Question 1

A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 35 C axillary. The nurse recognizes that cold stress may lead to?

Accepted Answer

Answer reason: Cold stress increases oxygen consumption and metabolic demand, causing pulmonary vasoconstriction and impaired gas exchange, which lowers PaO2. BMR rises (not lowers) and cold stress tends to cause metabolic acidosis, not alkalosis.

Question 2

When providing discharge instructions for a client with open-angle glaucoma, the nurse should advise the client to avoid?

Accepted Answer

Answer reason: Straining with constipation increases intraocular pressure, which can worsen glaucoma; the other options are not specific routine restrictions for open-angle glaucoma.

Question 3

The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse MOST likely to find?

Accepted Answer

Answer reason: Lead toxicity commonly causes neurologic manifestations such as peripheral neuropathy with paresthesias and possible footdrop. Wheezing, diaphoresis, or insomnia are not typical findings of lead poisoning.

Question 4

A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition MOST frequently follows which type of infection?

Accepted Answer

Answer reason: Pelvic inflammatory disease most commonly results from ascending sexually transmitted infections, especially Chlamydia trachomatis (with N. gonorrhoeae also common). Trichomoniasis usually causes vaginitis, and staphylococcal or streptococcal infections are not typical causes of PID.

Question 5

The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The BEST response by the nurse is?

Accepted Answer

Answer reason: Third-degree burns are full-thickness injuries involving epidermis, dermis, and subcutaneous tissue—i.e., all skin layers. Option D describes a deeper, fourth-degree injury; A and B describe more superficial burns.

Question 6

A clinic nurse is taking a health history from a 34-year-old man newly diagnosed with Buerger's disease. The nurse would expect the client's complaints to include?

Accepted Answer

Answer reason: Buerger's disease (thromboangiitis obliterans) causes inflammatory occlusion of small peripheral vessels leading to Raynaud-like symptoms; patients commonly report digital cold sensitivity. The other complaints are not characteristic.

Question 7

A 16 year-old boy is admitted for Ewing's sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment MOST often includes?

Accepted Answer

Answer reason: Ewing's sarcoma is typically treated initially with multimodal therapy—systemic chemotherapy combined with local control via radiation. Amputation or wide surgical excision is not the usual first-line approach, and bone marrow grafting is not standard initial therapy.

Question 8

The nurse is caring for a client with HIV infection who has a secondary Herpes Simplex 1 (HSV 1) infection. The nurse knows that the most likely cause of the HSV 1 infection is?

Accepted Answer

Answer reason: HIV causes immune deficiency, predisposing to opportunistic infections such as HSV-1; thus the secondary infection is most likely due to immunosuppression.

Question 9

The nurse is planning care for a newborn who was infected with HIV in utero. The nurse should be aware that?

Accepted Answer

Answer reason: HIV causes immunodeficiency; infants infected in utero are highly prone to opportunistic infections. Normal growth is not expected, incubation is not slower, and renal monitoring is not the primary concern.

Question 10

The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which of the following would the nurse recognize as cause for the symptoms?

Accepted Answer

Answer reason: Iron deficiency anemia lowers hemoglobin and thus the blood’s oxygen-carrying capacity, leading to tissue hypoxia that causes the symptoms. Cardiac output may compensate but is not the primary cause; SpO2 is typically normal and cerebral edema is unrelated.

Question 11

A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be MOST consistent with this diagnosis?

Accepted Answer

Answer reason: Bronchopulmonary dysplasia commonly develops in premature infants after prolonged mechanical ventilation and oxygen therapy; a 2‑week course of ventilation is most consistent with this diagnosis.

Question 12

The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following would the nurse suspect is related to this diagnosis?

Accepted Answer

Answer reason: Rheumatic fever is a post–group A streptococcal complication that typically follows strep pharyngitis by 2–6 weeks; recent exposure to strep throat best explains the diagnosis.

Question 13

A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the MOST likely cause of this problem stems from the infant's inability to?

Accepted Answer

Answer reason: Preterm RDS is primarily due to surfactant deficiency, leading to inability to maintain alveolar surface tension and resultant atelectasis. The other options are not the central cause.

Question 14

A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip, and hypoplastic philtrum of the upper lip. The mother states that the child seems to have problems in learning to count and recognizing basic colors. Based on this data, the nurse suspects that the child is MOST likely showing the effects of?

