Question 1

The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes mellitus. Which statement best illustrates an outcome criterion for this patient?

Accepted Answer

Answer reason: Outcome criteria in nursing care plans should be specific, measurable, and behaviorally stated so the nurse can directly evaluate whether the goal was met. Demonstrating an accurate self-monitoring blood glucose technique is an observable skill that can be validated through return demonstration. In contrast, statements like “follow instructions” are vague and not measurable, and “will not experience complications” is overly broad and influenced by many factors beyond immediate teaching. A clearly defined skill-based outcome best fits a newly diagnosed patient’s immediate learning needs for safe diabetes self-management.

Question 2

A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative instructions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: Diet advancement after surgery should follow assessment of gastrointestinal function to reduce aspiration and postoperative ileus risk. Bowel sounds and abdominal assessment help determine readiness to tolerate oral intake and guide whether clear liquids are appropriate to start. Implementing an intervention like giving fluids before assessing can worsen nausea/vomiting or reveal intolerance late. Elevating the head of bed is important for safe swallowing, but confirming GI readiness is the priority assessment step that determines whether PO intake should proceed at all. Ordering a lunch tray skips ordered progression and exceeds clear liquids.

Question 3

A male client who is 24hr post-operative for an exploratory laparotomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implement?

Accepted Answer

Answer reason: Listening for bowel sounds provides a focused assessment for postoperative ileus and helps determine whether peristalsis is returning. Advancing diet without evidence of GI motility increases risk for nausea, vomiting, and aspiration. A provider order may be required to change diet, but the nurse should first complete the relevant assessment that guides that decision and identifies complications needing follow-up.

Question 4

An adult female whit multiple sclerosis (MS) fell while walking to the bathroom. On transfer to the intensive care unit..she is confused and has projectile vomiting twice Which intervention should the nurse implemented first?

Accepted Answer

Answer reason: A focused head-to-toe neurologic assessment establishes current status (LOC, pupils, motor/sensory function) and creates a baseline for trending and urgent escalation of care. Treating nausea first can mask worsening neurologic deterioration and delays identification of a potentially life-threatening complication. Historical information (prior baseline or last corticosteroid dose) is important but does not supersede immediate assessment when acute neurologic decline is suspected.

Question 5

Emergency medical technicians transport a client to the emergency department. They tell the nurse that he fell from a 2-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has compound fracture of his left femur and is comatose. In his maintenance, he is incubated and the arterial oxygen pressure at 92 by pulse oximeter. Which intervention by the nurse is the highest priority?

Accepted Answer

Answer reason: Assessing distal pulses (along with color, temperature, capillary refill, sensation, and movement) rapidly identifies ischemia that requires immediate intervention to prevent permanent tissue loss. The client is already oxygenating adequately on pulse oximetry and is intubated, making airway/oxygenation less likely to be the current limiting threat based on the provided data. Trendelenburg is not an appropriate routine intervention for major trauma and can worsen intracranial pressure and respiratory mechanics. While LOC and pupil assessment are important for head injury monitoring, unchecked loss of limb perfusion is time-critical and directly actionable at the bedside in the setting of an open femur fracture.

Question 6

A client was diagnosed as having Dengue fever. You will say that there is slow capillary refill when the color of the nailbed that you pressed does not return within how many seconds?

Accepted Answer

Answer reason: In adults and older children, normal refill is generally ≤2 seconds, so a threshold of ≥3 seconds is commonly used to indicate slow/delayed capillary refill. This aligns with bedside triage for circulatory compromise when monitoring for dengue shock syndrome. Longer thresholds like 5–10 seconds are not used as the primary cutoff and would miss earlier clinically significant hypoperfusion.

Question 7

A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform?

Accepted Answer

Answer reason:  The priority with acute dyspnea in a patient with heart failure is rapid assessment of cardiopulmonary stability before initiating diagnostics. Vital signs (including blood pressure) help identify decompensation such as hypotension from poor cardiac output or hypertension precipitating pulmonary edema, and they guide immediate escalation of care and oxygen/positioning decisions. Asking the patient to lie flat can worsen orthopnea and respiratory distress in heart failure. Labs and imaging may be indicated, but they come after the initial focused assessment that determines urgency and immediate safety needs.

Question 8

A 27 year old female patient is admitted to the hospital for a suspected brain tumor. While assessing patient, nurse would keep in mind that most reliable index of cerebral status is?

