Question 1

A nurse is monitoring a newborn with a diabetic mother. The nurse understands that the newborn is at risk for what complication?

Accepted Answer

Answer reason: Infants of diabetic mothers are at increased risk of delayed fetal lung maturation due to the antagonistic effects of fetal hyperinsulinemia on surfactant production. This can lead to poor alveolar stability after birth, increased work of breathing, and hypoxemia shortly after delivery. The other listed choices are inconsistent with typical complications (more common issues include hypoglycemia and hyperbilirubinemia rather than hyperglycemia or low bilirubin).
Category reason: This is a patient-care monitoring question requiring nursing recognition of expected neonatal complications from maternal diabetes, which aligns with Physiological Adaptation—Pathophysiology.

Question 2

A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY?

Accepted Answer

Answer reason: Early cerebral edema and rising intracranial pressure commonly first present with subtle neurologic changes, especially altered mental status and decreased alertness. Pupillary changes and decerebrate posturing are later signs suggesting brainstem compression and more severe herniation risk. Seizures can occur with head injury but are not the most typical initial finding compared with a declining level of consciousness in expanding intracranial pathology.
Category reason: This item tests recognition of early clinical manifestations of intracranial pathology (subdural hematoma with cerebral edema) to anticipate patient status, which is nursing-focused physiologic adaptation/pathophysiology rather than pure anatomy.

Question 3

A nurse is assessing a client with liver cirrhosis who has been increasingly confused over the past 24 hours. The client's serum ammonia level is 95 mcg/dL (normal: 15-45 mcg/dL). When the nurse asks the client to extend both arms forward with wrists dorsiflexed and fingers spread apart, the client's hands begin to flap involuntarily. What is the PRIORITY nursing action?

Accepted Answer

Answer reason: B) Notify the healthcare provider immediately and prepare to administer lactulose The confusion, markedly elevated ammonia, and asterixis indicate hepatic encephalopathy, a potentially life-threatening complication requiring prompt treatment to reduce ammonia and prevent progression to coma. Lactulose is a first-line therapy that lowers ammonia by trapping it in the gut and promoting excretion, and the nurse should anticipate this intervention and communicate the change in status urgently. Routine monitoring alone delays necessary treatment, and restraints do not address the underlying metabolic cause and can worsen agitation. Increasing dietary protein can increase ammonia production and may exacerbate encephalopathy in the acute setting.
Category reason: This is a priority nursing action question focused on recognizing and responding to an acute complication of cirrhosis (hepatic encephalopathy) with timely intervention/notification, which aligns with NCLEX patient-care decision-making under Physiological Adaptation (Pathophysiology).

Question 4

Which statement is an example of a correctly written nursing diagnosis statement?

Accepted Answer

Answer reason: D. Ineffective coping related to response to positive biopsy test results. It uses an approved NANDA problem label and links it to an appropriate etiology with “related to,” forming a complete two-part (PES) nursing diagnosis. The etiology reflects a client response/condition that nursing interventions can address (support, coping strategies, counseling resources). By contrast, an infection or congestive heart failure are medical diagnoses rather than nursing etiologies, and a “risk for” diagnosis should not be paired with a current causative situation in the same way as an actual problem diagnosis.
Category reason: The item tests nursing judgment in formulating an appropriate nursing diagnosis statement (problem and related factor), which is part of clinical nursing practice rather than foundational biomedical science.

Question 5

A nurse in planning care for a client with hyperthyroidism. Which of the following nursing interventions is least appropriate?

Accepted Answer

Answer reason: Hyperthyroidism increases metabolic rate and commonly causes heat intolerance, sweating, and a tendency to feel overheated. Nursing care should promote comfort by maintaining a cool, well-ventilated environment and reducing stimuli that worsen hypermetabolic symptoms. Rest periods help limit fatigue, daily weights help monitor nutritional status and treatment response, and isotonic eye drops can reduce dryness/irritation with thyroid eye involvement.
Category reason: This is a patient-care planning question asking which nursing intervention is appropriate/least appropriate for a condition, requiring nursing judgment about comfort measures and monitoring in a physiologic disorder.