Accepted Answer

Answer reason: Short palpebral fissures, thin upper lip, and smooth/hypoplastic philtrum with cognitive/learning difficulties are classic features of fetal alcohol syndrome.

Question 15

A hospitalized patient has a history of gout; the nurse knows this type of arthritis occurs due to the accumulation of what substance in the blood?

Accepted Answer

Answer reason: Gout is caused by hyperuricemia with deposition of monosodium urate crystals in joints; thus uric acid accumulates. Creatinine reflects renal function, lactic acid relates to acidosis, and tyramine is a dietary amine not responsible for gout.

Question 16

A teenage patient recently started on lamotrigine develops red, irritated eyes; sore throat; chapped lips; and a diffuse rash with blistering and epidermal detachment. What is the most likely diagnosis?

Accepted Answer

Answer reason: Stevens-Johnson Syndrome is a severe mucocutaneous hypersensitivity reaction most commonly triggered by medications, especially lamotrigine. Key features include mucosal involvement, painful blistering, sloughing of the epidermis, and systemic symptoms.

Question 17

A patient presents with yellowish plaques around the eyes and multiple tendon nodules on the hands, elbows, and Achilles tendon. There is a family history of early cardiac disease. What is the diagnosis?

Accepted Answer

Answer reason: The combination of xanthelasma (eyelid plaques), tendon xanthomas, and premature cardiovascular disease is classic for familial hypercholesterolemia caused by LDL receptor defects.

Question 18

An elderly woman shows exaggerated thoracic kyphosis (“dowager’s hump”). Likely cause?

Accepted Answer

Answer reason: Elderly postmenopausal women commonly develop kyphosis due to osteoporosis-related vertebral compression fractures.

Question 19

A child presents with frequent nosebleeds. Which vitamin deficiency is the most likely cause?

Accepted Answer

Answer reason: Vitamin K is required for hepatic synthesis of clotting factors II, VII, IX, and X. Deficiency impairs coagulation, leading to mucosal bleeding, including recurrent epistaxis.

Question 20

A nurse is reviewing x-ray findings of a patient with a femur fracture. The image shows multiple bone fragments at the fracture site. What type of fracture is this most consistent with?

Accepted Answer

Answer reason: A comminuted fracture occurs when the bone shatters into several fragments, typically due to high-impact trauma, matching the description precisely.

Question 21

Which condition is MOST consistent with yellow discoloration of the sclera?

Accepted Answer

Answer reason: Yellow sclera (icterus) results from elevated bilirubin levels due to impaired hepatic conjugation or obstructed bile flow, most commonly caused by liver disease such as cirrhosis.

Question 22

Severe swelling and thickening of a lower limb caused by lymphatic obstruction is MOST likely due to?

Accepted Answer

Answer reason: Filariasis, caused by Wuchereria bancrofti and related parasites, obstructs lymphatic flow, resulting in massive swelling, fibrosis, and “elephantiasis.” The chronic lymphatic damage distinguishes it from DVT, cellulitis, or arterial disease.

Question 23

Which fracture type describes a bone broken into multiple fragments?

Accepted Answer

Answer reason: A comminuted fracture is defined by the bone splitting into three or more fragments—usually due to high-impact trauma. This pattern differentiates it from simple transverse, spiral, or oblique fractures.

Question 24

A patient presents with xanthelasma and tendon xanthomas plus a strong family history of premature cardiac disease. What is the most likely diagnosis?

Accepted Answer

Answer reason: Tendon xanthomas and xanthelasma alongside very early cardiac disease strongly suggest inherited LDL receptor defects consistent with familial hypercholesterolemia.

Question 25

An elderly woman develops a marked thoracic kyphosis (“dowager’s hump”). What is the most common cause?

Accepted Answer

Answer reason: Elderly women frequently experience osteoporotic vertebral collapse, which progressively increases kyphotic curvature and produces the characteristic “dowager’s hump.”

Question 26

A child presents with recurrent nosebleeds. Which vitamin deficiency is the most likely cause?

Accepted Answer

Answer reason: Vitamin K is essential for synthesis of clotting factors II, VII, IX, and X. Deficiency results in mucosal bleeding such as epistaxis.

Question 27

Which vitamin deficiency causes night blindness due to impaired rod function?

Accepted Answer

Answer reason: Vitamin A is necessary for rhodopsin production in rod cells. Deficiency leads to nyctalopia (night blindness), a classic manifestation.

Question 28

The nurse is examining a 42 year old woman with suspected grave’s disease. The nurse should assess this client for?

