Question 1

Which of the following is an early symptom of increased intracranial pressure (ICP)?

Accepted Answer

Answer reason: This can appear relatively early compared with late neurologic signs that reflect brainstem compression or herniation. Abnormal posturing and fixed, dilated pupils are typically ominous late findings associated with significant brainstem involvement. Elevated blood pressure can occur as part of Cushing response (with bradycardia and irregular respirations), which is also generally a later sign of severe ICP elevation.

Question 2

A nurse is performing a physical assessment on a client suspected of having acute pancreatitis. Which of the following findings would be anticipated when performing an abdominal assessment?

Accepted Answer

Answer reason: Periumbilical discoloration (Cullen sign) is a classic abdominal assessment finding associated with severe/hemorrhagic pancreatitis and indicates significant retroperitoneal/intraperitoneal bleeding risk. In contrast, bowel sounds are more often decreased (ileus) rather than hyperactive in acute pancreatitis. Sharp RUQ pain with inspiration is more consistent with acute cholecystitis (Murphy sign) rather than pancreatitis.

Question 3

The parents of a 2-year-old with Hirschsprung's disease are speaking with the nurse in the family clinic when they ask the nurse about treatment options for the disease. Which of the following does the nurse understand is the treatment of choice for Hirschsprung's disease?

Accepted Answer

Answer reason: This directly addresses the underlying congenital absence of enteric ganglion cells, which laxatives cannot correct. A temporary colostomy may be used in some cases as a staged approach or for severe enterocolitis/obstruction, but it is not the definitive treatment of choice. Osmotic agents and stimulant laxatives are supportive measures for constipation and may worsen distention or delay needed surgery in true Hirschsprung disease.

Question 4

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify?

Accepted Answer

Answer reason: This leads to dorsocervical fat pad accumulation along with truncal obesity, moon face, and thin extremities. Menstrual disturbances can occur but are more often oligomenorrhea/amenorrhea rather than heavy bleeding, making that choice less specific. Dependent edema and migraines are not hallmark findings and are less directly linked to the core endocrine pathophysiology being tested.

Question 5

The nurse is caring for a pediatric client presenting with enlarged tonsils, fever, and malaise. Which of the following findings, if present, would support a diagnosis of scarlet fever?

Accepted Answer

Answer reason: This finding is a classic supportive clinical sign and helps distinguish it from uncomplicated pharyngitis. Conjunctivitis is more typical of viral illnesses (e.g., adenovirus), and enlarged parotid glands suggest mumps. A high-pitched crowing cough points to croup (laryngotracheitis), not scarlet fever.

Question 6

Three days ago a patient underwent an invasive surgery with an open wound. The patient is febrile with drop in blood pressure. Laboratory test results shows elevated WBC count. This could be possible presentation of ?

Accepted Answer

Answer reason: The open wound provides a likely portal of entry for pathogens, and the blood pressure drop suggests evolving septic shock physiology (vasodilation/capillary leak). Atelectasis may cause low-grade fever early post-op but does not explain marked leukocytosis with hypotension. Internal hemorrhage typically causes hypotension with tachycardia and falling hemoglobin/hematocrit rather than fever and elevated WBC, and excess fluid volume would more often present with hypertension, edema, and pulmonary congestion.

Question 7

The nurse is teaching a patient who is taking insulin about the signs of diabetic ketoacidosis which include?

Accepted Answer

Answer reason: The body compensates by increasing depth and rate of breathing to blow off CO2, producing the characteristic deep, rapid breathing pattern. This finding is a high-yield, specific sign that points toward significant acidosis rather than uncomplicated hyperglycemia. Dry skin can occur with dehydration but is nonspecific, and excessive hunger is more consistent with hyperglycemia without severe acidosis; hypertension is not expected because volume depletion more commonly leads to hypotension.

Question 8

A nurse is caring for a child who is diagnosed with acute-stage Kawasaki disease. Upon assessing the child, the nurse notes which clinical manifestation of the said disease condition?