Question 6

In managing a patient with constrictive pericarditis, the goal of the nurse is to…………..?

Accepted Answer

Answer reason: Constrictive pericarditis causes a rigid, noncompliant pericardium that restricts diastolic filling, reducing stroke volume and cardiac output. Nursing management priorities focus on optimizing hemodynamics—supporting preload/afterload balance, monitoring for signs of low output and right-sided failure, and assisting with therapies such as diuretics and preparation for pericardiectomy when indicated. Pain control and relief of dyspnea/edema are important symptomatic measures, but they are secondary to restoring and maintaining adequate cardiac function, which drives those symptoms.
Category reason: This question asks for the overarching nursing goal when caring for a patient with a specific cardiovascular pathophysiology (constrictive pericarditis), emphasizing physiologic adaptation and hemodynamic support rather than foundational anatomy-only knowledge.

Question 7

A full-term newborn has bilirubin of 13 mg/dL at 24 hours old. What is the best nursing action?

Accepted Answer

Answer reason: A bilirubin level this high within the first 24 hours is concerning for pathologic hyperbilirubinemia and carries increased risk for bilirubin neurotoxicity. Immediate treatment is indicated because early-onset jaundice often rises quickly and may reflect hemolysis or other pathology. Phototherapy is the primary nursing-initiated intervention to enhance bilirubin excretion while further evaluation proceeds. Other measures like feeding support or IV fluids may be adjuncts but do not address the urgent need to reduce bilirubin promptly.
Category reason: This item asks for the best immediate nursing intervention to manage a newborn physiologic risk (early severe hyperbilirubinemia), which is a patient-care decision consistent with NCLEX-style Physiological Adaptation.

Question 8

Which fetal heart rate (FHR) pattern is most concerning?

Accepted Answer

Answer reason: C) Variable decelerations with slow return to baseline Variable decelerations are typically caused by umbilical cord compression, and a slow return to baseline suggests worsening or prolonged hypoxemia with reduced fetal reserve. This pattern is more concerning than early decelerations (head compression, usually benign), accelerations (reassuring), and moderate variability (reassuring indicator of intact neurologic function and adequate oxygenation). The prolonged recovery implies the fetus is taking longer to re-oxygenate after each deceleration, increasing the risk of fetal acidemia and need for intrauterine resuscitation and escalation of care.
Category reason: This item tests interpretation of fetal monitoring to identify a potentially pathologic FHR pattern requiring nursing recognition and urgent response, which aligns with NCLEX-style clinical judgment in physiologic adaptation/pathophysiology.

Question 9

The nurse is caring for a client with a suspected pneumothorax. The client's husband is anxious and asks the nurse how this could have happened. Which of the following responses would require follow-up? Select one?

Accepted Answer

Answer reason: A pneumothorax occurs when air enters the pleural space, commonly from trauma (e.g., penetrating injury) or rupture of alveoli/blebs, which can be associated with underlying lung disease such as COPD or malignancy. These mechanisms directly explain how a pneumothorax can happen. Empyema is pus in the pleural space from infection and is not a typical causal mechanism for air entering the pleural space; it is a different pleural complication. Therefore, linking a suspected pneumothorax to empyema would be inaccurate and needs follow-up/clarification.
Category reason: This item tests nursing judgment about whether an explanation of disease causation is accurate for a clinical condition (pneumothorax), which aligns with pathophysiology used in patient teaching and clinical reasoning rather than pure recall of anatomy.

Question 10

Which newborn finding is most concerning for sepsis?

