Question 1

A 5-month-old infant is admitted to the ER with a temperature of 6°F and irritability. The mother states that the infant had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of meningitis in the infant. Which sign would the nurse expect to observe?

Accepted Answer

Answer reason: In infants, the open fontanel provides a visible and palpable window into rising intracranial pressure, making bulging/tense fontanel a classic expected finding alongside fever, irritability, and possible seizures. Periorbital edema more strongly suggests renal or allergic etiologies rather than CNS infection. A positive Babinski reflex is normal in young infants and is not a specific indicator of meningitis, and the scarf sign primarily assesses neuromuscular tone rather than intracranial pathology.

Question 2

The nurse should tell the parents of a child with Duchenne muscular dystrophy that some of the progressive complications include?

Accepted Answer

Answer reason: Duchenne muscular dystrophy causes progressive skeletal muscle degeneration leading to weakness, immobility, and orthopedic deformities. As mobility declines, muscle shortening and imbalance commonly produce contractures, and reduced activity with steroid use can contribute to weight gain. Respiratory muscles also weaken over time, decreasing cough effectiveness and ventilation, which raises the risk of recurrent pulmonary infections. The other options describe findings more consistent with endocrine disorders, medication effects, or neurologic conditions rather than the typical progressive complications of Duchenne muscular dystrophy.

Question 3

The nurse is assessing a client with cirrhosis. Which of the following findings would be consistent with a diagnosis of cirrhosis?

Accepted Answer

Answer reason: Easy or spontaneous bruising is therefore a classic assessment finding consistent with advanced liver dysfunction. In contrast, DVT is not a typical direct manifestation because cirrhosis more commonly presents with coagulopathy-related bleeding signs rather than isolated venous thrombosis. High fever would suggest infection (e.g., cholangitis, SBP) rather than being a hallmark feature of cirrhosis itself, and steatorrhea is more characteristic of biliary obstruction or pancreatic insufficiency than cirrhosis.

Question 4

A male client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

Accepted Answer

Answer reason: Infrequent catheterization increases the risk of urinary retention and overdistention, which can provoke recurrent episodes and severe hypertension. Risk reduction focuses on keeping the bladder decompressed and promptly addressing obstruction (e.g., kinks, clots) rather than stretching catheterization intervals. By contrast, controlling bowel impaction and reducing skin/pressure irritation (smooth linens, avoiding unnecessary pressure) helps remove other common triggers.

Question 5

The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)?

Accepted Answer

Answer reason: As compliance worsens, higher pressures are required to deliver the same tidal volume, so rising peak inspiratory pressures are a key bedside cue of worsening lung mechanics consistent with ARDS. Increased pulse oximetry saturation would not suggest impending ARDS, since ARDS typically causes refractory hypoxemia. A PaO2/FiO2 ratio greater than 300 is normal (ARDS is suggested when it is ≤300), making that option inconsistent with ARDS risk.

Question 6

The nurse admits a client who is in sickle cell crisis. The nurse should prepare for which intervention as a priority in the management of the client?

Accepted Answer

Answer reason: Rapid IV hydration is a priority because it helps decrease viscosity, improves microvascular perfusion, and supports renal clearance of hemolysis byproducts. Opioid analgesia is essential but does not address the upstream trigger of worsening sickling related to hypovolemia. Oxygen is indicated if hypoxemic, and transfusion is typically reserved for severe anemia or complications (e.g., acute chest syndrome, stroke risk), not as the first routine priority in an uncomplicated pain crisis.

Question 7

A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to?

Accepted Answer

Answer reason: Nonabsorbable antibiotics like neomycin act locally in the gut to reduce ammonia-producing flora, lowering intestinal ammonia production and subsequent systemic levels. This helps improve neurologic status in patients who become obtunded or comatose from liver failure. Diuresis is addressed with diuretics for ascites/edema, not with this medication, and the goal is ammonia reduction rather than bowel acidification (more characteristic of lactulose therapy).

Question 8

The nurse caring for a client with pancreatitis assesses new ecchymoses on the client's flanks. How should the nurse report this finding and document it?

Accepted Answer

Answer reason: This physical finding is classically described as Grey Turner sign and should be documented using that terminology. Cullen’s sign is instead periumbilical ecchymosis, while Homan’s relates to suspected DVT and Kernig’s to meningeal irritation. Recognizing and reporting this sign helps prompt urgent evaluation for hemorrhagic pancreatitis and hemodynamic deterioration.

