Question 1

During the assessment of a child with pulmonic stenosis, the nurse would anticipate observing which of the following?

Accepted Answer

Answer reason: This classically results in a crescendo-decrescendo systolic ejection murmur, often best heard at the left upper sternal border and may be associated with an ejection click. A normal respiratory rate is not a defining expected finding in a hemodynamically significant outflow obstruction, and respiratory symptoms can occur with more severe disease. Delayed capillary refill suggests systemic hypoperfusion/shock, which is not the typical primary presentation of isolated pulmonic stenosis, and hyperactivity is nonspecific.

Question 2

A nurse is assessing a toddler with hypothyroidism. During the assessment, the nurse is most concerned when the toddler presents with which finding?

Accepted Answer

Answer reason: In a toddler, signs suggesting significant developmental impact indicate the highest-stakes complication because it reflects prolonged, clinically consequential hormone deficiency. Other findings like anemia or musculoskeletal changes can occur with hypothyroidism but are generally less urgent and more reversible with treatment. Cyanosis is not a typical hypothyroidism manifestation and suggests an alternate acute cardiopulmonary issue rather than the expected endocrine complication profile.

Question 3

The nurse has just admitted a client with sickle cell crisis. What is the priority intervention by the nurse?

Accepted Answer

Answer reason: Immediate priority nursing care is to improve perfusion by aggressive hydration (often IV) and to treat pain promptly with appropriate analgesia, helping reduce further sickling and stress-related oxygen demand. Blood transfusion is reserved for specific severe complications (e.g., acute chest syndrome, stroke, severe anemia) rather than being the universal first step on admission. Antibiotics are indicated only when infection is suspected/confirmed, and splenectomy is not an acute priority intervention for a pain crisis.

Question 4

The client is diagnosed with pericarditis. Which signs/symptoms should the nurse expect in this client?

Accepted Answer

Answer reason: Pericarditis is inflammation of the pericardial layers, producing sharp, persistent pleuritic chest pain and a characteristic pericardial friction rub from the inflamed surfaces rubbing together. The pain classically worsens with inspiration and when lying flat and improves when sitting up/leaning forward, making it more continuous than exertional ischemic pain. Pulsus paradoxus is more suggestive of significant pericardial effusion/tamponade (a complication), not an expected routine presentation. Fatigue and arthralgias can occur with systemic inflammatory illnesses but are nonspecific and do not best represent the hallmark findings of acute pericarditis.

Question 5

The nurse is admitting a client diagnosed with a mitral valve murmur. Which information supports this finding?

Accepted Answer

Answer reason: Rheumatic fever can cause chronic valvular damage from an autoimmune inflammatory response after streptococcal infection, and the mitral valve is most commonly affected. Resulting scarring and leaflet thickening lead to turbulent blood flow, producing a murmur consistent with mitral valve disease (e.g., stenosis or regurgitation). Daily oral anticoagulation may be used for atrial fibrillation or prosthetic valves but does not by itself explain why a murmur is present. Elevated troponin supports myocardial injury/acute coronary syndrome rather than a valvular murmur etiology.

Question 6

The nurse is providing education for a client with Cushing’s disease. Which of the following information would be important to include?

Accepted Answer

Answer reason: Cushing’s disease causes chronic excess cortisol, leading to characteristic body changes (e.g., truncal obesity, moon face, buffalo hump, skin fragility, bruising, and muscle weakness). Patient teaching should normalize these findings as manifestations of the endocrine disorder, which supports understanding, adherence, and coping. Teaching about diet in Cushing’s typically emphasizes sodium restriction (to reduce edema/HTN) and adequate protein (to counteract catabolism), making the sodium and protein options unsafe or inaccurate. Encouraging high fluids is not a core teaching point and can be inappropriate if fluid retention and hypertension are present.

Question 7

A 55-year-old client is admitted with hyperthyroidism. What is the most important nursing intervention?