Accepted Answer

Answer reason: Bilateral nonpurulent conjunctival injection is a hallmark acute-stage manifestation and helps differentiate it from many viral illnesses. Cyanosis (bluish lips) suggests hypoxemia/cardiopulmonary compromise and is not a typical defining feature of Kawasaki disease. “Moon face” is associated with corticosteroid excess, and cervical nodes in Kawasaki disease are more commonly enlarged rather than shrinking during the acute phase.

Question 9

A patient is admitted to the hospital with suspected pheochromocytoma. The patient exhibits profuse sweating and reports of a headache with the following most recent vital signs: temperature 99.6°F (37.5°C); blood pressure: 200/110 mmHg; heart rate: 110 beats/minute; and respirations: 20 breaths/minute. Which prescription should the nurse anticipate for this patient from the healthcare provider (HCP)?

Accepted Answer

Answer reason: Pheochromocytoma causes episodic catecholamine release leading to severe hypertension with symptoms such as headache, diaphoresis, and tachycardia. With a BP of 200/110 mmHg, the priority is rapid, titratable blood pressure reduction using an IV antihypertensive/vasodilator while the underlying cause is addressed. A nitroglycerin infusion can promptly decrease blood pressure via vasodilation and can be adjusted minute-to-minute in a monitored setting. Epinephrine would worsen the catecholamine excess and hypertension, and furosemide or acetaminophen do not address the immediate hypertensive crisis driving the symptoms.

Question 10

The nurse has attended a staff education program about caring for clients with acute osteomyelitis. Which of the following statements by the nurse would indicate a correct understanding of the teaching?

Accepted Answer

Answer reason: “A significant fever is present with typically greater than 101°F (38.3°C).” Acute osteomyelitis is an acute bacterial infection of bone, so systemic inflammatory signs such as fever and leukocytosis are common. A temperature above about 38.3°C (101°F) is consistent with the significant febrile response often seen in acute cases. IV antibiotic treatment typically lasts weeks (often 4–6 weeks), not just 7–14 days, making that statement inaccurate. Petechiae is not a typical hallmark finding of osteomyelitis; localized pain, warmth, swelling, and decreased movement of the affected area are more characteristic.

Question 11

A nurse is teaching an 8-year-old with diabetes and her parents about managing diabetes during illness. The nurse determines the parents understand the instruction when they indicate that, when the child is ill, they will provide?

Accepted Answer

Answer reason: Illness triggers a stress-hormone response (catecholamines, cortisol, glucagon) that increases hepatic glucose output and causes insulin resistance, raising blood glucose and ketone risk. Sick-day management typically requires continuing basal insulin and often increasing insulin doses based on more frequent glucose/ketone monitoring to prevent DKA. Reducing insulin during illness is unsafe because it promotes lipolysis and ketogenesis even if oral intake is decreased. Nutrition adjustments focus on maintaining hydration and carbohydrate intake as tolerated, not specifically lowering protein and fat as the primary strategy.

Question 12

A 78-year-old with left ventricular hypertrophy has questions regarding his diagnosis. The best explanation the nurse can provide is?

Accepted Answer

Answer reason: “The harder the heart has to work, the thicker the muscle becomes. Unfortunately, that also means it can’t pump as effectively.” Left ventricular hypertrophy is an adaptive response to chronic increased workload (most commonly long-standing hypertension or aortic stenosis) that thickens the ventricular wall. While thicker muscle can generate higher pressures, it reduces ventricular compliance and can impair filling and overall pumping efficiency, contributing to heart failure symptoms over time. This explanation accurately links cause (increased work) to structural change (hypertrophy) and the key functional consequence (reduced effectiveness). Option C focuses on possible manifestations rather than explaining the diagnosis, and option D incorrectly centers the mechanism on oxygen deprivation and tachycardia as the defining process.

Question 13

During a cardiovascular assessment, the nurse notes muffled heart sounds, a paradoxical pulse, and jugular vein distention. What disorder do these signs suggest?