Accepted Answer

Answer reason: In patients with intracranial pathology such as a brain tumor, subtle changes in arousal, orientation, and ability to follow commands often occur earlier than focal motor or pupillary changes. Pupillary response can remain normal until later stages or may be affected by medications and baseline differences, making it less reliable as an early global indicator. Deep tendon reflexes are influenced by spinal cord and peripheral factors and do not track acute changes in cerebral perfusion or rising intracranial pressure as directly as mental status does.

Question 9

The post-op craniotomy client's urinary output suddenly increases to 350ml in 30 mins. Which nursing action takes priority?

Accepted Answer

Answer reason: A sudden marked rise in urine output after craniotomy raises concern for diabetes insipidus from pituitary/hypothalamic disturbance, which causes excretion of large volumes of very dilute urine. The fastest bedside action to validate this suspected complication is assessing urine concentration via specific gravity; low values support DI and prompt urgent escalation and treatment to prevent rapid dehydration and hypernatremia. While BP and CVP help evaluate volume status, they may lag behind and do not directly confirm the underlying neuroendocrine cause of the polyuria. ICP monitoring is important post-craniotomy, but increased urine output is not an immediate indicator of rising intracranial pressure and the priority here is recognizing and confirming DI early.

Question 10

Which of the priority nursing assessment in the first 24 hours after admission of client with thrombotic CVA?

Accepted Answer

Answer reason: Frequent neuro checks, including pupil size and reactivity, can signal worsening cerebral edema, brain herniation risk, or hemorrhagic conversion and require immediate escalation. Cholesterol testing and echocardiography are important for secondary prevention and stroke workup but are not the highest-priority bedside assessments in the first 24 hours. Bowel sounds are not a sensitive or urgent indicator of acute stroke complications compared with focused neurologic assessment.

Question 11

A 10-year-old child has been involved in a motor vehicle accident. The emergency room nurse is performing a physical assessment. Which of the following symptoms may indicate a renal injury?

Accepted Answer

Answer reason: This finding directly links the mechanism (motor vehicle accident) to potential renal contusion or laceration and prompts further evaluation (vitals, abdominal/flank exam, urinalysis, and imaging as indicated). Dysuria and bladder spasms are more suggestive of lower urinary tract irritation/infection rather than renal trauma. Vomiting is nonspecific and can occur with many injuries, making it a weaker indicator of renal involvement than urinary bleeding.

Question 12

The nurse is caring for a 57-year-old client with Type II diabetes mellitus. Which of the following findings is most concerning?

Accepted Answer

Answer reason: Ankle-Brachial index of 0.38 An ABI well below 0.90 indicates peripheral arterial disease, and values

Question 13

A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?

Accepted Answer

Answer reason: In a mechanically ventilated client, this subtle change can be an early indicator of inadequate ventilation/oxygenation and the need to assess for and relieve secretion buildup (including suctioning when indicated). Drowsiness is more consistent with oversedation or worsening hypercapnia rather than a typical early cue for suctioning. A pulse of 92 is within normal range, and nausea is nonspecific and does not point to an airway clearance problem.

Question 14

While caring for a child with Reye's Syndrome, the nurse should give which action the highest priority?

Accepted Answer

Answer reason: Frequent neurologic checks detect subtle changes (confusion, lethargy, decreasing responsiveness) that may precede seizures, airway compromise, or herniation and require immediate escalation of care. Monitoring intake and output is important due to vomiting and potential fluid shifts, but it does not identify the life-threatening complication as directly or as early as neurologic assessment. Skin care and range-of-motion address immobility risks but are secondary to stabilizing and trending neurologic status.

Question 15

The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?

Accepted Answer

Answer reason: g., subclavian stenosis) and affect diagnosis and management. Measuring in both arms on initial evaluation helps identify the higher-reading arm, which should be used for subsequent consistent monitoring. Options focused on posture or timing (standing/sitting, supine, after exercise) may be used for specific indications (orthostatic hypotension or standardized resting measurements) but do not address the key initial comparison needed in new hypertension. Establishing the correct arm for ongoing readings reduces misclassification of severity and improves treatment decisions.

Question 16

The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is?

Accepted Answer

Answer reason: Applying pressure to a proximal muscle group such as the trapezius (or using firm peripheral stimulus at the arm) is commonly used to assess localization/withdrawal without causing focal tissue injury. Pinching “any body part” is nonspecific and risks bruising or soft-tissue injury, and a sternal rub can cause skin breakdown and is less preferred. Pressure on the eye orbit can injure the globe and is avoided, especially when there is concern for facial or orbital trauma.