Accepted Answer

Answer reason: Minimizing stimulation and promoting rest reduces sympathetic activation, helps control cardiovascular strain, and supports recovery while medical therapy is initiated. Keeping the client warm is inappropriate because these clients are typically heat intolerant and prone to hyperthermia. Encouraging increased activity would further increase metabolic demand and exacerbate tachycardia and fatigue.

Question 8

A client is diagnosed with atopic dermatitis. He is upset and asks how to avoid another outbreak. The nurse determines that the client needs information regarding?

Accepted Answer

Answer reason: Atopic dermatitis is a chronic inflammatory skin disorder with strong genetic/atopic predisposition, and recurrence reflects underlying immune-barrier dysfunction rather than acquisition of a specific infection. Teaching that helps the client understand inherited susceptibility (often associated with family history of eczema, asthma, or allergic rhinitis) addresses why flares recur and sets realistic expectations about long-term management. While secondary infection can complicate lesions, it is typically a consequence of skin breakdown and scratching, not the primary driver of new outbreaks. Therefore, focusing education on hereditary predisposition is the most accurate basis for preventing and managing future flares through trigger control and skin-care routines.

Question 9

The nurse is implementing interventions for the client who has increased ICP. The nurse knows that which result will occur if the increased ICP is left untreated?

Accepted Answer

Answer reason: As pressure gradients form between compartments, brain tissue shifts across rigid dural folds or through the foramen magnum, leading to rapid neurologic deterioration and possible death. Increased ICP does not improve cerebral perfusion; it typically lowers cerebral perfusion pressure (CPP = MAP − ICP) and worsens ischemia. CSF leakage and serum pH changes are not the expected direct outcome of untreated increased ICP compared with the life-threatening risk of herniation.

Question 10

The nurse is teaching a client about angina. Which statement by the nurse would be most accurate regarding the primary treatment goal?

Accepted Answer

Answer reason: Therapies such as rest, nitrates, beta-blockers, and oxygen (when indicated) work by decreasing myocardial oxygen demand and/or improving coronary blood flow, directly addressing ischemia. Infarction implies irreversible myocardial cell death, which is not the defining process in angina and therefore is not the primary goal. Risk-factor modification and anxiety reduction are important long-term adjuncts but do not represent the primary acute treatment target.

Question 11

Which response should a nurse offer to a client who asks why he’s having a vagotomy to treat his ulcer?

Accepted Answer

Answer reason: This directly addresses peptic ulcer pathophysiology where excess acid and impaired mucosal defenses contribute to ulcer formation. Repairing a hole describes treatment for a perforated ulcer, not the purpose of vagotomy as an ulcer-reducing procedure. Preventing stomach herniation into the chest relates to hiatal hernia management, and removing a malignant lesion is an oncologic resection rather than an acid-reducing operation.

Question 12

A 36-year-old client complains of fatigue, weight loss, and a low-grade fever. He also has pain in his fingers, elbows, and ankles. The nurse identifies these symptoms as indicative of?

Accepted Answer

Answer reason: A key principle is that systemic autoimmune disease commonly causes constitutional symptoms (fatigue, weight loss, low-grade fever) together with inflammatory, migratory polyarthralgias affecting small and large joints. This symptom cluster fits SLE, which often presents with joint pain/swelling plus chronic systemic inflammation even before more specific findings (rash, renal or hematologic abnormalities) are recognized. Anemia can explain fatigue but does not account for multi-joint inflammatory pain and fever as a primary syndrome. Leukemia can cause fever and fatigue, but prominent symmetric peripheral joint pain is more characteristic of an autoimmune connective-tissue disorder like SLE.

Question 13

A nurse is working on a medical/surgical unit and notes that one of the client’s assigned has a diagnosis of ankylosing spondylitis. The nurse would assess this client for?

Accepted Answer

Answer reason: Clients commonly report insidious onset low back pain with morning stiffness that improves with activity rather than rest. This presentation is more characteristic than peripheral joint erythema/swelling, which is more typical of acute inflammatory arthritis affecting appendicular joints. Cervical involvement can occur later, but early disease classically centers on the low back and sacroiliac region.