Accepted Answer

Answer reason: This produces Beck’s triad findings including muffled heart sounds and jugular venous distention, and it commonly features pulsus paradoxus due to exaggerated inspiratory drop in systolic blood pressure. The combination of these three assessment findings strongly points to acute hemodynamic compromise from pericardial pressure. Pericarditis more typically presents with sharp pleuritic chest pain and a pericardial friction rub rather than prominent JVD with pulsus paradoxus.

Question 14

A nurse is assessing a patient with aortic stenosis. Which of the following findings should the nurse expect?

Accepted Answer

Answer reason: Aortic stenosis causes fixed obstruction to left ventricular outflow, limiting the ability to increase cardiac output during activity. This leads to exertional dyspnea from elevated left-sided pressures and pulmonary congestion, and syncope from inadequate cerebral perfusion during exertion. Chest pain occurs due to myocardial oxygen supply–demand mismatch from left ventricular hypertrophy and increased wall stress. Bounding pulses with widened pulse pressure is more consistent with aortic regurgitation, while muffled heart sounds with JVD suggests pericardial tamponade/right-sided failure physiology rather than isolated aortic stenosis.

Question 15

Shock due to spinal cord injury is known as...?

Accepted Answer

Answer reason: Neurogenic shock occurs due to loss of sympathetic tone following spinal cord injury, leading to vasodilation, hypotension, and often bradycardia. The other shock types have different underlying mechanisms.

Question 16

High concentration of oxygen administration in premature infants can cause?

Accepted Answer

Answer reason: High oxygen levels in premature infants can damage developing retinal vessels, leading to retinopathy of prematurity (retrolental fibroplasia). This is a classic oxygen-related neonatal complication.

Question 17

Neurogenic shock typically occurs with a spinal injury above what level?

Accepted Answer

Answer reason: Neurogenic shock occurs with injuries above T6 due to loss of sympathetic tone, leading to hypotension and bradycardia.

Question 18

Which term would the nurse use to describe persistently elevated blood pressure with an unknown cause?

Accepted Answer

Answer reason: Primary (essential) hypertension refers to persistently elevated blood pressure with no identifiable underlying cause. It accounts for the majority of hypertension cases. Secondary hypertension, in contrast, has a known cause (e.g., renal disease, endocrine disorders). Accelerated and malignant hypertension describe severe, rapidly progressing forms, not the etiology.

Question 19

A client is undergoing testing for a diagnosis of ulcerative colitis. Which symptom would the nurse most likely identify during this initial diagnosis?

Accepted Answer

Answer reason: Ulcerative colitis is an inflammatory bowel disease characterized by inflammation of the colon mucosa, leading to frequent episodes of diarrhea, often with blood and mucus. Diarrhea is the most common and early symptom. Constipation is not typical, vomiting is less common, and weight loss may occur later but is not usually the initial presenting symptom.

Question 20

A child is admitted with temperature of 38.5 C (101.3 F), loss of appetite and vomiting The nurse observes several joints are red, swollen, warm and tender to touch. A non pruritic rash is on the child's trunk. Laboratory test results include an elevate erythrocyte sedimentation rate (ESR), a positive c reactive protein, and an elevated white blood cell count (WBC). The nurse should initiate the plan of care for?

Accepted Answer

Answer reason: These findings fit the classic Jones-criteria pattern for post–group A streptococcal acute rheumatic fever, for which nursing care must anticipate cardiac involvement and manage inflammation and pain. Meningitis would be expected to present with meningeal signs and neurologic changes rather than prominent joint inflammation and rash. Rotavirus primarily causes acute watery diarrhea and dehydration, not arthritis with inflammatory-marker elevation.

Question 21

A nurse is caring for a patient with syphilis. The nurse assesses the patient and notes the patient has a rash on their hands and feet. Which stage of syphilis is this patient experiencing?

Accepted Answer

Answer reason: This stage commonly presents with a diffuse maculopapular rash, mucous patches, and generalized lymphadenopathy rather than a localized lesion. Primary disease is characterized by a painless chancre at the inoculation site, not a palmar/plantar rash. Latent syphilis is asymptomatic, and tertiary disease develops years later with gummas, cardiovascular, or neurologic manifestations.