Question 17

The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?

Accepted Answer

Answer reason: The first contraction begins at 10:00 A.M. and the next begins at 10:15 A.M., so the interval between starts is 15 minutes. The end time (10:01 A.M.) is used to calculate duration, not frequency. Confusing duration with frequency can lead to inaccurate assessment of labor progress and uterine activity trends.

Question 18

What assessment data should the nurse obtain next?

Accepted Answer

Answer reason: Inspecting the eyes and tongue provides rapid data on mucous membrane moisture, tear production, and other dehydration clues that help determine urgency and guide next actions. This focused exam can be completed quickly before moving to more detailed history questions. Intake history and dietary patterns are important but are secondary to obtaining current physical indicators that may signal need for prompt intervention. Play activity is a less direct and less sensitive measure for acute volume status compared with oral/ocular assessment findings.

Question 19

Which of these questions is priority when assessing a client with hypertension?

Accepted Answer

Answer reason: " The key principle is identifying reversible causes and unsafe contributors that can acutely worsen blood pressure or interfere with prescribed antihypertensives. Many OTC agents (e.g., NSAIDs, decongestants like pseudoephedrine, stimulant-containing products, some herbal supplements) can raise blood pressure, cause fluid retention, or reduce medication effectiveness. This information immediately affects risk assessment and guides urgent teaching and provider notification if a harmful agent is being used. Lifestyle history (diet, exercise) and family history are important, but they typically inform long-term management rather than uncovering an immediate, modifiable trigger for uncontrolled hypertension.

Question 20

While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following assessments is appropriate for the nurse to perform?

Accepted Answer

Answer reason: The safest bedside assessment is to listen for a vascular bruit to support a vascular etiology while minimizing mechanical stress to the vessel. Palpation or percussion can increase pressure on a potentially fragile aneurysmal wall and is avoided when an aneurysm is suspected. Measuring “length” is not a typical immediate abdominal assessment and would not address the key safety concern.

Question 21

The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?

Accepted Answer

Answer reason: Assessing for this finding is the most direct bedside method to confirm patency and detect early thrombosis or occlusion. Irrigating an access is not a nursing patency check and can introduce infection or damage the access. Color/warmth and edema can reflect perfusion or complications, but they are indirect and less specific than checking for a thrill.

Question 22

A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to?

Accepted Answer

Answer reason: Continuous or frequent pulse oximetry provides rapid, objective detection of oxygenation deterioration and guides urgency of interventions (supplemental O2, repositioning, escalation). Turning, deep breathing, and coughing are important preventive measures but should follow immediate evaluation of respiratory status to ensure the patient is stable to participate. Suctioning is an intervention reserved for evidence of retained secretions or ineffective clearance, not the default first action after assessment unless obstruction is present.

Question 23

The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's mother reports that the child "feels very warm" to touch. The first action by the nurse should be to?

Accepted Answer

Answer reason: A parent’s report that a child feels warm suggests possible fever, but touch is an unreliable measure and the nurse needs a measurable baseline. Confirming the temperature guides next steps (e.g., need for antipyretic, hydration, or further postoperative evaluation). Giving acetaminophen or fluids first could mask a clinically important fever and delays appropriate assessment of postoperative complications.

Question 24

The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis?

Accepted Answer

Answer reason: Needing to stop and rest during play is a classic functional sign of limited cardiopulmonary reserve in young children. This finding directly reflects the physiologic impact of many CHD lesions (e.g., pulmonary overcirculation or cyanotic disease) on activity tolerance. By contrast, recurrent otitis media points more toward ENT issues, and being at the 10th percentile since birth can be constitutional rather than a specific CHD indicator without additional symptoms.

Question 25

A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?

Accepted Answer

Answer reason: In clients with impaired renal function, retained sodium and water can accumulate even when symptoms are subtle, making weight trends especially informative during intermittent (weekly) home visits. Intake and output records are often inaccurate at home and can miss insensible losses, while mucous membranes and skin turgor are subjective and less reliable, particularly in older adults. Therefore, tracking weight consistently under similar conditions provides the best indicator of fluid balance over time.

Question 26

An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider?