Question 14

The nurse is explaining the process of acute respiratory distress syndrome (ARDS) to a client. What is the best explanation for the nurse to tell the client?

Accepted Answer

Answer reason: ARDS is driven by diffuse inflammatory injury to the alveolar-capillary membrane, increasing permeability and causing noncardiogenic pulmonary edema. Protein-rich fluid and inflammatory debris enter the alveoli, decreasing lung compliance and creating shunt physiology with severe hypoxemia. This directly explains why gas exchange worsens despite oxygen therapy in many cases. Options describing overexpansion or improved gas exchange contradict the hallmark mechanism, and increased perfusion is not the defining problem compared with alveolar flooding and impaired diffusion/ventilation.

Question 15

A client with a fat embolism continues to be hypoxic following therapy with positive end-expiratory pressure. What is the priority intervention to reduce oxygen demand?

Accepted Answer

Answer reason: In refractory hypoxemia despite PEEP, a major driver of worsening oxygenation is high metabolic and ventilatory demand from agitation, dyssynchrony, and excessive work of breathing. Neuromuscular blockade can temporarily eliminate respiratory muscle activity, improve ventilator synchrony, and decrease whole-body oxygen consumption, allowing delivered oxygen to better meet demand while lung injury is managed. Diuretics do not directly lower oxygen demand and are not a primary therapy for fat embolism–related hypoxemia unless fluid overload is present. Bronchodilators target bronchospasm, which is not the key mechanism in fat embolism syndrome, and flattening the bed can worsen ventilation and oxygenation.

Question 16

The nurse is conducting a preoperative class for clients scheduled for gastric bypass surgery. One of the clients asks the nurse what the most common source of pulmonary embolism is. The most appropriate response by the nurse is?

Accepted Answer

Answer reason: Pulmonary emboli most commonly arise from thrombi that form in the deep veins (especially of the legs/pelvis) and then embolize to the pulmonary arterial circulation. Bariatric surgery patients are at increased VTE risk due to obesity, perioperative immobility, and the hypercoagulable state associated with major surgery, making DVT the key source to recognize. Amniotic fluid and fat/bone marrow emboli can cause acute pulmonary compromise but are uncommon and occur in specific settings (obstetric catastrophe or long-bone trauma). Septic emboli occur with infected thrombi/endocarditis but are not the most common overall source of PE.

Question 17

The nurse is caring for a client who is in the latter stages of Reye’s syndrome. What is the most important intervention by the nurse to prevent or reduce cerebral edema?

Accepted Answer

Answer reason: Deep sedation with neuromuscular blockade limits agitation, coughing, shivering, and ventilator dyssynchrony, all of which increase intrathoracic pressure and can impair venous drainage from the brain. This strategy also helps maintain controlled ventilation and oxygenation, reducing secondary brain injury. In contrast, liberal fluid replacement can worsen cerebral edema by increasing total body water and capillary hydrostatic pressure, and leaving ventilation nonassisted risks hypoventilation and hypercapnia, which promotes cerebral vasodilation and increases ICP.

Question 18

The nurse is providing postoperative care to a client with sickle cell anemia. What is the most important intervention for the nurse to include in the plan of care?

Accepted Answer

Answer reason: Postoperatively, maintaining adequate hydration helps reduce sickling risk and supports tissue perfusion, lowering the chance of pain crisis and acute chest syndrome. Encouraging coughing is typically important after surgery to prevent atelectasis and pneumonia; discouraging it would increase pulmonary complications. Adequate analgesia is essential because uncontrolled pain triggers stress and hypoventilation, both of which can precipitate sickling-related complications.

Question 19

Which intervention is indicated for a child in sickle cell vaso-occlusive crisis?

Accepted Answer

Answer reason: Local heat promotes vasodilation and can help increase blood flow to the painful area while providing comfort. Cold causes vasoconstriction, which can worsen ischemia and intensify pain in this setting. During acute crisis, aggressive activity like active ROM can exacerbate pain; comfort measures and supportive therapies are prioritized.