Accepted Answer

Answer reason: Newborns with infection may present with temperature instability, and hypothermia is a classic early sign of neonatal sepsis (often more common than fever). It reflects impaired thermoregulation and systemic illness, warranting urgent evaluation (vitals, glucose, cultures) and prompt treatment. By contrast, acrocyanosis is commonly normal in the immediate newborn period, and a present sucking reflex is reassuring. Jitteriness can occur with hypoglycemia, withdrawal, or hypocalcemia and is less specific for sepsis than temperature instability.
Category reason: This question tests recognition of a critical clinical sign in a newborn and the nurse’s identification of a potentially life-threatening condition (sepsis), which aligns with physiologic adaptation and pathophysiology in patient care.

Question 11

A nurse is caring for a client with pulmonary embolism. Which is the priority nursing diagnosis?

Accepted Answer

Answer reason: A pulmonary embolism obstructs pulmonary arterial blood flow, reducing perfusion to ventilated alveoli and impairing gas exchange, which can rapidly lead to hypoxemia and hemodynamic compromise. Priorities focus on ABCs; restoring/maintaining adequate oxygenation and cardiopulmonary perfusion is more urgent than mobility, bleeding risk from anticoagulation, or pain control. While pain and immobility may be present, they are secondary to the immediate threat of impaired perfusion and oxygen delivery. Therefore the priority nursing diagnosis centers on impaired tissue perfusion.
Category reason: This question asks for the priority nursing diagnosis in an acute, life-threatening condition (pulmonary embolism), requiring nursing judgment about immediate physiologic threats (ABCs) rather than testing foundational science facts.

Question 12

A client in the emergency department reports severe unilateral lower abdominal pain and vaginal spotting. Her last menstrual period was 7 weeks ago.The nurse suspects:

Accepted Answer

Answer reason: B) Ectopic pregnancy Severe unilateral lower abdominal pain with vaginal spotting in early pregnancy (around 6–8 weeks from LMP) is classic for an ectopic implantation, most commonly in the fallopian tube. This presentation is more concerning for potential tubal distension or rupture, which can rapidly progress to hemorrhage and shock. Placental abruption occurs after placental formation (typically later gestation) and presents with bleeding and abdominal pain, not an early 7-week LMP scenario. Threatened miscarriage usually causes cramping and bleeding but typically lacks marked unilateral pain suggestive of adnexal pathology.
Category reason: This item tests recognition of an early pregnancy emergency based on presenting signs and symptoms, requiring clinical judgment about likely pathophysiology in a patient-care context (emergency assessment).

Question 13

A client with cirrhosis develops confusion and asterixis. What medication should the nurse expect to administer?

Accepted Answer

Answer reason: B. Lactulose Confusion with asterixis in cirrhosis is classic for hepatic encephalopathy due to elevated ammonia and other neurotoxins. This medication reduces serum ammonia by trapping it in the gut (as ammonium) and promoting catharsis to increase excretion. Diuretics address ascites/edema and can worsen encephalopathy if they cause dehydration or electrolyte imbalance, and an H2 blocker does not treat the underlying neurotoxicity.
Category reason: This is a patient-care medication decision for a complication of liver failure (hepatic encephalopathy), requiring nursing judgment about appropriate treatment rather than basic science recall.

Question 14

A client with a known history of rheumatic heart disease presents with shortness of breath and fatigue. Which new assessment finding should concern the nurse most?

Accepted Answer

Answer reason: B. Fever and chills Fever with chills in a patient with underlying valvular disease is highly concerning for infective endocarditis, a time-sensitive condition that can rapidly lead to sepsis, embolic events, and acute valvular deterioration. Compared with the other findings, this represents a new systemic infection signal requiring prompt provider notification, blood cultures, and early antimicrobial evaluation. An irregular pulse may indicate dysrhythmia and a diastolic murmur may reflect chronic valvular disease, but neither is as immediately suggestive of a new life-threatening infectious process. Splinter hemorrhages can occur with endocarditis, but fever/chills is the more urgent red-flag systemic manifestation.
Category reason: This item asks the nurse to identify the most concerning new assessment finding indicating a potential acute complication (infective endocarditis) in a client with valvular disease, requiring nursing judgment about pathophysiologic risk and urgency of response.