Question 9

What is the most unique clinical presentation that occurs with a client diagnosed with a brain tumor (benign or malignant)?

Accepted Answer

Answer reason: This produces a morning-predominant headache, often accompanied by nausea/vomiting and sometimes improved after being upright. The other options reflect focal neurologic deficits or nonspecific constitutional changes that can occur with many neurologic disorders and are not as characteristic for a space-occupying intracranial lesion. Morning-worse headache is therefore the most distinctive presentation among the choices for a brain tumor.

Question 10

Which symptom would cause the nurse to suspect a fat embolism in the client with a fractured left femur?

Accepted Answer

Answer reason: Fat droplets enter the circulation and lodge in pulmonary capillaries, triggering V/Q mismatch and inflammatory injury that can rapidly reduce oxygen delivery to the brain. New restlessness/confusion is therefore a more concerning systemic warning sign than expected local findings around a fracture. Severe leg pain, dependent edema, and localized swelling/bruising are common with a femur fracture and are not specific indicators of embolic physiology.

Question 11

What assessment finding does a nurse expect to see in a patient with autonomic dysreflexia after a C4 spinal cord injury?

Accepted Answer

Answer reason: This causes sudden, dangerous elevation in blood pressure, often with headache, flushing/sweating above the lesion, and nasal congestion. The baroreceptor response may produce reflex bradycardia, making tachycardia less likely as the key finding. Hypotension is more consistent with neurogenic shock or orthostatic hypotension early after injury, not autonomic dysreflexia.

Question 12

The nurse is performing a postpartum assessment 12 hours after the prolonged vaginal delivery of a term infant. Which assessment findings should be reported to the health care provider?

Accepted Answer

Answer reason: Normal lochia has a fleshy, non-offensive odor, and a foul smell is a key warning sign even when other vitals are only mildly changed. Mild fundal tenderness/discomfort with palpation can occur as the uterus involutes and with uterine contractions in the early postpartum period. A temperature of 100.1 F at 12 hours postpartum and leukocytosis around 24,000/mm3 can be normal physiologic postpartum responses and are less concerning in isolation.

Question 13

A 28-year old woman presents to the trauma bay after being shot in the upper back. She can move the left side of her body but is unable to move the right. However, she cannot feel any pain on the left. The nurse knows these symptoms are suggestive of which type of spinal cord injury?

Accepted Answer

Answer reason: Here, right-sided inability to move indicates ipsilateral motor tract involvement, while loss of pain on the left indicates contralateral spinothalamic disruption, matching a hemicord lesion. This is classically an incomplete spinal cord injury because some tracts remain intact rather than a total transverse lesion. Central cord syndrome would more typically cause upper-extremity weakness greater than lower-extremity weakness, and anterior cord syndrome would cause bilateral motor and pain/temperature loss with preserved dorsal column function.

Question 14

A client is diagnosed with a terminal illness and the client's family member begins to breathe rapidly, appears anxious, and has a syncopal episode. The client's family member is evaluated after the transient loss of consciousness. What acid-base finding does the nurse expect to find in the family member's results?

Accepted Answer

Answer reason: pH 7.47 Acute anxiety with rapid breathing causes hyperventilation, which blows off CO2 and produces an acute respiratory alkalosis. In early/acute episodes there is little to no renal compensation yet, so the most direct expected finding is an elevated pH. Syncope can occur because hypocapnia leads to cerebral vasoconstriction and reduced cerebral blood flow. Options reflecting acidemia or elevated PaCO2 would instead suggest respiratory acidosis or metabolic acidosis, which do not fit the hyperventilation scenario.

Question 15

A nurse working in the Intensive Care Unit (ICU) receives report about a patient with a newly diagnosed pheochromocytoma that is being transferred to the ICU. What is the most important thing for the ICU nurse to monitor in this patient?

Accepted Answer

Answer reason: Continuous hemodynamic monitoring is the immediate priority in the ICU because severe elevations can rapidly lead to stroke, aortic dissection, pulmonary edema, or myocardial ischemia. Tight blood pressure control also guides urgent therapy (e.g., alpha-blockade and vasodilators) and helps assess response to interventions. ECG monitoring is important but is secondary to detecting and treating the primary instability driving end-organ damage: extreme blood pressure elevation.