Question 20

The nurse is performing a physical assessment on a client. The nurse asks the client to flex the neck. The neck flexion results in flexion of the hip and knee which is known as Brudzinski’s sign. Which condition is associated with Brudzinski’s sign?

Accepted Answer

Answer reason: Brudzinski’s sign reflects meningeal irritation from inflammation of the meninges, producing involuntary hip and knee flexion with passive neck flexion to reduce stretch on inflamed tissues. This finding is classically associated with acute meningitis (bacterial or viral) and is assessed alongside other meningeal signs and symptoms such as nuchal rigidity, headache, fever, and photophobia. Infections limited to the upper airway (pharyngitis, rhinosinusitis) or peritonsillar space typically cause sore throat and localized ENT findings rather than reflex posturing with neck flexion. Therefore the condition most directly linked to this neurologic exam sign is meningitis.

Question 21

A client is admitted to the medical floor with a diagnosis of pancreatitis. Which of the following nursing interventions is the priority?

Accepted Answer

Answer reason: Acute pancreatitis causes pancreatic inflammation and severe abdominal pain, and pancreatic stimulation worsens enzyme activation and tissue injury. Keeping the client NPO provides “pancreatic rest,” reducing exocrine secretion and helping limit progression of inflammation while other therapies (IV fluids, antiemetics) are started. Adequate analgesia is a priority because uncontrolled pain increases sympathetic stress, can impair ventilation, and worsens overall physiologic instability. A key distractor is encouraging oral intake, which increases pancreatic stimulation and is inappropriate early in acute pancreatitis; routine surgical management is not the initial priority unless complications mandate it.

Question 22

A nurse is teaching a client about atherosclerosis. The nurse determines further teaching is necessary when the client makes which of the following statements?

Accepted Answer

Answer reason: Atherosclerosis is a disease of arteries characterized by lipid-rich plaque formation within the arterial intima, leading to luminal narrowing and reduced tissue perfusion. Describing plaque obstruction as occurring in veins reflects confusion with venous disorders (e.g., thrombosis), not atherosclerotic plaque. The other statements align with arterial plaque reducing coronary blood flow, limiting vasodilation/elasticity, and producing myocardial ischemia manifested as angina. Therefore, the vein statement indicates misunderstanding and a need for further teaching.

Question 23

A client is admitted to the unit with intermittent claudication. Which of the following responses by the nurse would most accurately explain the cause of the condition to the client?

Accepted Answer

Answer reason: Peripheral arterial disease limits perfusion, so working muscles switch to anaerobic metabolism, producing pain/cramping that improves with rest as demand falls. This mechanism is best described as reduced oxygen delivery to the muscle tissue rather than a positioning problem. “Elevated” or “dependent” leg positions may change symptoms transiently, but they are not the underlying cause of the condition.

Question 24

A client was infected with tuberculosis (TB) bacillus 10 years ago but never developed the disease. He’s now being treated for cancer. The client begins to develop signs of TB. The nurse suspects the client is exhibiting?

Accepted Answer

Answer reason: Immunosuppression (e.g., from cancer therapy) can allow reactivation of previously contained TB organisms, converting an asymptomatic state into symptomatic disease. The key clue is that the client is now developing signs of TB, which indicates active disease rather than mere infection without symptoms. Latent TB implies no clinical manifestations and non-contagious status, whereas reactivation produces symptomatic illness and potential infectiousness. “Superinfection” and “tertiary infection” are not appropriate descriptors for TB reactivation in this context.

Question 25

A firefighter is being treated for smoke inhalation. He develops severe hypoxia 48 hours later, requiring intubation and mechanical ventilation. The nurse determines that the client is experiencing?

Accepted Answer

Answer reason: Smoke inhalation can trigger a delayed inflammatory lung injury with increased alveolar-capillary permeability, leading to noncardiogenic pulmonary edema and profound refractory hypoxemia. The 24–48 hour time course with rapid deterioration requiring intubation and mechanical ventilation is classic for this syndrome. This process causes diffuse alveolar collapse and shunt physiology, so oxygenation becomes difficult despite supplemental oxygen. Atelectasis can worsen oxygenation but is usually more focal and often improves with lung expansion maneuvers rather than progressing to severe ventilatory failure, and bronchitis is unlikely to cause such profound hypoxia so quickly without other signs.