Question 22

A client with hepatic encephalopathy has recently experienced a gastrointestinal bleed. The nurse anticipates a worsening in the client’s mental status due to which of the following?

Accepted Answer

Answer reason: Blood in the gastrointestinal tract is broken down into protein, which intestinal bacteria convert into ammonia. In hepatic encephalopathy, the liver cannot effectively detoxify ammonia, leading to its accumulation and worsening neurological status. This mechanism directly explains the decline in mental function following a GI bleed.

Question 23

Which of the following types of cardiomyopathy can be associated with childbirth?

Accepted Answer

Answer reason: This matches the dilated cardiomyopathy phenotype rather than a primary hypertrophic or restrictive process. Myocarditis can be a cause of dilated cardiomyopathy, but it is not itself classified as a cardiomyopathy type in this option set and does not most directly describe the childbirth-associated syndrome. Therefore, the childbirth-associated cardiomyopathy described is best aligned with the dilated form.

Question 24

A nurse is caring for a client with type I diabetes mellitus presenting with abdominal pain and fruity breath. Which of the following actions should the nurse take as the priority?

Accepted Answer

Answer reason: Fruity breath and abdominal pain in a client with type 1 diabetes strongly suggest diabetic ketoacidosis, in which osmotic diuresis causes significant volume depletion and impaired perfusion. Immediate isotonic IV fluid resuscitation is the priority to restore circulating volume, support renal clearance of glucose/ketones, and reduce risk of shock while other therapies are initiated. Insulin is essential but is typically started after fluids are begun and after confirming/monitoring potassium to avoid precipitating dangerous hypokalemia. Hourly glucose checks are important for monitoring response but do not correct the life-threatening dehydration. A high-carbohydrate snack is inappropriate because this presentation is hyperglycemic ketosis rather than hypoglycemia.

Question 25

A patient is admitted with exacerbation of congestive heart failure. What would you expect to find during your admission assessment?

Accepted Answer

Answer reason: This typically produces inspiratory crackles on auscultation, often diffuse when edema is significant. Sympathetic activation and increased systemic vascular resistance can elevate blood pressure, especially in acute decompensation. A common distractor is bradycardia; CHF more often presents with tachycardia as a compensatory response unless there is conduction disease or medication effect. Flat neck veins and a dry furrowed tongue suggest hypovolemia/dehydration, the opposite of the usual CHF picture.

Question 26

A 35-year-old client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?

Accepted Answer

Answer reason: This approach is favored because many vaginal tumors are not ideal for wide surgical excision without significant anatomic and functional morbidity. Surgery may be used in select small, localized lesions, but it is not the usual first-line treatment overall. Chemotherapy is more often used as an adjunct (e.g., radiosensitizer) rather than the primary standalone treatment, and immunotherapy is not considered the typical initial therapy for most cases.

Question 27

Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy?

Accepted Answer

Answer reason: These hemodynamic changes most commonly manifest as recurrent episodes of congestive symptoms (dyspnea, edema, orthopnea) consistent with heart failure. Diabetes mellitus can be a risk factor for developing cardiomyopathy but is not the typical “recurring condition” caused by it. Myocardial infarction is usually a precipitating cause of ischemic cardiomyopathy rather than a common recurrent outcome, and pericardial effusion is not a characteristic frequent complication of cardiomyopathy.

Question 28

The nurse notices that a client with liver cirrhosis has asterixis and confusion. What lab value should be checked?

Accepted Answer

Answer reason: Asterixis and confusion are classic signs of hepatic encephalopathy, which occurs due to accumulation of neurotoxic substances—primarily ammonia—when the liver cannot adequately detoxify it. Elevated serum ammonia levels directly contribute to altered mental status and neuromuscular abnormalities such as asterixis. ALT reflects liver injury but does not correlate with encephalopathy severity. Potassium and hemoglobin are not the primary indicators of this neurologic condition.