Question 16

A one-week old infant is suspected of having Hirschsprung’s disease. What findings by the nurse would support this diagnosis?

Accepted Answer

Answer reason: Hirschsprung’s disease is caused by absence of enteric ganglion cells in the distal bowel, leading to functional obstruction and failure of normal colonic motility. A key early neonatal clue is delayed passage of meconium, classically beyond 24–48 hours, often accompanied by abdominal distention and constipation. Blood and mucus in stool is more suggestive of infectious colitis or intussusception, while projectile vomiting points more toward pyloric stenosis. Mild spit-up and feeding refusal are nonspecific and do not directly reflect distal colonic obstruction.

Question 17

The nurse assesses a client with arterial insufficiency reporting lower leg pain when walking up the stairs, but states that it is relieved by rest. The nurse suspects the client has what condition?

Accepted Answer

Answer reason: Climbing stairs increases oxygen demand in the leg muscles, unmasking inadequate perfusion and producing predictable, reproducible pain. Rest reduces metabolic demand, allowing limited blood flow to meet tissue needs and the pain to subside. Raynaud's phenomenon typically causes episodic color changes and pain/numbness in fingers or toes triggered by cold or stress rather than exertional calf pain. Lazarus syndrome is unrelated to peripheral arterial insufficiency.

Question 18

A client is diagnosed with pancreatitis. Which assessment would be of most concern to the nurse?

Accepted Answer

Answer reason: Hemorrhagic pancreatitis is associated with rapid clinical deterioration, shock, and high mortality, making it a priority concern requiring urgent escalation of care. By contrast, elevated amylase, abdominal pain, and a low-grade fever are common expected findings in pancreatitis and are less immediately life-threatening. The presence of periumbilical ecchymosis signals significant bleeding and systemic inflammatory response risk that demands prompt intervention and close hemodynamic monitoring.

Question 19

A 93-year-old client has been functioning independently in the home but has suddenly become confused. A family member asks the nurse, “Does this mean Dad has Alzheimer’s disease?” Which of the following is the most appropriate response?

Accepted Answer

Answer reason:  Sudden confusion in an older adult is more consistent with acute delirium than a progressive dementia such as Alzheimer’s disease. A key nursing principle is to first consider reversible, physiologic causes of acute mental status change—especially infection (e.g., UTI, pneumonia), dehydration, or medication effects. This response provides accurate education and prompts timely assessment for treatable conditions without making a diagnosis. In contrast, suggesting Alzheimer’s is premature and potentially misleading, and “monitored over time” delays evaluation of a potentially urgent cause.

Question 20

A nurse is admitting a client who was treated for a bone marrow transplant 8 weeks ago. The client now reports fever, rash, and diarrhea. The client states "I feel very bad." The nurse should expect which of the following?

Accepted Answer

Answer reason: Acute GVHD commonly occurs within the first ~100 days and characteristically affects skin (rash), GI tract (watery diarrhea/abdominal pain), and can be associated with systemic symptoms including fever and malaise. The timing at 8 weeks post-transplant strongly supports this complication over an isolated infection or nutrient deficiency. While viral infection is possible in immunosuppressed patients, the triad of fever plus rash plus diarrhea in this post-transplant window is most suggestive of GVHD and requires prompt evaluation and immunosuppressive management.

Question 21

A child is diagnosed with Reye’s syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan?

Accepted Answer

Answer reason: A low-stimulus environment (quiet, dim lighting) supports neurologic stability and helps prevent exacerbation of symptoms such as irritability and decreased level of consciousness. Monitoring urine output is important for general status but is less directly targeted to the primary life-threatening neurologic complication. Routine repositioning is good pressure-injury prevention but does not address the core pathophysiologic risk that drives immediate care planning in this condition.

Question 22

A nurse is caring for a patient who feels the need to defecate but has not been able to pass a stool or flatus in over 8 hours. The nurse will know that the patient has a small bowel obstruction if which of the following is present?

Accepted Answer

Answer reason: This spasmodic pattern is a classic differentiator from large bowel obstruction, where pain may be more mild initially and distension more prominent. “Diffuse and constant” pain raises concern for complications such as peritonitis, ischemia, or perforation rather than uncomplicated obstruction. “Diarrhea around the impaction” points to fecal impaction/overflow in the colon, not a small bowel process.