Question 26

A client has been diagnosed with a pulmonary embolism and begins to experience chest pain. The client asks the nurse what is causing the pain. The most appropriate response by the nurse is?

Accepted Answer

Answer reason: Pleuritic chest pain with a pulmonary embolism is typically caused by pulmonary infarction and irritation of the pleura, which triggers an acute inflammatory response. This inflammation stimulates pain fibers in the pleural surfaces, producing sharp pain that often worsens with deep inspiration or coughing. An MI can also cause chest pain, but it is a separate cardiac ischemic process and does not explain PE-related pleural irritation as the primary mechanism. Costochondritis is musculoskeletal chest wall inflammation and is not the expected cause in the setting of an acute embolic event.

Question 27

A client with a pulmonary embolism tells the nurse that he feels a sense of “impending doom.” The nurse recognizes that this manifestation is caused by what?

Accepted Answer

Answer reason: Acute hypoxemia and the resulting sympathetic surge (tachycardia, anxiety, catecholamine release) commonly produce the subjective sensation of intense anxiety or “impending doom.” This finding reflects an immediate physiologic threat from impaired oxygen delivery rather than structural loss of lung tissue. Inflammation of the parenchyma is more characteristic of pneumonia and does not typically cause this sudden, dramatic symptom onset.

Question 28

A nurse is observing an infant with thyroid hormone deficiency. Which signs would the nurse commonly observe?

Accepted Answer

Answer reason: Reduced energy and poor neuromuscular tone also contribute to weak feeding and overall lethargy. In contrast, tachycardia, sweating, and diarrhea are classic hyperthyroid findings due to increased metabolic activity. The key nursing cue is the cluster of “slowed” physiologic functions consistent with hypothyroidism.

Question 29

During an initial nursing assessment, a nurse determines that an 8-year-old child has right lower quadrant pain, a low-grade fever, nausea, rebound tenderness, and a positive psoas sign. The nurse suspects that the client has which condition?

Accepted Answer

Answer reason: A positive psoas sign supports appendiceal inflammation, especially when the appendix is retrocecal and irritates the iliopsoas muscle during hip movement. Nausea commonly accompanies the evolving inflammatory process. In contrast, gastroenteritis typically causes diffuse crampy abdominal pain with prominent diarrhea rather than focal RLQ tenderness and peritoneal signs.

Question 30

The nurse is caring for a client in stage V of Reye’s syndrome. The nurse documents which assessment data?

Accepted Answer

Answer reason: This produces profound neurologic deterioration with seizures progressing to decorticate/decerebrate changes, loss of motor tone (flaccidity), and ultimately apnea/respiratory arrest. Earlier stages are characterized by vomiting/lethargy (stage I), irritability or disorientation (stages II–III), and coma with abnormal respirations such as hyperventilation (stage IV). Therefore, the findings reflecting terminal neurologic and respiratory collapse best match stage V.

Question 31

Which clinical manifestation would the nurse assess in the client with a T-12 spinal cord injury (SCI) who is experiencing spinal shock?

Accepted Answer

Answer reason: Spinal shock is the acute phase after a spinal cord injury characterized by transient loss of all neurologic activity below the level of injury, including areflexia and flaccid motor tone. With a T12 SCI, findings would primarily involve the lower extremities, producing flaccid paralysis below the lesion early on. Spasticity is typical later, after spinal shock resolves and upper motor neuron signs emerge. Headache with hypertension and bradycardia suggests autonomic dysreflexia, which is usually associated with injuries at or above T6 rather than T12 and is not the defining presentation of spinal shock.

Question 32

The nurse is caring for a client with an opportunistic infection of the central nervous system. The nurse knows that opportunistic infections affecting the central nervous system are extremely likely once the CD4 count drops below which level?