Question 15

A nurse is caring for a 4-month old infant who has meningitis. Which of the following findings associated with this diagnosis?

Accepted Answer

Answer reason: Meningitis in infants commonly presents with signs of increased intracranial pressure and meningeal irritation, including irritability and an abnormal, inconsolable cry. A high-pitched cry is a classic neurologic warning sign in young infants and should raise concern for CNS infection or rising ICP. A depressed anterior fontanel suggests dehydration rather than meningitis; meningitis more often causes a bulging/tense fontanel. Constipation is nonspecific and not a hallmark finding, and the rooting reflex can still be present at 4 months and does not specifically indicate meningitis.

Question 16

Which assessment finding suggests a client with cirrhosis is developing hepatic encephalopathy?

Accepted Answer

Answer reason: Acute mental status changes such as confusion indicate evolving cerebral dysfunction, and asterixis (flapping tremor) is a classic neurologic sign associated with this condition. These findings together strongly point to encephalopathy rather than isolated cholestasis or nonspecific constitutional symptoms. Clay-colored stools and yellow sclera reflect impaired bile flow and hyperbilirubinemia, while decreased appetite is common in chronic liver disease but is not specific for encephalopathy.

Question 17

The nurse is aware that a child with the diagnosis of acute post-infectious glomerulonephritis will exhibit which of following symptom?

Accepted Answer

Answer reason: This fluid retention commonly presents with edema (often periorbital) and an increase in body weight, along with possible oliguria and hypertension. A sudden increase in energy is not characteristic of a fluid-overloaded, hypertensive child. Abdominal pain is not a typical primary finding for this condition compared with weight gain from edema.

Question 18

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

Accepted Answer

Answer reason: A declining level of consciousness indicates worsening cerebral function and often precedes overt herniation findings. In contrast, bradycardia and widening pulse pressure are components of Cushing’s triad, which are typically later indicators of significant ICP elevation. A dilated, fixed pupil suggests cranial nerve III compression and is also a late, ominous sign rather than an early change.

Question 19

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?

Accepted Answer

Answer reason: A hemorrhagic or petechial/purpuric rash is a classic bedside clue of bleeding tendency and is especially concerning in severe meningococcal infection associated with meningitis and DIC. Edema and dyspnea are nonspecific and more consistent with fluid shifts or cardiopulmonary problems rather than primary coagulation factor depletion. Cyanosis reflects impaired oxygenation/perfusion but does not specifically indicate a bleeding diathesis from DIC.

Question 20

A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

Accepted Answer

Answer reason: Common triggers include bladder distention, bowel impaction, skin irritation, or other painful/irritating stimuli that the brain cannot appropriately modulate. The other options are effects or different shock states rather than precipitating triggers for the dysreflexic episode. Identifying and removing the offending stimulus is the key immediate nursing priority to prevent complications such as stroke or seizures.

Question 21

The diabetic client is having ketoacidosis. Which of the following is the appropriate initial nursing action?

Accepted Answer

Answer reason: Diabetic ketoacidosis is driven by an absolute/relative insulin deficiency causing hyperglycemia, lipolysis, and ketone production with metabolic acidosis. The fastest way to halt ketogenesis and reduce serum glucose is IV regular insulin, which is the priority medication intervention once initial assessment and IV access are established. Providing glucose-containing fluids or oral carbohydrates would worsen hyperglycemia and does not treat the underlying insulin deficiency. Oral intake like juice or milk is also inappropriate in an acute DKA setting where dehydration, nausea/vomiting, and altered mental status may be present, and IV therapy is required.

Question 22

The primary physiological alteration in the development of asthma is?

Accepted Answer

Answer reason:  Asthma is characterized by reversible airflow obstruction driven largely by airway hyperresponsiveness leading to acute bronchoconstriction. Contraction of bronchial smooth muscle rapidly narrows the airways, increasing resistance and producing wheeze and difficulty exhaling. Airway inflammation and mucus hypersecretion are important contributors, but they are not the most immediate primary alteration responsible for episodic obstruction. Infection can trigger an exacerbation, yet asthma itself is not primarily an infectious process.