Accepted Answer

Answer reason: Graves disease causes hyperthyroidism with increased sympathetic activity and metabolic rate. Common manifestations include tachycardia, palpitations, heat intolerance, and warm, moist skin with weight loss despite increased appetite. Cold skin and weight gain are typical of hypothyroidism, and anorexia is not characteristic in Graves. Therefore, tachycardia is the most expected finding.

Question 29

Risk Factors for Pancreatic Cancer?

Accepted Answer

Answer reason: Cigarette smoking is the strongest and most well-established modifiable risk factor for pancreatic cancer. Smokers have significantly higher incidence due to chronic inflammation and carcinogenic exposure affecting pancreatic tissues.

Question 30

A patient who suffered a traumatic brain injury last year has developed narcolepsy and excessive daytime sleepiness. Which of the following side effects of this condition would the nurse most likely expect to see in this patient?

Accepted Answer

Answer reason: Narcolepsy commonly includes cataplexy, a sudden loss of muscle tone triggered by emotions such as laughter or surprise. This presents as transient loss of voluntary muscle control while consciousness is preserved. Sleep terrors are parasomnias seen more often in children and are not typical of narcolepsy. Tachycardia/diaphoresis or anger outbursts are not hallmark features of narcolepsy.

Question 31

Which of the following should the nurse expect to observe as the primary initial symptoms for a patient with perforative peptated duodenal ulcer?

Accepted Answer

Answer reason: A perforated duodenal ulcer typically causes sudden, severe abdominal pain due to leakage of gastric/duodenal contents into the peritoneal cavity, leading to chemical peritonitis. This acute pain is usually the earliest and most prominent initial symptom, often described as sharp and may be associated with a rigid, board-like abdomen. Fever and vomiting may occur later as inflammation progresses, and dizziness is more consistent with significant bleeding or shock rather than the primary initial sign of perforation.

Question 32

Patient’s blood pressure is 170/100 mmHg with a history of hypertension. The nurse writes: “Risk for stroke related to uncontrolled hypertension.” This is an example of?

Accepted Answer

Answer reason: The statement “Risk for stroke related to uncontrolled hypertension” is a nursing diagnosis because it identifies an actual or potential patient problem (risk) and links it to an etiology (“related to”). Planning would involve setting goals and selecting interventions; implementation is carrying out those interventions; evaluation is judging outcomes after care is provided. Here, the nurse is defining a priority risk based on assessment data (BP 170/100 and history of hypertension).

Question 33

Which shock is linked to severe blood loss?

Accepted Answer

Answer reason: Severe blood loss leads to decreased circulating volume, reduced preload, and inadequate tissue perfusion, which defines hypovolemic shock. Cardiogenic shock results from pump failure, neurogenic shock from loss of sympathetic tone, and septic shock from systemic infection and vasodilation.

Question 34

A laboring client with chorioamnionitis (maternal fever 38.5°C, foul-smelling fluid) is 9 cm dilated. What is the nurse’s next action?

Accepted Answer

Answer reason: Chorioamnionitis is an intra-amniotic infection that requires prompt broad-spectrum IV antibiotics and expedited vaginal delivery if there are no other obstetric contraindications. At 9 cm dilation, continuing labor while treating the infection is appropriate and avoids unnecessary surgical risk from cesarean in an infected field. Delaying delivery to “finish” antibiotics is unsafe, and chorioamnionitis alone is not an indication to stop labor and schedule cesarean. Restricting maternal fluids does not address the infection and may worsen maternal/fetal status.

Question 35

In case of concealed hemorrhage, what nursing finding is expected?

Accepted Answer

Answer reason: Concealed hemorrhage (classically with placental abruption) involves bleeding trapped behind the placenta, so visible vaginal bleeding may be minimal. As blood accumulates within the uterus, the uterus becomes firm/boardlike with increased tone and significant tenderness. This contrasts with placenta previa, which typically presents with painless vaginal bleeding and a soft, non-tender uterus. Therefore, a rigid, tender uterus is the expected nursing finding.

Question 36

Which of the following would the nurse identify as the priority nursing diagnosis during a toddler’s vaso-occlusive sickle cell crisis?