Question 29

A patient with complete spinal cord injury who is in neurogenic shock will demonstrate hypotension and what other clinical signs?

Accepted Answer

Answer reason: Neurogenic shock results from loss of sympathetic tone, leading to hypotension and bradycardia (not tachycardia). A complete spinal cord injury also causes loss of motor function below the level of injury. These findings together distinguish neurogenic shock from other shock types.

Question 30

Which is the leading cause of death in infants younger than 1 year?

Accepted Answer

Answer reason: Congenital anomalies (birth defects) are the leading cause of death in infants under 1 year of age. While SIDS is a major contributor, it is not the leading overall cause. Understanding underlying disease processes supports accurate prioritization and prevention strategies.

Question 31

The nurse caring for a patient with an acute exacerbation of sickle cell anemia would focus interventions based on?

Accepted Answer

Answer reason: Nursing care prioritizes optimizing oxygenation and perfusion (e.g., supplemental oxygen as ordered, treating triggers like infection, avoiding cold stress, and supporting ventilation) to limit further sickling and end-organ ischemia. Pain control is essential but is largely a downstream effect of vaso-occlusion rather than the primary driver that worsens the crisis. Interventions aimed at increasing stroke volume are not central to the mechanism, and increasing urine output may be supportive via hydration but does not address the main precipitant of ongoing sickling as directly as preventing hypoxia.

Question 32

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

Accepted Answer

Answer reason: A Levine (nasogastric) tube helps decompress the stomach, reduces vomiting/aspiration risk, and supports keeping the patient NPO during the acute phase. Routine q15-minute blood pressure checks are not universally indicated unless the patient is actively unstable or in shock requiring frequent titration and reassessment. Continuous ECG monitoring can be appropriate in severe illness, but it is less directly tied to the core pancreatitis management than decompression to support pancreatic rest and prevent complications.

Question 33

The nurse is assessing a client with leukemia. Which of the following assessment findings would be expected?

Accepted Answer

Answer reason: Leukemia causes malignant proliferation of abnormal white blood cell precursors in bone marrow, crowding out normal hematopoiesis. Decreased platelets commonly lead to easy bruising/bleeding, and decreased red blood cell production produces fatigue from anemia. Bone marrow expansion and increased cellular turnover can cause bone pain, particularly in long bones or the sternum. In contrast, primary bradycardia/palpitations patterns are not characteristic baseline findings of leukemia without another cardiac process or severe anemia-related compensation.

Question 34

The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parent during the assessment?

Accepted Answer

Answer reason: " Rheumatic fever is a delayed, immune-mediated complication that follows an untreated or inadequately treated group A streptococcal pharyngitis infection, typically within the prior several weeks. Asking about a recent sore throat helps identify the likely precipitating infection and supports a focused history around timing, prior testing, and antibiotic treatment adherence. This information is clinically important because it guides prevention of recurrence (e.g., secondary prophylaxis) and helps distinguish rheumatic fever from other causes of fever and joint symptoms. The other options focus on urinary symptoms, varicella exposure, or GI illness, which are not key antecedent triggers for rheumatic fever in standard evaluation.

Question 35

Jerry has been diagnosed with appendicitis. He develops a fever, hypotension, and tachycardia. The nurse suspects which of the following complications?

Accepted Answer

Answer reason: When the inflamed appendix leaks bacteria into the peritoneal cavity, peritoneal infection can rapidly trigger vasodilation and capillary leak, leading to hypotension and compensatory tachycardia. Intestinal obstruction or bowel ischemia would more typically present with prominent abdominal distention, vomiting, severe pain out of proportion, or GI bleeding patterns rather than a primary septic picture. “Deficient fluid volume” can contribute to tachycardia and hypotension, but it does not explain the fever as directly as an intra-abdominal infection from appendiceal perforation.

Question 36

A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?

Accepted Answer

Answer reason: The liver is one of the most common sites because it receives large-volume portal venous drainage from the gastrointestinal tract and has a rich sinusoidal blood supply that facilitates tumor cell seeding. By contrast, the colon is more commonly a primary tumor site rather than a frequent destination organ for distant metastasis. White blood cells are circulating immune cells, not a typical anatomic site of solid-tumor metastasis, and “reproductive tract” is not among the classic most common distant sites overall (lung, liver, bone, brain).