Question 23

The nurse is caring for a child with hemolytic uremic syndrome. The nurse is aware that this may lead to which of the following conditions or treatments?

Accepted Answer

Answer reason: When kidney function declines significantly (e.g., severe azotemia, hyperkalemia, fluid overload, metabolic acidosis), renal replacement therapy becomes necessary. Hemodialysis is a common acute treatment option to rapidly correct electrolyte and volume derangements while renal recovery is awaited. Hypotension is not a typical primary consequence (hypertension is more common from volume overload/renal ischemia), and cerebrovascular accident is not the classic expected complication compared with renal failure requiring dialysis.

Question 24

A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse observe?

Accepted Answer

Answer reason: Kussmaul respirations occur as a compensatory response to metabolic acidosis, where the body increases alveolar ventilation to blow off CO2 and raise blood pH. This pattern is characteristically deep and typically regular, with an increased rate reflecting the drive to correct acidemia in diabetic ketoacidosis. Slow, regular breathing is more consistent with hypoventilation rather than metabolic acidosis compensation. Periods of apnea for several seconds suggests Cheyne-Stokes or central apnea patterns, not the classic compensatory breathing of DKA.

Question 25

An elderly client with pneumonia may appear with which of the following symptoms first?

Accepted Answer

Answer reason: Early pneumonia in the elderly may first manifest as acute confusion/delirium, decreased intake, and dehydration rather than prominent respiratory complaints. This reflects systemic effects of infection and hypoxemia along with impaired thirst mechanism and baseline comorbidities. Fever and chills are common in younger adults but may be absent or delayed in geriatric patients, making mental status change a key early clue.

Question 26

Based on Mr. W's diagnosis of MAC, which of the following information should be provided to this client?

Accepted Answer

Answer reason: Clients should be taught that this diagnosis often reflects a very low CD4 count and higher risk for additional opportunistic conditions. Because advanced HIV/AIDS can involve multisystem complications and medication toxicities, evaluation for other concurrent problems (e.g., anemia) is appropriate. While antiretroviral therapy is important, the key client education tied specifically to MAC in this item is recognizing likely AIDS status and the need to screen for other comorbidities.

Question 27

A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?

Accepted Answer

Answer reason: Encouraging fluid intake of at least 2000 ml. per hour Sickle cell crisis is driven by vaso-occlusion that worsens with dehydration, which increases blood viscosity and promotes further sickling. The highest priority nursing intervention is to support perfusion by aggressive hydration as ordered to reduce sickling and improve microcirculatory flow. Pain control and comfort measures are important but do not address the upstream trigger of ongoing vaso-occlusion as directly as hydration. Frequent blood pressures and positioning may be supportive, but they are not as central to reversing the pathophysiology driving the crisis and preventing complications such as acute chest syndrome or kidney injury.

Question 28

A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report?

Accepted Answer

Answer reason: g., hepatitis) and warrants prompt provider notification. In a client with recent travel and diarrhea, new jaundice raises concern for complications beyond uncomplicated gastroenteritis, including liver inflammation or hemolysis, which changes urgency and management. The other findings are common, expected manifestations of infectious diarrhea and dehydration and are typically managed with assessment, hydration, and symptom control unless severe. Reporting jaundice supports timely diagnostic testing (liver function tests, hepatitis evaluation) and helps prevent progression to acute liver dysfunction.

Question 29

During a home visit the nurse assesses the skin of a client with eczema who reports than an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

Accepted Answer

Answer reason: A new dog introduces fresh exposures such as dander, saliva proteins, and outdoor allergens carried on fur, all of which can precipitate an exacerbation over days to a week. In contrast, a topical corticosteroid is typically used to reduce inflammation and would be less likely to explain worsening unless there was irritation from the vehicle or misuse, which is not suggested. A visitor with eczema does not cause another person’s eczema to flare because it is not contagious.