Accepted Answer

Answer reason: Worsening lethargy already suggests declining neurologic status; the addition of impaired speech indicates focal cortical involvement and may reflect an evolving stroke. Incontinence and generalized weakness can occur after a stroke but are less specific for an acute change requiring immediate escalation compared with a new language/speech deficit. A rapid pulse is nonspecific and does not directly indicate neurologic deterioration in the same urgent way.

Question 27

A nurse admits a client transferred from the emergency room. The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. The first action by the nurse should be?

Accepted Answer

Answer reason: Vital signs (especially blood pressure, heart rate, oxygen saturation, and respiratory status) determine whether analgesia like an opioid is safe and whether the patient is progressing toward cardiogenic shock or dysrhythmias. After initial assessment, the nurse can promptly facilitate diagnostics and therapies (e.g., obtain ECG per protocol/notify provider and prepare access), but those actions should be guided by the patient’s current physiologic status. Jumping directly to morphine or IV start without first checking hemodynamics risks masking deterioration or causing harm (e.g., hypotension/respiratory depression).

Question 28

A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem?

Accepted Answer

Answer reason: The associated sleep disruption can contribute to nocturnal enuresis, making this combination of symptoms highly suggestive. Initial nursing assessment should focus on exposure history, household contacts with itching, and signs of perianal excoriation, with confirmation typically via the morning “tape test.” Scabies more often causes generalized intense itching (often on hands, wrists, and trunk) rather than isolated perianal itching with nighttime predominance.

Question 29

As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis?

Accepted Answer

Answer reason: " Neuroblastoma commonly presents in young children as an abdominal mass arising from the adrenal gland or sympathetic chain, leading to increasing abdominal girth or a firm, distended abdomen. A parent noticing that clothing is becoming tighter across the abdomen is a practical indicator of progressive intra-abdominal tumor growth and warrants follow-up assessment for mass effect. Weight loss and listlessness can occur with many chronic illnesses and are less specific to this malignancy. Dark, scant urine suggests dehydration/oliguria rather than a typical presenting feature of neuroblastoma.

Question 30

On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the RN anticipate finding?

Accepted Answer

Answer reason: This produces otalgia and systemic/behavioral signs in toddlers such as irritability, along with URI symptoms like rhinorrhea. The hallmark otoscopic finding is a bulging, erythematous tympanic membrane with decreased mobility and loss of landmarks/light reflex. A pearly white tympanic membrane suggests a normal exam, and periorbital edema or enlarged parotid gland point to alternate diagnoses rather than middle-ear infection.

Question 31

For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?

Accepted Answer

Answer reason: Serial daily weights are the most sensitive, objective indicator of changing fluid volume and response to therapy in an edematous child. Regular weights also help detect worsening retention early, which can precede escalation of hypertension and pulmonary edema. Seizure precautions are typically reserved for severe hypertension/encephalopathy, while protein intake and vigorous activity are not priority interventions during acute renal inflammation and volume overload.

Question 32

When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?

Accepted Answer

Answer reason: The priority is to continue focused post-procedure assessment and trending of respiratory status for early detection of sedation-related hypoventilation or deterioration. Measuring oxygen saturation can be helpful, but it is not the first action when the primary finding is a normal respiratory rate and no distress is described. Vigorous stimulation is unnecessary and potentially unsafe unless there is evidence of apnea, decreased level of consciousness, or declining ventilation.

Question 33

A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

Accepted Answer

Answer reason: A Glasgow Coma Scale score quantifies level of consciousness and communicates neurologic status clearly across the care team. Given the client is nonresponsive but has independent, stable breathing, documenting regular respirations alongside a low GCS most precisely captures the condition without implying absent brainstem function. Descriptors like “comatose” or “appears to be sleeping” are less precise and can be misleading in neuromuscular disorders where paralysis may mimic decreased responsiveness.

Question 34

A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment?

Accepted Answer

Answer reason: The expected assessment picture is an otherwise well infant who may be fussy/irritable around feeds and can have increased oral/nasal secretions from frequent regurgitation. Fever with lethargy would suggest infection; diarrhea with poor turgor suggests dehydration from gastroenteritis; and persistent somnolence/listlessness is not typical for simple reflux. Nursing assessment prioritizes identifying benign reflux features versus red flags requiring urgent evaluation (e.g., fever, dehydration, failure to thrive).

Question 35

The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for a gastostomy tube placement, the priority is to?