Question 23

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?

Accepted Answer

Answer reason: Multiparity and delivery of a large baby both increase uterine overdistention, making firm uterine involution less likely. Prior oxytocin induction can contribute to receptor desensitization and myometrial fatigue, further increasing atony risk. In contrast, simply being 4–6 hours postpartum without added atony risk factors is less predictive of hemorrhage than the combined overdistention/fatigue factors in this client.

Question 24

A client has developed sepsis. Which arterial blood gas results does the nurse identify as aligning with sepsis?

Accepted Answer

Answer reason: Sepsis commonly causes lactic acidosis from impaired tissue perfusion and increased anaerobic metabolism, producing a primary metabolic acidosis. This pattern shows acidemia with a markedly low bicarbonate, indicating metabolic acidosis. The low paCO2 reflects appropriate respiratory compensation (hyperventilation) to blow off CO2. In contrast, an isolated elevated paCO2 with normal bicarbonate would indicate primary respiratory acidosis, which does not best match the typical early ABG pattern seen with septic shock-related lactate elevation.

Question 25

Which of the following statements indicates the client understands the expected course of Ménière's disease?

Accepted Answer

Answer reason: " Ménière’s disease is a chronic inner-ear disorder characterized by episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness, with a relapsing-remitting course. Treatment focuses on reducing frequency and severity of attacks (e.g., diet/trigger management and medications) rather than eliminating the underlying condition. Progressive hearing loss can occur, but it is not inevitably bilateral in all clients. It is an ear disorder and does not characteristically “extend to the eyes,” so that statement reflects misunderstanding of the disease process.

Question 26

The ED nurse is caring for a client with type 1 diabetes who was brought in by ambulance after losing consciousness. Upon assessment, the client's breath was noted to be fruity. Which of the following ABG results would the nurse expect?

Accepted Answer

Answer reason: Fruity breath in a type 1 diabetic with altered consciousness strongly indicates diabetic ketoacidosis with metabolic acidosis from ketone accumulation. Metabolic acidosis is characterized by a low pH and decreased bicarbonate due to buffering of excess acids. This option shows acidemia (7.28) with low HCO3 (16), fitting the expected primary disturbance; PCO2 may be normal early or decrease with respiratory compensation (Kussmaul respirations). The other choices either suggest primary respiratory acidosis or normal ABGs, which do not match ketoacidosis physiology.

Question 27

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child’s record and expects to note which sign of this disorder documented?

Accepted Answer

Answer reason: This process produces the classic “currant jelly” stool, characterized by blood mixed with mucus. This finding is more specific for intussusception than watery diarrhea, which is typical of infectious gastroenteritis. Ribbon-like stools suggest anorectal narrowing (e.g., Hirschsprung disease/anal stenosis), and profuse projectile vomiting is more consistent with hypertrophic pyloric stenosis.

Question 28

A newly admitted client with traumatic brain injury (TBI) on continuous mechanical ventilation develops increased intracranial pressure (ICP). What prescription for treating the increased ICP does the nurse clarify with the healthcare provider (HCP)?

Accepted Answer

Answer reason: Routine or prolonged hyperventilation is no longer recommended because lowering PaCO2 causes cerebral vasoconstriction, which can reduce cerebral blood flow and worsen neurologic outcomes in TBI. It may be used only as a brief rescue measure for impending herniation while definitive therapies are initiated, so an order to hyperventilate broadly should be clarified for indication and targets. In contrast, sedation and osmotic/diuretic therapy are standard strategies to reduce metabolic demand, agitation, and intracranial volume, and antipyretics help prevent fever-related increases in cerebral metabolic rate.

Question 29

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect?

Accepted Answer

Answer reason: This produces the classic “currant jelly” stool description, reflecting blood mixed with mucus. Black, sticky stools are more consistent with melena from an upper GI bleed, and greasy, foul-smelling stools suggest malabsorption/steatorrhea. Thin, ribbon-like stools point toward distal obstruction or anorectal narrowing rather than episodic ischemic bleeding.

Question 30

The client with celiac disease has been diagnosed with malabsorption syndrome. The nurse is observing the client for signs and symptoms of vitamin deficiencies that may occur with this disorder. What findings would occur the nurse expect to observe?