Question 30

The nurse is performing a physical assessment on a patient with a rib fracture two days ago. The nurse observes the patient with a pulse ox of 82, tachypnea, tachycardia, and dyspnea. What should the nurse expect that is occurring?

Accepted Answer

Answer reason:  Acute hypoxemia with tachypnea, tachycardia, and dyspnea developing 24–72 hours after a traumatic fracture is classic for fat embolism syndrome due to fat globules entering the circulation and causing pulmonary microvascular obstruction and inflammation. The very low oxygen saturation (82%) indicates significant gas-exchange impairment that can occur abruptly with this syndrome. Infection is less likely this early and typically presents with fever and evolving localized/systemic infectious signs rather than sudden severe hypoxemia. Compartment syndrome is a limb perfusion emergency with pain out of proportion, pallor, paresthesia, and diminished pulses, not a primary respiratory presentation.

Question 31

The nurse notes that a client has a history of fibroids. When the client is being assessed, which change of the health status would suggest that the client may require a hysterectomy?

Accepted Answer

Answer reason: Persistent or worsening bleeding is a primary clinical driver for considering hysterectomy because it directly reflects uterine pathology severity and impacts safety and quality of life. Urinary tract infections are not a typical direct consequence of fibroids; large fibroids more often cause urinary frequency or retention from bladder compression rather than infection. Dyspareunia can occur but is a less specific indicator of needing definitive uterine removal, and recurrent bacterial vaginoses is not a characteristic fibroid complication and points more toward vaginal flora imbalance than uterine mass effects.

Question 32

A patient with a fractured pelvis is initially treated with bedrest with no turning from side to side permitted. The next day after admission the patient develops chest pain, tachypnea, and tachycardia. The nurse determines the patient’s symptoms are most likely related to fat embolism when the assessment when patient reveals?

Accepted Answer

Answer reason: Petechiae are often noted on the upper chest, neck, axillae, or conjunctiva and are a key distinguishing assessment finding. The neurologic changes (e.g., confusion, restlessness) can occur in fat embolism, but they are less specific than the petechial rash. Findings like a warm reddened area on a cast point more toward localized inflammation/infection or pressure issues, not fat embolization.

Question 33

The nurse is caring for a 2-day-old infant with a suspected diagnosis of Hirschsprung's disease. The nurse would expect the stool to have which of the following appearances?

Accepted Answer

Answer reason: When stool is able to pass through a constricted segment, it may appear thin and pencil- or ribbon-like. This fits the expected pattern of constipation/obstructive symptoms in a neonate (often also with delayed meconium passage and abdominal distention). Blood and mucus suggests inflammatory/infectious colitis or severe enterocolitis, watery stool suggests gastroenteritis, and fatty stool points to malabsorption (e.g., cystic fibrosis or celiac disease) rather than a distal obstructive process.

Question 34

A 6-year-old child is admitted with abdominal pain, weight loss, bloody diarrhea, and anemia. The nurse suspects that the child may have which of the following conditions?

Accepted Answer

Answer reason: Ongoing mucosal ulceration leads to hematochezia and iron-deficiency anemia, and chronic inflammation can impair nutrition and growth causing weight loss. Pyloric stenosis presents in young infants with nonbilious projectile vomiting rather than diarrhea or blood loss. Intussusception is typically acute and episodic with colicky pain and “currant jelly” stools, not a chronic weight-loss/anemia picture.

Question 35

The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

Accepted Answer

Answer reason: This fluid shift is compounded by reduced hepatic albumin synthesis, which lowers plasma oncotic pressure and further promotes third-spacing. As a result, abdominal distention and a positive fluid wave consistent with peritoneal fluid accumulation are expected assessment findings. The other options reflect primarily respiratory or neuro-ophthalmic changes and are not characteristic manifestations of elevated portal venous pressure.

Question 36

The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit?

