason: This symptom reflects inflammation of the urethral mucosa from Chlamydia trachomatis. Fluid-filled lesions are more consistent with herpes simplex infection, and genital warts indicate HPV. Thick, purulent discharge is classically associated with gonorrhea rather than chlamydia.

Question 33

Which statement indicates the client diagnosed with angina needs more discharge teaching?

Accepted Answer

Answer reason: Isometric (static) exercise increases systemic vascular resistance and blood pressure, which raises myocardial oxygen demand and can precipitate angina. Discharge teaching for stable angina emphasizes aerobic, graded activity (e.g., walking) with warm-up/cool-down rather than sustained straining. Proper nitroglycerin storage in a dark container and dietary fat/cholesterol reduction are appropriate risk-reduction measures. Avoiding cold exposure is also appropriate because cold-induced vasoconstriction can trigger chest pain.

Question 34

The nurse is planning care for a client with Addison’s disease. What is the most appropriate outcome for this client?

Accepted Answer

Answer reason: An appropriate outcome is that the client demonstrates stress-reduction behaviors that help minimize avoidable stress triggers and support stable coping. Fluid restriction is inappropriate because these clients are prone to dehydration and hypotension from mineralocorticoid deficiency. Avoiding high-sodium foods is also incorrect because sodium replacement is often needed due to aldosterone deficiency and salt wasting.

Question 35

Which instruction should be given to a female client newly diagnosed with genital herpes?

Accepted Answer

Answer reason: Genital herpes is a lifelong HSV infection with episodic recurrences triggered by physiologic stressors and immune suppression. Teaching clients to reduce stress and emotional upset helps decrease outbreak frequency/severity and supports self-management over time. Condom use only when lesions are present is incomplete because viral shedding can occur without visible lesions, so safer-sex counseling must emphasize avoiding sex during outbreaks and consistent barrier use. Annual Pap testing and lubricants may be helpful in other contexts, but they do not address a key, evidence-based factor that influences recurrence patterns.

Question 36

The nurse is taking a hospital admission history of the client- The nurse considers that the cheat may have IBS when the client makes which statement?

Accepted Answer

Answer reason: " IBS is a functional bowel disorder characterized by recurrent abdominal discomfort with altered bowel habits, and it commonly includes mucus in the stool without systemic toxicity. Mucus reflects colonic irritation and hypersecretion that can occur with IBS, especially with diarrhea-predominant patterns. Bloody diarrhea and unintentional weight loss are alarm features that suggest inflammatory bowel disease, malignancy, or infection rather than IBS. Persistent vomiting is not a typical primary IBS feature and points more toward an acute GI illness or obstruction requiring further evaluation.

Question 37

The nurse is caring for the client with acute cholecystitis. The nurse anticipates that conservative treatment will include which component?

Accepted Answer

Answer reason: Anticholinergics decrease parasympathetic stimulation, which can reduce gallbladder contraction and biliary tract spasm, supporting symptom control as part of nonoperative management alongside bowel rest, IV fluids, and analgesia. Diet is typically NPO initially rather than oral “bland/low-texture” intake. Keeping the head of bed flat does not address biliary inflammation and may worsen comfort or aspiration risk if vomiting occurs, and laxatives are not a routine or targeted therapy for this condition.

Question 38

The nurse is caring for the client who has severe craniocerebral trauma. Which finding indicates that the client is developing D1?

Accepted Answer

Answer reason: A urine volume of 1500 mL in 4 hours represents significant polyuria and is a key early clinical indicator prompting concern for DI and impending hypovolemia/hypernatremia. In contrast, a very high urine specific gravity would suggest concentrated urine and is more consistent with dehydration or SIADH rather than DI. Hyperglycemia can cause osmotic diuresis, but the question frames a post-craniocerebral trauma complication where ADH-related water loss is the classic concern.

Question 39

The nurse is caring for the infant tentatively diagnosed with esophageal atresia. What should be the priority nursing outcome?

Accepted Answer

Answer reason: Esophageal atresia creates a high risk for airway compromise because pooled secretions and possible tracheoesophageal fistula can lead to aspiration and respiratory distress. In ABC priority setting, maintaining a patent airway and adequate ventilation overrides concerns about hydration and nutrition. An effective breathing pattern is the most immediate, measurable outcome that reflects prevention of aspiration and stabilization before surgical correction. Fluid balance and nutrition are important but are addressed after respiratory stability is ensured, while parental coping is a longer-term psychosocial goal.

Question 40

The nurse is caring for the infant with bronchiolitis. Which goal should the nurse identify as essential?

Accepted Answer

Answer reason: An essential nursing goal is to maintain adequate fluid balance (often via small frequent feeds or IV fluids as needed) to support perfusion and help keep secretions thinner. Antibiotics are not routinely indicated because the usual cause is viral, and unnecessary use increases adverse effects and resistance. Mist tents are no longer standard therapy and can increase agitation without improving outcomes. Cough suppressants are generally avoided in infants due to safety concerns and because coughing helps clear secretions.

Question 41

Which nursing diagnosis takes the highest priority during the first 24 hours following surgical repair of esophageal atresia and tracheoesophageal fistula?

Accepted Answer

Answer reason: Infants with recent TEF/EA surgery are also at risk for respiratory complications such as atelectasis and pneumonia, and their ability to clear secretions is limited, making vigilant respiratory management essential. Nutrition and feeding problems are important but are typically managed after airway stability, often with NPO status and ordered gastric decompression/IV fluids initially. Psychosocial concerns like parenting risk do not supersede life-sustaining physiologic needs in the immediate postoperative period.

