Question 1

A patient scheduled for a diagnostic gastroscopy is suspected with ulcers. During the insertion of the scope the patient experiences a vasovagal response. All should be expected by the nurse except?

Accepted Answer

Answer reason: A vasovagal response increases parasympathetic (vagal) tone, leading to bradycardia and increased gastric secretions; atropine may be given to blunt this. Pupil dilation is a sympathetic effect—vagal stimulation causes miosis—so dilated pupils are not expected.

Question 2

The nurse is caring for a client with stage III Alzheimer's disease. A characteristic of this stage is?

Accepted Answer

Answer reason: Stage III (late/severe) Alzheimer’s is marked by a profound cognitive decline, with loss of verbal communication and total dependence. Memory loss and nighttime wandering are earlier features; object recognition problems occur in the moderate stage.

Question 3

A client is diagnosed with Stage II Hodgkin's lymphoma. The nurse recognizes that the client has involvement?

Accepted Answer

Answer reason: Stage II Hodgkin’s lymphoma affects two or more lymph node regions but remains confined to one side of the diaphragm. Stage I involves one node, Stage III involves both sides of the diaphragm, and Stage IV shows disseminated involvement.

Question 4

A client with the diagnosis of Parkinson's disease asks the nurse, "Why do I drool so much?" Which is the nurse's best response?

Accepted Answer

Answer reason: In Parkinson's disease, automatic involuntary movements, such as spontaneous swallowing, decrease due to bradykinesia/akinesia. Saliva is not cleared effectively, leading to drooling. This is not due to throat paralysis, and rigidity alone is not the primary cause.

Question 5

When educating parents about known antecedent infections in acute glomerulonephritis, which of the following should the nurse cover?

Accepted Answer

Answer reason: Acute poststreptococcal glomerulonephritis commonly follows group A beta-hemolytic streptococcal infections of the throat or skin; impetigo is a classic antecedent skin infection. Scabies, herpes simplex, and varicella are not typical causes.

Question 6

The nurse is caring for a client with suspected AIDS-dementia complex. The first sign of dementia in the client with AIDS is?

Accepted Answer

Answer reason: Early HIV-associated dementia presents with subtle cognitive changes, such as difficulty concentrating and slowed thinking. Motor changes, speech problems, and seizures are later findings.

Question 7

The physician diagnoses a 28-year-old woman seen in the clinic with Graves' disease. Which of the following symptoms would the nurse expect the client to exhibit?

Accepted Answer

Answer reason: Graves' disease causes hyperthyroidism with an increased metabolic rate, leading to weight loss. Cold intolerance, lethargy, and reduced deep tendon reflexes are associated with hypothyroidism; hyperthyroidism typically shows heat intolerance and hyperreflexia.

Question 8

A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to?

Accepted Answer

Answer reason: Children with Tetralogy of Fallot often develop chronic hypoxemia, leading to polycythemia and increased blood viscosity, which predisposes them to thromboembolic events and stroke. A sudden seizure is consistent with a cerebrovascular accident.

Question 9

The physician's orders for a client with acute pancreatitis include the following: strict NPO and a nasogastric tube to low intermittent suction. The nurse recognizes that withholding oral intake will?

Accepted Answer

Answer reason: NPO with NG suction minimizes GI stimulation that triggers pancreatic secretion, thereby reducing pancreatic enzyme release. It does not affect insulin needs, does not fully prevent gastric acid secretion, and pain medication is still required.

Question 10

The client, who is 2 weeks post-burn with a 40% deep partial-thickness injury, still has open wounds. The nurse’s assessment reveals the following findings: temperature 96.5°F, BP 87/40, and severe diarrhea. What problem does the nurse most likely suspect?

Accepted Answer

Answer reason: Two weeks after major burns, clients are at high risk for gram-negative sepsis. Hypothermia (96.5°F), hypotension (87/40), and severe diarrhea point to endotoxemia from gram-negative organisms, which often presents with shock and a low temperature rather than fever.

Question 11

A client with type O, Rh-positive blood gives birth. The neonate has type B, Rh-negative blood. When the nurse assesses the neonate 11 hours after birth, the infant's skin appears yellow. What is the most likely cause?