Accepted Answer

Answer reason: Anemia reduces oxygen delivery to tissues, presenting clinically as tiredness, weakness, and decreased exercise tolerance. This aligns with a nurse’s assessment for vitamin/nutrient deficiency manifestations in malabsorption. Weight gain is inconsistent with chronic malabsorption (more typical is weight loss), and hypertension or renal calculi are not hallmark findings of vitamin deficiency from celiac-related malabsorption.

Question 31

A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Which action prescribed by the health care provider will you implement first?

Accepted Answer

Answer reason: Sickle cell crisis is driven by vaso-occlusion from sickled erythrocytes, and dehydration increases blood viscosity and promotes further sickling. Rapid IV hydration is a first-line intervention because it improves intravascular volume and microcirculatory flow, helping reduce ongoing ischemia risk while other therapies are initiated. Oxygen is appropriate if hypoxemic, but routine 100% oxygen via nonrebreather is not the universal first action without evidence of respiratory compromise. Opioids are essential for pain control but do not address the underlying hemoconcentration driving progression of vaso-occlusion, and vaccines are not an acute-crisis priority.

Question 32

Louis develops peritonitis and sepsis after surgical repair of ruptures diverticulum. The nurse in charge should expect an assessment of the client to reveal?

Accepted Answer

Answer reason: With a ruptured diverticulum, bacterial contamination of the peritoneal cavity makes this finding especially expected and clinically specific. In contrast, bowel sounds typically decrease or become absent due to ileus rather than increase. Sepsis can produce tachycardia, but it is less specific to peritoneal irritation than the classic rigidity finding.

Question 33

The clinic nurse reviews the record of an infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

Accepted Answer

Answer reason: Narrow, “ribbon-like” stools can occur when only a small amount of stool passes through a spastic, narrowed aganglionic segment, and stool stasis can contribute to a foul odor. Diarrhea is not typical and would suggest a different GI process unless complicated by enterocolitis, which is not the classic presenting cue. Vomiting or simple regurgitation are less specific for distal colonic obstruction and more consistent with upper GI conditions or feeding intolerance.

Question 34

A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating?

Accepted Answer

Answer reason: Tachypnea with deeper respirations along with increasing hypoxemia is a classic presentation of a hypercyanotic episode rather than a behavioral issue. Anxiety or a temper tantrum would not explain the physiologic drop in oxygenation. This interpretation is important because it prompts rapid supportive measures (e.g., knee-chest positioning and oxygen) to reduce shunting and improve pulmonary blood flow.

Question 35

A client with myasthenia gravis is experiencing prolonged periods of weakness, and the health care provider prescribes an edrophonium (Enlon) test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?

Accepted Answer

Answer reason: Edrophonium is a short-acting acetylcholinesterase inhibitor; if weakness improves after administration, it supports undermedication/myasthenic crisis, but if weakness worsens it indicates excessive acetylcholine at the neuromuscular junction. Increased acetylcholine can cause depolarization blockade and further muscle weakness, consistent with cholinergic crisis from anticholinesterase overdosage. This interpretation guides urgent management toward holding anticholinesterase drugs and treating muscarinic effects as needed (e.g., atropine) while supporting respirations. A common distractor is myasthenic crisis, which would be suggested by transient strength improvement after the test dose, not deterioration.

Question 36

The nurse is caring for a patient with septic shock presenting with a temperature of 102 degrees F, heart rate 98 beats/minute, and blood pressure of 126/84 mmHg. Which phase of septic shock is this patient experiencing?

Accepted Answer

Answer reason: Early (warm) septic shock is characterized by fever and a compensated hemodynamic state due to systemic vasodilation with increased cardiac output, so blood pressure can still be normal. The patient has fever and only mild tachycardia with a normal BP, which fits the hyperdynamic phase rather than decompensated shock. In later/progressive (hypodynamic/cold) phases, myocardial depression and worsening maldistribution lead to hypotension and signs of poor perfusion. Because hypotension is absent here, the presentation is most consistent with the warm hyperdynamic stage.

Question 37

The nurse is providing care for several clients who are at risk for acid-base imbalance. Which client is most at risk for respiratory acidosis?

Accepted Answer

Answer reason: Chronic emphysema (a COPD condition) impairs ventilation and gas exchange, making chronic hypercapnia and CO2 retention likely, so this client has the highest risk. Daily antacid use is more associated with metabolic alkalosis from increased base load. Anxiety commonly leads to hyperventilation and respiratory alkalosis, while salicylate intoxication typically causes early respiratory alkalosis followed by metabolic acidosis.