Accepted Answer

Answer reason: In a vaso-occlusive sickle cell crisis, sickled erythrocytes obstruct microcirculation, causing ischemia and tissue hypoxia, which produces severe acute pain and can rapidly worsen without prompt management. For a toddler in crisis, uncontrolled pain is an immediate physiologic priority that also signals ongoing hypoperfusion. The other options are not the typical priority diagnosis for vaso-occlusive crisis: decreased cardiac output is not the primary acute issue, excess fluid volume is incorrect (hydration is usually needed), and ineffective coping is secondary to stabilizing physiologic needs.

Question 37

What type of shock is hypovolemic shock?

Accepted Answer

Answer reason: Hypovolemic shock results from a significant loss of intravascular fluid volume, such as from hemorrhage, dehydration, or plasma loss. The primary mechanism is reduced preload and decreased circulating blood volume, which leads to impaired cardiac output and tissue hypoperfusion. Therefore, hypovolemic shock is classified as a fluid-deficit type of shock.

Question 38

A nurse cares for a client who has excessive catecholamine release. Which assessment finding should the nurse correlate with this condition?

Accepted Answer

Answer reason: Excess catecholamine release (e.g., epinephrine/norepinephrine) activates the sympathetic nervous system, producing tachycardia and increased cardiac contractility. This commonly presents as an increased pulse, often with hypertension and other “fight-or-flight” signs. Decreased blood pressure and decreased respiratory rate are opposite of typical sympathetic effects. Increased urinary output is not a primary expected finding, as sympathetic activation tends to reduce renal perfusion and promote urinary retention rather than diuresis.

Question 39

A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?

Accepted Answer

Answer reason: In acute pancreatitis, a key early management priority is pancreatic rest by keeping the client NPO and reducing gastric/pancreatic stimulation. An order for a nasogastric tube (e.g., Levine tube) may be anticipated, especially with significant nausea/vomiting, gastric distention, or ileus, to decompress the stomach and help decrease vomiting/aspiration risk. Routine dressing changes are not specific to pancreatitis, and cardiac monitoring or very frequent blood pressure checks may be used based on instability but are not as universally anticipated as GI decompression/rest measures. Therefore, insertion of a Levine tube is the best expected order.

Question 40

The nurse is caring for a client with diabetic ketoacidosis and observes that the client is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record?

Accepted Answer

Answer reason: Kussmaul's respirations observed. Kussmaul respirations are characteristically deep, rapid, and regular and occur as a compensatory response to metabolic acidosis such as diabetic ketoacidosis. The client increases ventilation to blow off CO2 and raise blood pH. Apnea is absence of breathing, bradypnea is slow respirations, and Cheyne-Stokes is a cyclic waxing/waning pattern with periods of apnea rather than sustained deep rapid breathing.

Question 41

Which of the following signs and symptoms will most likely make the nurse suspect that the patient is having hydatidiform mole?

Accepted Answer

Answer reason: Passage of clear vesicular mass per vagina Hydatidiform mole (gestational trophoblastic disease) can present with passage of grape-like/vesicular tissue from the vagina, which is a highly suggestive finding. While vaginal bleeding, absent fetal heart tones, and an enlarged uterus can occur, they are less specific and may be seen in other pregnancy complications. The vesicular mass reflects swollen chorionic villi and is more characteristic of a molar pregnancy than the other options.

Question 42

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. The nurse would anticipate that the client is at risk for which problem?

Accepted Answer

Answer reason: Acute kidney injury. Post-cardiac surgery oliguria (20–25 mL/hr) with elevated BUN (45 mg/dL) and creatinine (2.2 mg/dL) indicates impaired renal perfusion and/or renal injury rather than a simple, rapidly reversible volume deficit. The minimal urine output response after a 500 mL IV bolus supports ongoing renal dysfunction, placing the client at risk for acute kidney injury. Glomerulonephritis and UTI would not be the most immediate explanation for acute postoperative oliguria with rising nitrogenous wastes.

Question 43

A hospitalized 2-year-old child with croup is receiving corticosteroid therapy. The mother asks the nurse why the health care provider did not prescribe antibiotics. The nurse makes which response to the mother?

Accepted Answer

Answer reason: “Antibiotics are not indicated unless a bacterial infection is present.” Croup is most commonly caused by a viral infection (e.g., parainfluenza), and corticosteroids help reduce airway inflammation and improve symptoms. Antibiotics treat bacterial infections and do not improve viral illness, so they are not routinely prescribed unless there is evidence of secondary bacterial infection. The other options are incorrect because age alone does not preclude antibiotic use, allergy is not the primary rationale, and maternal antibodies wane significantly by this age and do not replace appropriate antimicrobial therapy when indicated.