Question 37

A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin’s disease. Which of the following symptoms is typical of Hodgkin’s disease?

Accepted Answer

Answer reason: This option directly reflects those classic systemic manifestations that raise suspicion for Hodgkin disease in an oncology workup. Cervical lymphadenopathy in Hodgkin disease is typically painless (pain after alcohol is a rare association), making painful nodes less characteristic. Nausea/vomiting and weight gain are not typical presenting features and are more often related to treatment effects or other conditions.

Question 38

A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during the acute management of this patient?

Accepted Answer

Answer reason: This acid–base pattern can appear before later progression to an anion-gap metabolic acidosis as oxidative phosphorylation becomes uncoupled and organic acids accumulate. Close monitoring of respiratory rate, ABGs, and mental status is critical because worsening toxicity can rapidly shift the acid–base status and increase CNS salicylate penetration. Metabolic alkalosis is not an expected primary disturbance in aspirin overdose and would misdirect acute assessment priorities.

Question 39

A 37-year-old client with uterine cancer asks the nurse, “Which is the most common type of cancer in women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in women?

Accepted Answer

Answer reason: Lung cancer has the highest death rate among women because it is often asymptomatic until advanced stages, leading to diagnosis after metastasis and limited curative options. In contrast, breast cancer is more common but has lower mortality due to screening (mammography) and effective targeted/hormonal therapies when found early. Colon and rectal cancer also contributes significantly to mortality, but it is typically less lethal than lung cancer overall and has effective screening with colonoscopy that reduces deaths. This distinction between “most common” and “most deadly” is a frequent counseling and public-health concept tested in nursing care.

Question 40

When assessing a patient with high blood glucose levels, how will the nurse best determine if the patient is in diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome?

Accepted Answer

Answer reason: Arterial/venous blood gas results (pH and bicarbonate) directly identify the presence and severity of acid-base disturbance, making it the most discriminating test between these two hyperglycemic emergencies. Blood glucose may be markedly elevated in both conditions and therefore does not reliably distinguish them. Urine testing for bacteria may help find a precipitating infection but does not determine whether the hyperglycemia is accompanied by ketoacidosis.

Question 41

A 63-year-old client has hypothyroidism and the nurse is told he has myxedema. Which of the following would the nurse most likely find on the patient assessment?

Accepted Answer

Answer reason: The global slowing of metabolic processes also produces CNS and neuromuscular depression, which can present as slowed mentation and slurred speech. In contrast, jitteriness and involuntary movements are more consistent with hyperthyroidism due to increased adrenergic activity. Increased GI motility is also a hyperthyroid feature, whereas hypothyroidism typically causes decreased motility and constipation.

Question 42

A nurse is monitoring clients in labor with varying fetal heart rate patterns. Which of the following clients requires immediate attention?

Accepted Answer

Answer reason: Late decelerations (onset after the contraction begins with nadir after the peak and recovery after the contraction ends) indicate uteroplacental insufficiency and fetal hypoxemia, which is the most urgent fetal heart rate pattern requiring prompt intrauterine resuscitation. This option describes decelerations that persist into the end of the contraction with delayed recovery, consistent with a late pattern rather than benign early decelerations. Options describing brief decelerations that resolve by the end of the contraction are more consistent with early decelerations (head compression) and are typically expected. Accelerations are generally reassuring and not an immediate concern.

Question 43

A nurse is performing a respiratory assessment on a 76-year-old client admitted with pneumonia. The client is febrile, with a productive cough and increasing shortness of breath. Upon auscultation, the nurse hears bronchial breath sounds in the left lower lung field posteriorly. Which of the following is the best interpretation of this finding?