Question 38

A patient comes to the emergency room with high levels of anxiety. The client’s arterial blood gas results are pH 7.48, Pao2 98, Pco 30, and HCO3 24. Which intervention is most appropriate for this client?

Accepted Answer

Answer reason: The core principle is to identify the acid–base disorder and treat the underlying cause. The ABG shows alkalemia (pH 7.48) with low PaCO2 (30) and normal HCO3 (24), consistent with acute respiratory alkalosis from hyperventilation commonly triggered by anxiety/panic. With a normal PaO2 (98), additional oxygen is not indicated and does not correct hypocapnia. Sodium bicarbonate would worsen alkalosis, and an antacid is unrelated to this gas pattern; reducing anxiety (and thereby hyperventilation) is the most appropriate intervention.

Question 39

The nurse obtains a health history from a client admitted with acute glomerulonephritis that is associated with beta-hemolytic Streptococcus. The nurse expects which of the following to be significant in the health history?

Accepted Answer

Answer reason: Post-streptococcal glomerulonephritis is an immune-mediated complication that typically follows a group A beta-hemolytic Streptococcus infection after a latent period of about 1–3 weeks. A recent pharyngitis history fits this timing and mechanism (immune complex deposition leading to glomerular inflammation). Family history is not the classic trigger for this acute, postinfectious process. Prior renal stones or remote renal trauma do not explain an acute nephritic presentation linked to streptococcal infection.

Question 40

The nurse is assessing a client with carbon monoxide (CO) poisoning. Which of the following would be an expected finding?

Accepted Answer

Answer reason: Early manifestations are often neurologic and flu-like, with headache being the classic and most common presenting symptom. Pulse oximetry can appear normal because it cannot reliably distinguish oxyhemoglobin from carboxyhemoglobin, making decreased SpO2 an unreliable expected finding. Compensatory responses more often include tachycardia and tachypnea rather than bradycardia, and “hyperarousal” is not a typical hallmark compared with headache, dizziness, and confusion.

Question 41

The nurse is assessing a client with systolic heart failure. Which of the following would be an expected finding of right-sided heart failure?

Accepted Answer

Answer reason: Right-sided heart failure causes systemic venous congestion due to impaired right ventricular pumping into the pulmonary circulation. This raises venous hydrostatic pressure and leads to fluid shifting into dependent tissues and body cavities, producing findings like peripheral edema, hepatomegaly, and ascites. Ascites specifically reflects abdominal fluid accumulation from chronic venous congestion and portal venous hypertension. In contrast, tachypnea, cough, and orthopnea are more characteristic of left-sided failure from pulmonary congestion and fluid in the lungs.

Question 42

The nurse is reviewing the medical record of a young adult client who is suspected of having systemic lupus erythematosus (SLE). Which assessment finding should the nurse expect to document that is related to this diagnosis?

Accepted Answer

Answer reason: The malar (“butterfly”) rash over the cheeks and nasal bridge is a classic assessment finding associated with SLE and commonly prompts further diagnostic evaluation. Ascites is more consistent with advanced liver disease or severe hypoalbuminemia rather than a typical presenting SLE finding. Hemoglobin S genes indicate sickle cell disease/trait, which is unrelated to SLE, and embolic events are not the hallmark assessment feature being sought here.

Question 43

A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. The nurse monitors for which earliest clinical manifestation of acute respiratory distress syndrome (ARDS)?

Accepted Answer

Answer reason: The earliest bedside sign is typically tachypnea as the patient compensates for worsening oxygenation and decreased lung compliance. Cyanosis and pallor are later signs of significant hypoxemia, and a diffuse “white-out” chest x-ray reflects more advanced alveolar flooding. Adventitious breath sounds can occur but are less sensitive and may be absent early, especially compared with an increasing respiratory rate trend after trauma.

Question 44

The nurse in the emergency department assesses a client diagnosed with burns. Which observation most concerns the nurse?

Accepted Answer

Answer reason: Full-thickness (third-degree) burns destroy the dermis and often extend into subcutaneous tissue, producing a leathery/charred, waxy white appearance with loss of normal sensation and a high risk of major fluid shifts and systemic complications. This finding signals deeper tissue necrosis and a greater likelihood of needing aggressive resuscitation, eschar management, and possible grafting. In contrast, redness, blistering, and pain are more consistent with superficial or partial-thickness burns where viable nerve endings remain and systemic risk is generally lower for the same burn size. The depth suggested here is therefore the most urgent and concerning observation.