Accepted Answer

Answer reason: Jaundice at 11 hours is pathologic. With a type O mother and a type B infant, maternal anti-B IgG can cause hemolysis and early hyperbilirubinemia consistent with ABO incompatibility. Rh incompatibility requires an Rh-negative mother and Rh-positive infant; physiologic jaundice appears after 24 hours.

Question 12

Which sign or symptom should the nurse expect to assess in the client diagnosed with hemophilia A?

Accepted Answer

Answer reason: Hemophilia A (factor VIII deficiency) causes impaired coagulation and bleeding tendencies; epistaxis is a common bleeding manifestation. Petechiae indicate platelet disorders, and the other options are unrelated conditions.

Question 13

Which stage is called the fastigium in a patient with fever?

Accepted Answer

Answer reason: Fastigium is the second stage of fever in which body temperature remains at its peak due to a reset hypothalamic set point until the underlying cause begins to resolve.

Question 14

A nurse admits a child to the hospital with an identification of pyloric stenosis. On admission assessment, which data would the nurse expect to obtain when asking the mother about the child's symptoms?

Accepted Answer

Answer reason: Hypertrophic pyloric stenosis classically presents with non-bilious projectile vomiting after feeds. Diarrhea is uncommon, bile is not present, and urine output is typically decreased with dehydration—not increased.

Question 15

A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition?

Accepted Answer

Answer reason: Cardiogenic shock is due to failure of the heart to pump effectively, leading to inadequate tissue perfusion. It is not primarily caused by low blood volume (hypovolemic shock), not usually fleeting, and may be reversible with treatment.

Question 16

30 years old female complained of wetting her dress while coughing. Which condition should be suspect?

Accepted Answer

Answer reason: Leakage of urine with coughing indicates stress urinary incontinence, commonly due to anterior vaginal wall prolapse of the bladder (cystocele).

Question 17

The nurse caring for a client with anemia recognizes which clinical manifestation as the one that is specific for a hemolytic type of anemia?

Accepted Answer

Answer reason: Hemolytic anemia causes increased RBC destruction with elevated bilirubin, producing jaundice—unlike fatigue or tachycardia, which are nonspecific to all anemias.

Question 18

What significant health history does the nurse expect in a client admitted with acute glomerulonephritis associated with beta-hemolytic streptococcus?

Accepted Answer

Answer reason: Acute poststreptococcal glomerulonephritis typically develops 1–3 weeks after a group A beta-hemolytic streptococcal throat infection, so a recent sore throat is the most relevant history.

Question 19

A postterm infant delivered vaginally is exhibiting tachypnea, grunting, retractions, and nasal flaring; these findings are indicative of which condition?

Accepted Answer

Answer reason: Postterm infants are at high risk for meconium-stained fluid and aspiration. The signs of respiratory distress (tachypnea, grunting, retractions, nasal flaring) in a postterm, vaginally delivered newborn most strongly indicate meconium aspiration rather than RDS (seen in preterm due to surfactant deficiency) or TTN (more common after cesarean).

Question 20

Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure?

Accepted Answer

Answer reason: The ictal phase of a generalized tonic–clonic seizure is characterized by sudden loss of consciousness followed by tonic stiffening and clonic rhythmic muscle contractions.

Question 21

Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem?

Accepted Answer

Answer reason: Rising intracranial pressure affecting the brainstem disrupts respiratory centers, producing slow, irregular breathing (part of Cushing response).

Question 22

During history taking of a client admitted with newly diagnosed Hodgkin's disease, which symptom should the nurse expect the client to report?

Accepted Answer

Answer reason: Hodgkin lymphoma commonly presents with B symptoms: fever, drenching night sweats, and unintentional weight loss. Lymph nodes are typically painless, and headaches/visual changes are not characteristic.

Question 23

Mrs. Tihut is a 26-year-old multigravida who is pregnant for the third time. It is about 24 weeks since she experienced her LMP and three weeks since she began to present some pregnancy related complaints such as, absence of fetal movement and brownish vaginal discharge. In addition, her Ultrasound investigation signifies “no advancement in fundal height” and “absent fetal heart beat”. Which form of abortion would you suspect in the scenario above?

Accepted Answer

Answer reason: Fetal death with retention in utero presents with absent fetal heart tones and movement, brownish discharge, and lack of uterine growth—classic for missed abortion.

Question 24

A 23-year-old man with Addison's disease comes to the health clinic. The nurse should expect the client to report that his skin has become?