Accepted Answer

Answer reason: Injecting a small amount of air and listening over the stomach for a rush of air is the only option provided that directly attempts to verify gastric location at the bedside. Placing the tube end in water is a method used to detect airflow from an airway placement, but it does not confirm correct gastric positioning for feeding and is not appropriate for a gastrostomy tube. Pulling back to check resistance risks dislodgement and tissue injury, and measuring nose-to-epigastrium applies to nasogastric tubes rather than a gastrostomy.

Question 36

During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?

Accepted Answer

Answer reason: " Glaucoma causes progressive optic nerve damage that classically produces peripheral visual field loss (tunnel vision) before central acuity is affected. A client compensates for constricted peripheral fields by scanning the environment and turning the head to bring objects into the remaining central field. Unilateral “can’t see on my left side” is more suggestive of a neurologic hemianopia rather than bilateral glaucoma. Floaters point toward vitreous/retinal pathology (e.g., posterior vitreous detachment or retinal tear) rather than chronic glaucoma.

Question 37

An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

Accepted Answer

Answer reason: The immediate nursing priority is to assess airway-protective reflexes and swallowing safety before continuing oral intake. Evaluating the gag reflex helps identify compromised oropharyngeal protective mechanisms and supports the need to hold PO intake and request a formal swallow evaluation if abnormal. Thickening liquids may be helpful for dysphagia, but implementing it without first assessing swallow safety can still allow aspiration and is not the best next step. Increasing IV fluids does not address the acute aspiration risk during feeding.

Question 38

A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?

Accepted Answer

Answer reason: Continuous assessment is the priority when an infant is unstable and receiving a thermoregulation intervention, because it determines whether the treatment is effective and whether the infant is trending toward hypothermia or hyperthermia. Temperature is the key physiologic parameter guiding isolette adjustments and prompts escalation (e.g., additional warming measures, glucose monitoring) if the infant remains cold-stressed. Failure to closely monitor can allow ongoing heat loss or overheating, both of which increase oxygen consumption and metabolic demand in a neonate. The other actions may reduce heat loss or prevent injury in some contexts, but they do not provide the immediate safety feedback needed to manage a newborn with impaired thermoregulation in a warming device.

Question 39

At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states "My blood pressure is usually much lower." The nurse should tell the client to?

Accepted Answer

Answer reason: The safest nursing advice is prompt follow-up within a few days to repeat measurements under standardized conditions and determine whether urgent treatment evaluation is needed. Waiting 2 months risks prolonged uncontrolled hypertension and missed end-organ risk. Immediate provider evaluation is generally reserved for hypertensive crisis (e.g., ≥180/120 and/or acute symptoms or target-organ damage), which is not indicated by the information provided.

Question 40

The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees F for a post surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?

Accepted Answer

Answer reason: Waiting briefly and then rechecking helps differentiate true postoperative fever from an artifact due to the route/timing of measurement. This is an appropriate direction to a UAP because it involves a routine, noninvasive reassessment within their role, while the nurse interprets and acts on the results. Simply documenting the value without addressing the likely cause risks reporting an inaccurate abnormal finding and unnecessary escalation.

Question 41

The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory?

Accepted Answer

Answer reason: " Recent memory is assessed by the ability to register and recall new information over minutes, commonly tested with immediate repetition and short-delay recall of a few unrelated words. This prompt evaluates encoding/registration and very recent recall, which are often impaired in organic brain disorders such as delirium or dementia. Option A primarily assesses orientation to time, which can be abnormal for many reasons and is not a direct test of recent memory formation. Option B assesses attention and concentration (serial sevens), and option D assesses naming/object recognition and comprehension (language/praxis), not recent memory.

Question 42

An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

Accepted Answer

Answer reason: Dependent peripheral edema that improves overnight can indicate fluid retention related to cardiac dysfunction, and the most clinically useful next step is to assess for associated symptoms of decreased cardiac reserve. Exertional dyspnea during normal activities is a key early indicator of heart failure severity and functional limitation, helping determine urgency and need for further evaluation. Asking about a recent heart attack is less targeted and may miss chronic, progressive causes of edema. Orthopnea assessment (pillows at night) is relevant but the edema resolves when supine, so screening for exertional dyspnea more directly evaluates day-to-day cardiopulmonary impact.

Question 43

A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would need to be explored by the nurse to clarify information?