Question 44

Which assessment finding is most characteristic of early dumping syndrome?

Accepted Answer

Answer reason: Dizziness and tachycardia 15–30 minutes after a meal Early dumping syndrome occurs shortly after eating when hyperosmolar gastric contents rapidly enter the small intestine, drawing fluid into the bowel. This intravascular volume shift and release of vasoactive mediators leads to vasomotor symptoms such as dizziness, palpitations, and tachycardia within 10–30 minutes of a meal. Findings several hours after eating are more consistent with late dumping due to reactive hypoglycemia. Symptoms like constipation and bloating are not characteristic of dumping syndrome.

Question 45

A 5-week-old boy is admitted to the hospital for pyloric stenosis. While assessing the infant, the nurse is most likely to note which of the following?

Accepted Answer

Answer reason: Projectile vomiting Pyloric stenosis causes gastric outlet obstruction from hypertrophy of the pyloric muscle, leading to progressively worsening, nonbilious forceful emesis after feeds in a young infant. Ongoing vomiting can also contribute to dehydration and hypochloremic, hypokalemic metabolic alkalosis, but the hallmark finding is the characteristic vomiting pattern. Currant jelly stools are more consistent with intussusception rather than pyloric stenosis. Abdominal distention is not the classic primary assessment finding for this condition.

Question 46

A 94 year-old female is admitted to the med-surg unit with a temperature of 101.5 degrees F, malodorous urine, and a confirmed UTI. Upon admission, she is disoriented and speaking to many “people” she says are sitting on her bed. Her granddaughter confirms this is not her baseline and she is very confused. The most likely complication described is?

Accepted Answer

Answer reason: Delirium An acute change from baseline mental status with disorientation and hallucinations in an older adult is most consistent with delirium, commonly precipitated by infection such as a UTI. Delirium develops abruptly and fluctuates, unlike dementia which is typically gradual and chronic. Fever and signs of infection provide a clear reversible trigger for acute confusional state. Septic shock would require evidence of hypotension and end-organ hypoperfusion rather than isolated acute confusion.

Question 47

Which factor places a woman at highest risk for postpartum hemorrhage?

Accepted Answer

Answer reason: Uterine atony is the leading cause of postpartum hemorrhage because inadequate uterine contraction prevents compression of uterine blood vessels after placental separation. A prior episode strongly predicts recurrence, making it a more significant risk factor than the other listed choices. A short labor can be associated with uterine fatigue or precipitate labor-related trauma, but it is not as predictive as a documented prior atony. Low BMI and multiparity of 2 are not major, high-yield risk factors compared with a known history of atony.

Question 48

A pediatric nurse is caring for a 6 week-old infant diagnosed with tetralogy of Fallot. The nurse is attempting to keep the patient comfortable and prevent “tet” spells. She knows an effective way to prevent these spells is to?

Accepted Answer

Answer reason: Crying and agitation increase oxygen demand and can trigger right-to-left shunting in tetralogy of Fallot, precipitating hypercyanotic (“tet”) spells. Prompt comforting reduces stress and catecholamine surge, helping prevent sudden worsening cyanosis. Other helpful measures during a spell include knee-chest positioning and oxygen, but among the listed prevention strategies, minimizing crying is the most directly protective. The other options are not standard, evidence-based preventive strategies for tet spells and may delay appropriate calming measures.

Question 49

A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first?

Accepted Answer

Answer reason: Early Alzheimer’s disease most commonly presents with mild short-term memory impairment and difficulty with new learning, which leads to losing items and forgetting where objects were placed. More advanced cognitive decline is typically required before significant disorientation affecting clothing choices becomes prominent. Personality changes can occur but are less consistent as the earliest hallmark than memory lapses. Failure to recognize family members is a later-stage finding associated with moderate to severe disease progression.

Question 50

A nurse is teaching a parent of a child with sickle cell anemia about preventing a crisis. Which statement indicates further teaching is needed?

Accepted Answer

Answer reason: s." Sickle cell crises are commonly triggered by dehydration, hypoxia, cold exposure, and high altitude, all of which promote sickling and vaso-occlusion. Ensuring hydration, avoiding high-altitude exposure, and dressing warmly in cold weather are appropriate preventive strategies. Taking regular naps is not a specific, evidence-based intervention to prevent vaso-occlusive crises and suggests a gap in understanding of the key triggers and prevention measures.

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