Question 42

Which findings would the nurse assess in a premature neonate who may have necrotizing enterocolitis?

Accepted Answer

Answer reason: Progressive bowel edema and gas production commonly cause abdominal distention, often an early and important bedside assessment finding. Occult blood in stool is more consistent with the condition than guaiac-negative stools, making those options less plausible. Metabolic acidosis (from sepsis/poor perfusion) is more typical than metabolic alkalosis, so choices featuring alkalosis are not the best fit.

Question 43

Which reason necessitates tracheostomy tube placement in long-term care of infants with neonatal chronic lung disease (bronchopulmonary dysplasia)?

Accepted Answer

Answer reason: Infants with bronchopulmonary dysplasia may require ongoing ventilatory support and repeated failed extubation attempts, making long-term translaryngeal intubation unsafe and impractical. Tracheostomy can improve comfort, facilitate secretion clearance, and support chronic ventilation in home or long-term care settings. Increased respiratory distress is an acute assessment finding that triggers escalation of respiratory support, but it does not by itself define the long-term airway decision as clearly as persistent ventilator dependence.

Question 44

A client with a spinal cord injury tells the nurse that he has difficulty recognizing the symptoms of urinary tract infection (UTI) before it’s too late. The nurse explains to the client that an early symptom of UTI is?

Accepted Answer

Answer reason: Spinal cord injury can blunt or eliminate typical lower urinary tract sensations, so dysuria and frequency may be absent or hard to detect early. Clients are taught to monitor for more objective or systemic cues such as fever and cloudy/foul-smelling urine, which may be the first noticeable indicators for them. These findings suggest infection is developing even when classic symptoms are not perceived. In contrast, lower back pain is more consistent with upper-tract involvement (e.g., pyelonephritis) and is not the earliest or most reliable sign in this population.

Question 45

A nurse has identified ineffective airway clearance as a nursing diagnosis for a client with pneumonia. Which goal would be appropriate for this client?

Accepted Answer

Answer reason: Ineffective airway clearance focuses on the client’s ability to mobilize and remove secretions to maintain a patent airway and adequate ventilation. In pneumonia, retained secretions and inflammation commonly produce adventitious sounds (e.g., crackles/rhonchi), so an appropriate outcome is improved lung aeration reflected by clearer breath sounds. A respiratory rate of 32/min indicates tachypnea and ongoing respiratory distress rather than improvement. Pain control and temperature normalization may be relevant pneumonia goals but they do not directly evaluate resolution of the airway clearance problem.

Question 46

The nurse is caring for the client with varicose veins. Which action should indicate to the nurse that an expected outcome has been met?

Accepted Answer

Answer reason: Regular ambulation activates the calf-muscle pump, which enhances venous return and decreases edema and discomfort, aligning with recommended self-management. A decreased need for compression is not an appropriate goal because compression is a core supportive therapy rather than something to discontinue based on symptoms alone. Prolonged standing worsens venous stasis, and the electrolyte-focused diet choice is unrelated to venous insufficiency management.

Question 47

Glucocorticoids are prescribed for the child diagnosed with congenital adrenal hyperplasia. Which nursing assessment finding indicates that therapy is successful?

Accepted Answer

Answer reason: When androgens are controlled and cortisol is adequately replaced, linear growth pattern tends to normalize rather than being compromised by early epiphyseal closure. A common pitfall is focusing on lack of iatrogenic Cushingoid features; absence of those signs suggests dosing is not excessive but does not confirm adequate disease control. Findings like feminization or precocious penile enlargement reflect ongoing androgen effects and indicate poor control rather than successful therapy.

Question 48

The nurse is caring for the adolescent diagnosed with Lyme disease. Which nursing problem should the nurse document in the plan of care?

Accepted Answer

Answer reason: A nursing diagnosis centered on pain directly reflects the expected physiologic response to Borrelia infection and guides symptom management (assessment, analgesia, activity modification, and monitoring for progression). The other options describe problems that are not characteristic primary features of Lyme disease (diarrhea, hyperalert-related insomnia, pruritus-related skin breakdown) and are less likely to be appropriate as the main documented problem without additional findings. Focusing on inflammatory joint/muscle pain also supports surveillance for complications such as worsening arthritis or neurologic involvement if symptoms persist or escalate.

Question 49

A client is being evaluated for hepatitis A. Which activity places him at the highest risk for contracting hepatitis A?

Accepted Answer

Answer reason: Ingestion of improperly handled or undercooked seafood is a classic exposure because it can concentrate the virus from contaminated waters and is often linked to outbreaks. Blood exposure (e.g., assisting with a nosebleed) and transfusions are much more associated with hepatitis B/C risk rather than hepatitis A. Sexual transmission is possible but typically lower risk than foodborne exposure unless specific high-risk practices with fecal contamination are involved.

Question 50

Which nursing intervention is most appropriate for a child with cystic fibrosis who is having difficulty clearing secretions?

Accepted Answer

Answer reason: Airway clearance is a primary respiratory management priority in cystic fibrosis because thick, tenacious mucus obstructs airways and promotes atelectasis and infection. Chest physiotherapy (often with postural drainage and percussion/vibration) mobilizes secretions so they can be expectorated or suctioned, directly addressing the child’s difficulty clearing mucus. Pancreatic enzymes and a high-calorie/high-protein diet are important for malabsorption and growth but do not treat acute secretion retention. Routine continuous oxygen is not indicated unless the child is hypoxemic and it does not remove mucus plugs.

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