Accepted Answer

Answer reason: Cancer staging reflects extent of disease, with higher stages indicating greater tumor burden and/or spread, not less. A stage 3 testicular cancer generally implies regional lymph node involvement (and is more advanced than stages 1–2), so this statement signals a misunderstanding that requires clarification and teaching. The other statements describe commonly taught aspects of management such as inguinal orchiectomy with possible retroperitoneal lymph node dissection, fertility preservation via sperm banking prior to gonadotoxic therapy, and optional testicular prosthesis. Clarifying staging is important because it affects prognosis, treatment planning, and informed decision-making.

Question 44

An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?

Accepted Answer

Answer reason: Assessing neurologic status first helps determine immediate safety risks (airway protection, aspiration risk, fall risk) and whether urgent escalation is needed. Fever-related confusion may occur even before focal infection findings are obvious, especially in geriatric clients. Lung sounds and urine output help localize infection sources, but they are secondary once immediate stability and neurologic function are verified. Appetite is least urgent and does not address potential acute instability.

Question 45

BRADEN SCALE IS USED FOR ASSESSING THE RISK FOR?

Accepted Answer

Answer reason: Lower scores indicate higher risk and prompt preventive interventions such as turning schedules, pressure-redistributing surfaces, and moisture management. This directly targets prevention of skin breakdown from sustained pressure and shear. The other options are medical conditions or infections that are not what the Braden Scale measures or predicts.

Question 46

During the ictal phase, which of the following is important in the assessment of the client?

Accepted Answer

Answer reason: During the ictal phase, the priority assessment is characterizing the seizure activity as it occurs (motor manifestations, eye/head deviation, tone, and progression), because these observations help classify seizure type and localize onset. Noting rigidity, rhythmic movements, and eye deviation also helps determine if the event is focal vs generalized and supports evaluation of airway risk during convulsive activity. Vital signs and pulse oximetry are often unreliable or unsafe to obtain during active convulsions and are more appropriate immediately after the seizure (postictal). Aura type and what the client was doing beforehand are preictal data and are typically collected after the episode when the client is stable.

Question 47

A nurse is educating the caregiver of a child diagnosed with Duchenne muscular dystrophy. Which is the best description of Gower’s sign?

Accepted Answer

Answer reason: ” Gower’s sign reflects proximal muscle weakness, especially of the hip and thigh muscles, which is characteristic of Duchenne muscular dystrophy. When standing, the child compensates by pushing on the floor and then using the hands on the knees/thighs to climb up the body to achieve an upright posture. This is a classic assessment finding that indicates weakness rather than abnormal involuntary movements or a reflex phenomenon. The other choices describe a deep tendon reflex response, fatigability, or tremor, none of which specifically define this compensatory rise maneuver.

Question 48

A 59-year-old client comes to the clinic due to a blistering, linear rash on the left chest. The client reports itching and pain around the rash. What is the priority question for the nurse to ask the client?

Accepted Answer

Answer reason: " A unilateral, painful, blistering linear rash on the chest is most consistent with herpes zoster reactivation in a dermatomal pattern, which occurs only after prior varicella infection. Establishing a history of chickenpox (or varicella vaccination) is the fastest way to confirm the most likely etiology and guides timely antiviral treatment to reduce duration and risk of postherpetic neuralgia. Asking about new medications is less prioritized because drug eruptions are typically more diffuse and not dermatomal. Symptom-relief questions are important but come after identifying the likely cause driving infection-control counseling and treatment decisions.

Question 49

The most important assessment for the nurse to make after a client has had a femoropopliteal bypass for peripheral vascular disease would be?

Accepted Answer

Answer reason: Distal pedal pulses are a direct, repeatable indicator of arterial flow beyond the surgical site and should be assessed frequently and compared bilaterally (often with Doppler if needed). Capillary refill is supportive but less specific and can be influenced by temperature and vasoconstriction, making it a secondary indicator. Incisional pain is expected postoperatively and is not as time-critical as detecting compromised circulation. Hair growth reflects chronic perfusion status and is not useful for immediate postoperative assessment.

Question 50

..In which of the following clients is a rectal temperature most usually contraindicated?

Accepted Answer

Answer reason: Rectal temperature measurement can stimulate the vagus nerve via rectal mucosal manipulation, which may trigger bradycardia and dysrhythmias. After a myocardial infarction, minimizing vagal stimulation and avoiding hemodynamic instability is a key safety principle during assessment. Therefore, choosing a noninvasive route (oral/tympanic/temporal, as appropriate) is safer in this population. Seizure risk, Parkinsonism, or diabetic neuropathy are not typical primary contraindications for the rectal route compared with the cardiac risk from a recent infarction.

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