Accepted Answer

Answer reason: Opportunistic CNS infections in advanced HIV/AIDS correlate with profound cellular immunosuppression, and the risk rises sharply as CD4 counts fall to very low levels. Many severe opportunistic pathogens (e.g., CMV disease and some CNS presentations) are most strongly associated with CD4 counts below 50 cells/mm3, reflecting minimal T-cell–mediated defense. By contrast, a CD4 threshold of 200 cells/mm3 is classically tied to risks like Pneumocystis jirovecii pneumonia rather than being the point at which CNS opportunistic infections are “extremely likely.” Therefore, the lowest CD4 threshold offered best matches the level at which these infections become highly probable and clinically expected.

Question 33

A nurse is caring for a client recently diagnosed with acute pancreatitis. Which statement indicates that a short-term goal of nursing care has been met?

Accepted Answer

Answer reason: Acute pancreatitis commonly causes significant epigastric/upper abdominal pain, and a primary short-term nursing goal is relief of pain and improved comfort. A client report of no abdominal pain directly reflects effective management of the acute inflammatory process and/or analgesic and supportive interventions. Absence of thirst is not a reliable pancreatitis outcome indicator because thirst can be influenced by many factors and pancreatitis can involve fluid shifts and dehydration. Lack of pain at McBurney’s point is more consistent with ruling out appendicitis, and swallowing liquids without coughing relates to aspiration risk rather than pancreatitis goals.

Question 34

An adolescent client ingests a large number of acetaminophen (Tylenol) tablets in an attempt to commit suicide. Which laboratory result is most consistent with acetaminophen overdose?

Accepted Answer

Answer reason: This injury classically produces rising aminotransferases (AST/ALT), often within 24–72 hours, and is a key lab indicator of toxicity severity. Metabolic acidosis can occur in massive overdose or late hepatic failure but is not the most typical early hallmark compared with transaminitis. Creatinine may rise if renal injury occurs, and WBC elevation is nonspecific and not characteristic of this toxidrome.

Question 35

The nurse is admitting a new client with a diagnosis of myxedema. During the initial assessment, the nurse is most concerned when the client presents with which findings?

Accepted Answer

Answer reason: A low heart rate signals reduced cardiac output and risk for hypotension, hypothermia, and progression toward myxedema coma, making it a high-priority assessment finding. Cognitive slowing/mental status changes also indicate significant CNS depression and can be an early warning of decompensation. In contrast, heat intolerance, emotional lability, weight loss, and increased appetite are more consistent with hyperthyroidism rather than myxedema.

Question 36

The nurse is reviewing the diagnoses of her assigned clients and notes that one of the clients has Cushing’s syndrome. The nurse is aware that this client is at risk for which of the following?

Accepted Answer

Answer reason: This volume expansion raises blood pressure and increases cardiac workload, predisposing to fluid overload and congestive heart failure. Cortisol also increases vascular sensitivity to catecholamines, further contributing to hypertension. In contrast, hypotension and hyponatremia are more consistent with adrenal insufficiency rather than cortisol excess.

Question 37

A client is in diabetic ketoacidosis, secondary to infection. As the condition progresses, which symptoms might the nurse see?

Accepted Answer

Answer reason: The body compensates by increasing depth and rate of breathing (Kussmaul respirations) to blow off CO2 and raise pH. Volatile ketones (especially acetone) produce a characteristic fruity breath odor as ketosis worsens. Choices describing decreased/shallow respirations conflict with the expected respiratory compensation, and Cheyne-Stokes is more associated with severe neurologic/cardiac instability rather than typical DKA progression.

Question 38

The nurse is caring for the client with elevated growth hormone (GH) levels. Which problem should the nurse exclude from the plan of care?

Accepted Answer

Answer reason: Therefore, a body-image problem would be related to enlarged, not undersized, features, making this option inconsistent with the condition and appropriate to exclude. Elevated GH can also contribute to glucose intolerance and diaphoresis, and mass effects can contribute to complications that affect sleep and communication. A common distractor is focusing on “hands/feet/jaw” while missing that the direction of change is opposite of what occurs with GH excess.