Accepted Answer

Answer reason: Primary adrenal insufficiency increases ACTH, which stimulates melanocytes and causes diffuse hyperpigmentation (bronzing). Other options reflect different disorders (e.g., Cushing’s with ruddy/oily or hypothyroidism with pale, dry skin).

Question 25

Ms. Selam, a 19-year-old primigravida, presents to the emergency department at 32 weeks’ gestation. She is complaining of blurring of vision, and severe occipital headache. On examination her BP is 170/120 mmHg. What is the most likely diagnosis?

Accepted Answer

Answer reason: Pregnant at 32 weeks with severe hypertension (170/120) plus visual changes and severe headache indicates severe preeclampsia; eclampsia would require seizures, which are not present.

Question 26

Which new doctor’s order should the nurse question for a child with Acute Glomerulonephritis?

Accepted Answer

Answer reason: Acute glomerulonephritis management focuses on controlling fluid balance, monitoring for hypertension, and assessing renal function. Daily weights, BP measurements, and strict intake/output are essential. Routine “bed rest” is outdated and not evidence-based unless the child is severely hypertensive or experiencing significant edema or fatigue, so this order should be questioned.

Question 27

Which of the following is a symptom of diabetic ketoacidosis?

Accepted Answer

Answer reason: DKA is characterized by hyperglycemia with ketosis and metabolic acidosis. Deep vein thrombosis and jaundice are not features of DKA.

Question 28

Which manifestations should the nurse include in the teaching plan for a client with polycythemia vera?

Accepted Answer

Answer reason: Polycythemia vera increases blood viscosity, producing neurologic and ocular symptoms such as blurred vision/visual disturbances. Hearing loss and orthopnea are not typical; gout is a complication and weight loss is nonspecific.

Question 29

The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will?

Accepted Answer

Answer reason: Ventricular septal defect causes a left-to-right shunt with increased pulmonary blood flow and signs of heart failure, leading to poor feeding and easy fatigability. Normal growth is unlikely, increased calories is an intervention rather than a defining effect, and viral susceptibility is not specific.

Question 30

The complete blood count of a client admitted with anemia reveals that the red blood cells are hypochromic and microcytic. The nurse recognizes that the client has?

Accepted Answer

Answer reason: Hypochromic, microcytic red cells are classic for iron deficiency; aplastic and hemolytic anemias are usually normocytic, and pernicious anemia is macrocytic.

Question 31

A newborn diagnosed with bilateral choanal atresia is scheduled for surgery soon after delivery. The nurse recognizes the immediate need for surgery because the newborn?

Accepted Answer

Answer reason: Bilateral choanal atresia obstructs the posterior nasal airway. Newborns are obligate nose breathers, so bilateral obstruction causes immediate respiratory distress, necessitating urgent surgical correction.

Question 32

A client is hospitalized with an acute myocardial infarction. Which nursing diagnosis reflects an understanding of the cause of acute myocardial infarction?

Accepted Answer

Answer reason: An acute MI is caused by an acute occlusion of a coronary artery, resulting in impaired myocardial tissue perfusion. The other diagnoses describe effects or symptoms rather than the cause.

Question 33

A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of?

Accepted Answer

Answer reason: Low-grade fever, fatigue, night sweats, and hemoptysis are classic symptoms of pulmonary tuberculosis.

Question 34

During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is?

Accepted Answer

Answer reason: Herpes simplex typically presents as painful vesicular blisters on the vulva. Syphilis chancres are painless, gonorrhea does not cause blisters, and condylomata (HPV) are warty growths, not painful vesicles.

Question 35

The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with?

Accepted Answer

Answer reason: Uremic frost is a manifestation of advanced uremia from chronic kidney failure. These clients commonly develop secondary hyperparathyroidism due to phosphate retention and calcium imbalance, linking uremic frost with parathyroid disorders.

Question 36

The mother of a 1-year-old with sickle cell anemia wants to know why the condition didn't show up in the nursery. The nurse's response is based on the knowledge that?

Accepted Answer

Answer reason: Newborns have predominantly fetal hemoglobin (HbF), which resists sickling. Symptoms typically appear after several months when HbF declines and HbS becomes predominant. Other options are incorrect: newborn screening detects abnormal hemoglobin, insensible losses are unrelated, and infections can occur in infants.

Question 37

The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort decreases when he?