Accepted Answer

Answer reason: In infants, a key early sign of rising intracranial pressure is behavioral change—especially increased fussiness and difficulty consoling—before more severe neurologic depression appears. Lethargy can occur but is often a later or more ominous finding compared with early irritability. A depressed fontanel suggests decreased intracranial pressure/dehydration rather than shunt failure, and a negative Moro is a nonspecific neurologic finding not most characteristic of acute increased intracranial pressure.

Question 37

The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?

Accepted Answer

Answer reason: Venous blood backs up because the right atrium and ventricle cannot fill effectively, producing jugular venous distention as part of Beck’s triad (with hypotension and muffled heart sounds). Pulse pressure typically narrows rather than widens due to the fall in stroke volume. A pleural friction rub reflects pleural inflammation, not pericardial fluid compression, and bradycardia is not the expected early compensatory pattern because tachycardia is more common.

Question 38

The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?

Accepted Answer

Answer reason: Because the key next assessment is to confirm progression to the typical exanthem and its distribution (often starting on the face/hairline and spreading downward), examining the skin directly supports recognition of the disease pattern. This also has immediate infection-control implications because measles is highly contagious via airborne transmission and early recognition prompts rapid isolation and notification. In contrast, auscultating lungs can be part of a general respiratory assessment but is less specific to the diagnostic clue provided by Koplik spots.

Question 39

A client was admitted to the eating disorder unit with bulimia nervosa. The nurse assessing for a history of complications of this disorder expects

Accepted Answer

Answer reason: Bulimia is also associated with salivary gland hypertrophy, classically painless parotid enlargement, from recurrent stimulation and inflammation. These findings are characteristic historical complications that a nurse would specifically screen for when assessing bulimia. In contrast, the alternative options list complications that are not typical hallmark consequences of bulimia’s purge behaviors or are physiologically mismatched to the expected acid-base effects.

Question 40

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: Early findings can include irritability, hyperactivity, decreased attention span, and sleep disturbance, making sleep difficulty a likely assessment finding. Respiratory findings like wheezing are not characteristic of lead exposure and point more toward asthma or infection. Peripheral neuropathy (numbness/tingling) is more typical of chronic, higher-level exposure and is less common as a presenting complaint in young children.

Question 41

The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure?

Accepted Answer

Answer reason: " In young children, seizures are commonly triggered by acute infections through fever (febrile seizure) or, less commonly, by intracranial spread such as meningitis. A recent ear infection points to an acute infectious process that can raise body temperature and lower the seizure threshold, making it a key clue to likely cause. This history also prompts urgent assessment for red flags (persistent altered mental status, neck stiffness, bulging fontanel, toxic appearance) that would change management. By contrast, increased naps or dietary changes are nonspecific and do not strongly link to an acute seizure trigger compared with an intercurrent infection.

Question 42

The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to?

Accepted Answer

Answer reason: Limiting visitors reduces environmental stimulation (noise, conversation, emotional stress) that can provoke agitation and BP surges. The other options either increase stimulation by permitting visits, position the client in a way that can raise intra-abdominal/intrathoracic pressure and impair venous return, or add unnecessary warming that may raise metabolic demand and BP. Nursing care should emphasize quiet environment, minimal stimulation, and prevention of avoidable BP spikes to reduce rupture risk.

Question 43

Which statements by the client would indicate to the nurse an understanding of the issues with end stage renal disease?

Accepted Answer

Answer reason: End-stage renal disease reduces erythropoietin production, leading to normocytic anemia that is commonly treated with epoetin alfa to improve hemoglobin and reduce transfusion needs. This statement reflects accurate understanding of a key chronic complication and its ongoing outpatient management. In contrast, ESRD more often causes anemia (not excess RBCs/“thick blood”), making the clot-from-too-many-RBCs claim incorrect. ESRD also predisposes to renal osteodystrophy with hypocalcemia and bone demineralization rather than stronger bones with higher calcium.

Question 44

The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?