Question 39

The client is admitted with a diagnosis of colon cancer. Which finding in the client’s admission information should prompt the nurse to consider that the cancer may be located in the client’s descending colon?

Accepted Answer

Answer reason: This “obstructive” pattern is a classic localization clue for distal colon cancer compared with right-sided lesions, which more often cause occult bleeding and iron-deficiency anemia. Bright red blood can occur with distal sources but is less specific because hemorrhoids and rectal lesions also cause it. Nausea and vomiting are more consistent with more advanced obstruction and are not a key early localization finding.

Question 40

A client is admitted with right lower quadrant pain, anorexia, nausea, lowgrade fever, and elevated white blood cell count. Based on these assessments, which of the following complications is the client most likely experiencing?

Accepted Answer

Answer reason: The most common initiating mechanism is luminal obstruction of the appendix, classically by a fecalith, which leads to bacterial overgrowth, inflammation, and localized peritoneal irritation. This mechanism fits the systemic inflammatory findings (fever, elevated WBC) better than mechanical problems like postoperative kinking. General bowel occlusion would more typically present with diffuse cramping, vomiting, distention, and obstipation rather than localized RLQ tenderness and inflammatory signs.

Question 41

A client with chronic gastritis asks why they need to have injections of vitamin B12. Which response by the nurse is most appropriate?

Accepted Answer

Answer reason:  Chronic gastritis can damage gastric parietal cells and reduce intrinsic factor production, which is required for vitamin B12 absorption in the terminal ileum. When absorption is impaired, oral replacement may be ineffective, so parenteral administration bypasses the GI tract. This teaching directly explains the mechanism and the reason injections are needed. The low energy statement is nonspecific and symptom-focused, and the WBC statement is not the typical deficiency effect (B12 deficiency primarily causes macrocytic anemia and possible neurologic changes).

Question 42

A client complains of low back pain that radiates down the right leg, with numbness and weakness of the right leg. Based on the subjective data, the nurse recognizes these complaints as related to which disorder?

Accepted Answer

Answer reason: A herniated intervertebral disc can protrude and compress a spinal nerve root, producing dermatomal pain and neurologic deficits such as sensory loss and decreased strength. Osteoarthritis more often causes localized joint/back pain and stiffness without a sharp radicular pattern with focal neurologic findings. Muscular dystrophy and Parkinson’s disease cause progressive generalized motor issues rather than acute unilateral radicular pain with sensory symptoms.

Question 43

A client with a T1 spinal cord injury arrives at the emergency department with a blood pressure of 82/40 mm Hg, pulse of 34 beats/minute, dry skin, and flaccid paralysis of the lower extremities. Which condition should be suspected?

Accepted Answer

Answer reason: This produces hypotension with marked bradycardia and often warm/dry skin from impaired sympathetic-mediated sweating and vasoconstriction. The presentation fits neurogenic shock rather than autonomic dysreflexia, which classically causes severe hypertension with reflex bradycardia. Sepsis typically causes tachycardia and signs of infection, and hypervolemia would not explain profound bradycardia with distributive hypotension after spinal cord injury.

Question 44

After a motor vehicle collision, a client has a chest tube inserted in the left upper chest. The tube begins to drain a large amount of dark red fluid. The nurse determines that?

Accepted Answer

Answer reason: Large-volume, dark red drainage from a chest tube after blunt chest trauma most strongly indicates blood accumulating in the pleural space. A chest tube placed for traumatic chest injury can evacuate air or blood; when the output is frank/bloody and substantial, hemothorax is the most direct, clinically meaningful interpretation. This finding is not an expected baseline outcome because excessive sanguineous output signals ongoing intrathoracic bleeding requiring prompt assessment and potential escalation. While a vessel injury from insertion is possible, trauma-related pleural bleeding is the more likely and testable determination based on the presentation.