Accepted Answer

Answer reason: Duodenal ulcer pain typically improves with food or antacids and occurs 2–3 hours after meals; therefore eating a meal or snack provides relief.

Question 38

Which of the following findings would be expected in the infant with biliary atresia?

Accepted Answer

Answer reason: Biliary atresia causes cholestasis with fat malabsorption and failure to thrive, and hepatomegaly/ascites leading to abdominal distention. Stools are typically pale, not dark. Thus poor weight gain with abdominal distention is expected.

Question 39

A client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal?

Accepted Answer

Answer reason: Renal transplant rejection causes impaired renal function and fluid retention, leading to hypertension. The other options reflect normal or opposite findings (normal creatinine, adequate urine output, weight gain—not loss—would occur).

Question 40

Cystic fibrosis is an exocrine disorder that affects several systems of the body. The earliest sign associated with a diagnosis of cystic fibrosis is?

Accepted Answer

Answer reason: In cystic fibrosis, thick intestinal secretions can obstruct the ileum at birth, causing meconium ileus—the earliest typical clinical sign. Steatorrhea, recurrent respiratory infections, and salty sweat usually become evident later.

Question 41

A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history-taking the nurse first asks the client about a recent history of?

Accepted Answer

Answer reason: Acute poststreptococcal glomerulonephritis commonly follows a recent group A streptococcal infection of the throat or skin; assessing for this history is most relevant.

Question 42

Which information obtained from the mother of a child with cerebral palsy correlates to the diagnosis?

Accepted Answer

Answer reason: Postnatal CNS infection such as meningitis is a known cause of cerebral palsy. Full-term birth, benign physiologic jaundice, and frequent sore throats do not correlate with CP.

Question 43

In assessing a post partum client, the nurse palpates a firm fundus. Also observed is a constant trickle of bright red blood from the vagina. The nurse suspects?

Accepted Answer

Answer reason: A firm uterus rules out uterine atony or retained placenta (which usually cause a boggy fundus). A steady trickle of bright red blood postpartum is characteristic of genital tract lacerations, not a systemic clotting disorder.

Question 44

The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which of the following recent illnesses would the nurse recognize as increasing the risk to develop Reye's Syndrome?

Accepted Answer

Answer reason: Reye's syndrome risk increases after viral illnesses such as varicella or influenza, especially with aspirin exposure. Among the options, varicella is the associated illness.

Question 45

An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this condition was caused by?

Accepted Answer

Answer reason: Salicylates stimulate the respiratory center causing hyperventilation (tachypnea), which decreases PaCO2 and produces respiratory alkalosis. The other options relate to metabolic disturbances or do not cause respiratory alkalosis.

Question 46

When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by?

Accepted Answer

Answer reason: In sickle cell disease, hemolysis shortens RBC lifespan dramatically, and bone marrow production cannot keep up, causing anemia. This is not due to iron deficiency or inability of cells to regenerate.

Question 47

A client has had his entire stomach removed surgically. Which of the following assessment would the nurse anticipate finding?

Accepted Answer

Answer reason: Total gastrectomy removes parietal cells and intrinsic factor, causing vitamin B12 malabsorption and pernicious (megaloblastic) anemia, which presents with fatigue. Other options reflect deficiencies unrelated to intrinsic factor (A: vit C/zinc for wound healing, A deficiency for night vision, C/K for bruising).

Question 48

The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the BEST response by the nurse should be that?

Accepted Answer

Answer reason: Greenstick fractures are incomplete fractures typical of children because their bones are more porous and pliable, making them prone to bending with a partial cortical break. Thus the best explanation emphasizes children’s more porous bones and incomplete breaks.

Question 49

The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which of the following assessments would the nurse expect to find?

Accepted Answer

Answer reason: Late-stage ALS causes progressive weakness of respiratory muscles (diaphragm/intercostals), leading to shallow respirations; visual field loss, seizures, and confusion are not typical ALS findings.

Question 50

A client with testicular cancer has had an orchiectomy. Prior to discharge the client expresses his fears related to his prognosis. The nurse should base the response on the knowledge that?

Accepted Answer

Answer reason: Testicular cancer is highly curable with early detection and appropriate therapy, with cure rates around 90% or higher. It is not usually fatal, and orchiectomy is primary therapy; chemotherapy is stage-dependent rather than universally intensive by default.

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