Accepted Answer

Answer reason: When they are heard in a distal lung area, it suggests that normally air-filled alveoli have become fluid- or exudate-filled, which transmits higher-pitched tubular sounds more efficiently. In pneumonia, this pattern is classically due to alveolar consolidation, matching the client’s fever, productive cough, and worsening dyspnea. Pleural effusion more commonly decreases or muffles breath sounds rather than producing true bronchial sounds in that area.

Question 44

An abnormal electroencephalogram (EEG) indicates that a 2-year-old client has epilepsy, but the parents say they have never observed a seizure. The pediatric nurse concludes that the child may be experiencing which type of seizure?

Accepted Answer

Answer reason: These events often present as staring spells with minimal or no motor activity and rapid return to baseline, so parents may not recognize them as seizures. An abnormal EEG may detect characteristic generalized spike-and-wave activity even when clinical events are not witnessed. In contrast, myoclonic, Jacksonian (focal motor), and grand mal seizures typically have obvious motor manifestations that are more likely to be observed.

Question 45

The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?

Accepted Answer

Answer reason: The elevated systolic pressure reflects a sympathetic response to maintain cerebral perfusion pressure, while the baroreceptor-mediated vagal response produces a slow heart rate. Respiratory irregularity (often Cheyne-Stokes or other irregular patterns) occurs as the medulla becomes compromised. Choices featuring hypotension or tachycardia are inconsistent with the typical late compensatory pattern seen in worsening ICP.

Question 46

Nurse Harper is evaluating Mr. Jensen, a 52-year-old male client suspected of having a pulmonary embolism. During her assessment, she looks for typical signs of this condition. Which finding should Nurse Harper recognize as a common clinical manifestation of pulmonary embolism?

Accepted Answer

Answer reason: This typically presents with sudden shortness of breath and tachypnea, often with pleuritic chest pain and anxiety. Slow breathing or decreased respiratory rate is not expected in an acute hypoxemic event and would suggest alternative causes such as CNS depression. Bradycardia is also atypical early, as sympathetic stimulation more commonly produces tachycardia.

Question 47

A client is experiencing confusion and tremors is admitted to a nursing unit. An initial ABG report indicates that the PaCO2 level is 72 mm Hg, whereas the PaO2 level is 64 mm Hg. A nurse interprets that the client is most likely experiencing?

Accepted Answer

Answer reason: The markedly high PaCO2 (72 mm Hg) with low PaO2 (64 mm Hg) supports ventilatory failure with hypercapnic hypoxemia. Confusion and tremors are consistent with hypercapnia-related neurologic effects, progressing to somnolence if untreated. Carbon monoxide poisoning typically shows normal PaO2 on ABG despite tissue hypoxia, and respiratory alkalosis would have a low PaCO2 rather than an elevated value.

Question 48

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated?

Accepted Answer

Answer reason: This causes sudden severe hypertension along with flushing, anxiety, and a pounding headache. The baroreceptor response then induces reflex parasympathetic activation above the lesion, leading to bradycardia. Shock would more strongly suggest neurogenic hypotension with bradycardia (early after injury), and respiratory depression is more consistent with high cervical involvement (e.g., C3–C5) or medication effects rather than this presentation.

Question 49

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?

Accepted Answer

Answer reason: Rising intracranial pressure triggers Cushing’s response due to brainstem ischemia and loss of normal autonomic regulation. The hallmark vital sign trend is widening pulse pressure and hypertension as the body attempts to maintain cerebral perfusion pressure. Baroreceptor-mediated reflex bradycardia occurs in response to the elevated blood pressure. Respiratory rate often slows and becomes irregular as brainstem respiratory centers are compressed, and temperature may rise with hypothalamic dysfunction.

Question 50

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits?

Accepted Answer

Answer reason: Neck flexion causing involuntary hip/knee flexion indicates meningeal inflammation, making this finding highly suggestive of meningitis. In contrast, a negative Kernig’s sign and absence of nuchal rigidity are findings that argue against meningeal irritation. A normal GCS of 15 indicates intact consciousness and does not specifically support meningitis as a postoperative complication.

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

Pathophysiology NCLEX Practice Test

Continue Learning