Accepted Answer

Answer reason: Rheumatic fever is a delayed, immune-mediated inflammatory complication that can follow untreated or inadequately treated group A streptococcal pharyngitis. A recent history of strep throat (typically within the prior few weeks) is the key association that supports suspicion for this diagnosis. Viral illnesses like chickenpox and superficial fungal infections do not trigger the classic autoimmune cross-reactivity responsible for rheumatic carditis and other manifestations. Otitis media is usually not caused by group A streptococcus and is not the characteristic antecedent infection for rheumatic fever.

Question 45

A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect in assessing this client?

Accepted Answer

Answer reason: Passive flexion of the neck can trigger involuntary flexion of the hips and knees (Brudzinski sign), which is a typical assessment finding. This response helps differentiate meningeal irritation from nonspecific headache or fever alone. Options mentioning rebound tenderness point toward abdominal peritoneal irritation rather than a CNS infection. Neck findings described with shoulder movement are not the standard provocative maneuver associated with meningitis screening.

Question 46

The nurse is taking care of a child who presents with intermittent abdominal pain and vomiting. The nurse suspects possible intussusception. The nurse would expect the stool to appear as which of the following?

Accepted Answer

Answer reason: This injury produces the classic “currant jelly” stool from a mixture of mucus and blood. The child’s intermittent, colicky abdominal pain and vomiting fit the intermittent obstruction pattern as the bowel invaginates and relaxes. Watery stool is more consistent with infectious gastroenteritis, while ribbon-like stool suggests distal obstruction or anal/rectal narrowing rather than vascular congestion and mucosal bleeding.

Question 47

The nurse assesses a client suspected of having shingles. Which lesion pattern does the nurse expect to observe?

Accepted Answer

Answer reason: This leads to grouped vesicular lesions on an erythematous base in a unilateral, band-like pattern that follows one dermatome and typically does not cross the midline. This characteristic distribution is the key bedside clue distinguishing shingles from more diffuse rashes. Serpiginous patterns are more typical of migrating/creeping eruptions (e.g., cutaneous larva migrans) rather than a nerve-root distribution. Recognizing the pattern supports timely isolation precautions and antiviral treatment to reduce complications such as postherpetic neuralgia.

Question 48

The nurse is conducting a teaching session with the parents of a child newly diagnosed with asthma. The priority topic for the nurse to cover is?

Accepted Answer

Answer reason: Recognizing early and worsening respiratory distress is the highest priority because timely action prevents hypoxemia and respiratory failure. Parents must know key warning signs (e.g., increasing wheeze/cough, chest tightness, retractions, trouble speaking, decreased activity, poor response to rescue medication) to seek urgent care promptly. Skill-based monitoring (peak flow) is helpful but is secondary to being able to identify a potentially life-threatening exacerbation even without equipment. Immunizations and community resources support long-term health but do not address immediate safety during an acute attack.

Question 49

The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy?

Accepted Answer

Answer reason: Ectopic pregnancy typically presents with unilateral lower abdominal/pelvic pain due to tubal distention or rupture, often accompanied by vaginal bleeding and signs of intraperitoneal irritation. A sudden, sharp/stabbing lower-quadrant pain is classic for acute worsening and can indicate rupture with intra-abdominal bleeding, making it the most concerning and characteristic symptom listed. Painless vaginal bleeding is more consistent with placenta previa later in pregnancy rather than an early ectopic process. Upper-quadrant throbbing pain is not the typical pain location for an unruptured or ruptured tubal implantation.

Question 50

An infant is being prepared for surgical repair of a ventricular septal defect (VSD). Which of the following problems will be prevented by closing the defect?

Accepted Answer

Answer reason: The resulting tachypnea and increased work of breathing raise caloric expenditure, while fatigue during feeds reduces caloric intake, leading to poor weight gain. Surgical closure removes the shunt, reducing pulmonary overcirculation and heart failure burden, which directly improves feeding tolerance and growth. By contrast, conduction disturbances are more often related to surgical proximity to the conduction system rather than being a baseline VSD problem prevented by closure, and respiratory alkalosis is not a typical primary VSD complication.

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