Question 45

A 3-month-old infant is in the emergency room for acute abdominal pain. The nurse suspects intussusception. Which assessment data would further support the nurse’s suspicion?

Accepted Answer

Answer reason: This produces the classic “currant jelly” appearance and is a key supporting assessment finding in infants with intermittent severe abdominal pain. Melena suggests upper GI bleeding, ribbon-like stools point more toward obstructive lesions like Hirschsprung or anorectal narrowing, and frothy foul-smelling stools are more consistent with malabsorption/infection rather than bowel ischemia.

Question 46

A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?

Accepted Answer

Answer reason: Edrophonium is a short-acting acetylcholinesterase inhibitor; if weakness worsens after administration, it indicates excessive acetylcholine at the neuromuscular junction causing depolarizing block and increased muscarinic effects. This pattern is consistent with cholinergic crisis (often from overmedication with anticholinesterases). In contrast, myasthenic crisis would improve transiently with edrophonium because it temporarily increases acetylcholine availability and strength. The nurse should anticipate interventions such as holding anticholinesterase doses and monitoring/assisting ventilation due to risk of respiratory compromise.

Question 47

A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse carries out which of the following prescribed measures as the most effective means to treat the problem?

Accepted Answer

Answer reason: Timely antimicrobial therapy treats gram-negative sepsis, reducing the physiologic drive to blow off CO2 and correcting the acid–base disturbance at its source. Antipyretics may reduce fever-related tachypnea but do not address the infection and are supportive only. Rebreathing techniques (paper bag or partial rebreather) are inappropriate and potentially dangerous in sepsis because they can worsen hypoxemia and delay definitive treatment.

Question 48

The nurse is assessing a client who had an open cholecystectomy 36 hours ago. The client's vital signs are as follows: temperature, 99.8° F (37.7° C); pulse, 118; respirations, 28; blood pressure, 156/94 mm Hg; oxygen saturation, 94%. The client is restless and has tremors. Based on these findings, it would be essential for the nurse to?

Accepted Answer

Answer reason: Restlessness, tremors, tachycardia, and tachypnea about 24–72 hours after surgery are classic for alcohol withdrawal (early withdrawal/impending delirium tremens), which requires urgent screening and treatment planning. A low-grade temperature and an SpO2 of 94% are not the dominant cues here and do not explain tremors. While infection or bleeding assessments are important, they do not best account for the neuromotor agitation and autonomic hyperactivity pattern noted.

Question 49

A nurse is caring for a 28-year-old pregnant client with a history of renal disease. The patient has developed reversible posterior leukoencephalopathy (RPLE). Based on this diagnosis, which symptom would the nurse most likely expect to see?

Accepted Answer

Answer reason: Posterior involvement commonly produces acute visual disturbances (blurred vision, visual field deficits, cortical blindness) along with headache, seizures, and altered mental status. In a peripartum patient, sudden loss of vision fits this posterior cerebral edema pattern and may be reversible with prompt blood pressure control and magnesium therapy when indicated. The other options are not characteristic neurologic manifestations of PRES and do not reflect the typical CNS end-organ effects of severe hypertension in pregnancy.

Question 50

A client with a diagnosis of septic shock has an upward-trending glucose level (180-225 mg/dL) requiring control with insulin. The client's wife asks why he needs insulin as he is not a diabetic. What is the most appropriate response?

Accepted Answer

Answer reason: "The increase in glucose is a normal response to stress by the body. We give insulin to keep the level at 140-180 mg/dL." Critical illness (including septic shock) triggers a stress-hormone response (catecholamines, cortisol, glucagon) that increases hepatic glucose production and causes insulin resistance, so hyperglycemia can occur even without preexisting diabetes. In the ICU, moderate glycemic control is recommended to reduce complications like infection risk and poor wound healing while avoiding dangerous hypoglycemia. A common target range is 140–180 mg/dL for most critically ill adults. Statements claiming the patient was “secretly diabetic” or that the goal is strict normal glucose (80–110 mg/dL) are inappropriate because overly tight control increases hypoglycemia risk and is not standard in septic shock care.

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