Question 45

A client who is scheduled for a pneumonectomy asks the nurse how thoracic cavity will be filled. The best response by the nurse would be?

Accepted Answer

Answer reason: After removal of an entire lung, the empty hemithorax does not stay as an air-filled void because the postpneumonectomy space gradually accumulates sterile serous fluid. This progressive fluid fill and mediastinal shift stabilize intrathoracic pressures and helps prevent excessive dead space over time. Leaving the space “filled with air only” would imply a persistent large pneumothorax-like cavity, which is not the expected longer-term physiologic course. The remaining lung compensates mainly by hyperinflation and improved function rather than physically growing across to replace the removed lung.

Question 46

The nurse assesses the client in her third trimester with suspected placenta previa. Which findings should the nurse associate with placenta previa?

Accepted Answer

Answer reason: The classic presentation is sudden, bright red bleeding without uterine tenderness or pain because the bleeding is not caused by abruption-related myometrial irritation. A transverse or abnormal lie can be associated with placenta previa, but it is less specific than the hallmark bleeding and may be seen in other conditions. Cervical effacement and absent fetal movement are not defining findings for placenta previa and would prompt evaluation for labor progression or fetal compromise rather than being characteristic features.

Question 47

The nurse is caring for a postoperative client who has undergone removal of the pituitary gland and tumor (hypophysectomy). The nurse is aware that the client may be at risk for?

Accepted Answer

Answer reason: Removal or trauma to the pituitary can reduce antidiuretic hormone (ADH) secretion, placing the client at risk for central diabetes insipidus. With inadequate ADH, the kidneys cannot concentrate urine, leading to polyuria with very dilute urine and a low urine specific gravity. Ongoing free-water losses also increase risk for dehydration and rising serum osmolality (often hypernatremia), but the key urine finding is dilute output. Options describing concentrated urine or high specific gravity are inconsistent with the expected post-hypophysectomy ADH deficiency pattern.

Question 48

The nurse is caring for a client who has experienced a cerebral vascular accident. The client is displaying oliguria and hyponatremia. The nurse suspects which of the following disorders?

Accepted Answer

Answer reason: The retained free water expands intravascular volume and reduces urine output, explaining oliguria. In contrast, diabetes insipidus after CNS injury causes impaired ADH effect leading to polyuria and hypernatremia, the opposite pattern. Thyrotoxic crisis presents with hypermetabolic findings (fever, tachycardia) rather than dilutional hyponatremia with low urine output, and primary adrenal insufficiency typically causes hypotension and hyperkalemia with volume depletion.

Question 49

A 20-year-old client developed osteomyelitis 2 weeks after a fishhook was removed from the client’s foot. Which rationale best explains the expected long-term antibiotic therapy needed?

Accepted Answer

Answer reason: Osteomyelitis often requires prolonged antibiotics because infected bone is relatively poorly perfused compared with soft tissue, limiting immune cell access and reducing antibiotic delivery to the site. Necrotic bone and sequestra can further isolate bacteria, making eradication slow and increasing relapse risk if treatment is too short. Therefore, extended therapy is needed to maintain adequate tissue drug levels over time to penetrate the infected bone and suppress residual organisms. In contrast, contamination from a fishhook may explain how infection started, but it does not by itself account for the long duration of therapy once infection is established in bone.

Question 50

A client with chronic obstructive bronchitis asks the nurse why he is receiving diuretic therapy. What is the best response by the nurse?

Accepted Answer

Answer reason: Diuretics are used to decrease intravascular volume and edema, which can reduce pulmonary vascular congestion and the work of breathing in clients who develop cor pulmonale or fluid overload with chronic bronchitis. Lower circulating volume decreases right-sided heart strain and can lessen peripheral and pulmonary fluid accumulation that worsens gas exchange. This leads to improved ventilation/perfusion matching and easier respiratory mechanics. By contrast, sputum production is primarily related to airway inflammation and mucus hypersecretion, not total body fluid volume, so volume reduction is not the direct mechanism for that outcome.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Pathophysiology NCLEX Practice Test

Continue Learning