Question 1

During a scoliosis screening, a school nurse notices a raised iliac crest height. She should suspect which condition?

Accepted Answer

Answer reason: This functional malalignment can also produce a compensatory spinal curve that may mimic or contribute to scoliosis. In contrast, forward head posture relates to cervical alignment, while increased thoracic kyphosis and increased lumbar lordosis are sagittal-plane curvature changes that do not primarily present as unequal iliac crest heights. Therefore, the most direct explanation for a raised iliac crest is a leg length discrepancy.

Question 2

What findings would the nurse expect when palpating the muscles of a child with muscular dystrophy?

Accepted Answer

Answer reason: On physical exam, affected muscles—especially the calves—often feel firm or “woody” rather than normally supple due to fibrosis and fatty infiltration. A soft finding is less consistent with the typical pseudohypertrophic phase and would not match expected structural replacement changes. “Extremely hard” suggests marked spasticity/rigidity or calcification rather than the common dystrophic palpation finding, and “no muscle consistency” is nonspecific and not a recognized expected assessment characteristic.

Question 3

A client’s echocardiogram indicates vegetation on the heart valves. The nurse knows that the vegetation may be caused by which condition?

Accepted Answer

Answer reason: Valvular vegetations are hallmark findings of infective endocarditis, in which microorganisms adhere to damaged endocardium and form platelet-fibrin thrombi containing bacteria. Echocardiography visualizes these masses on the valve leaflets, most commonly due to bacteremia (e.g., Staphylococcus or Streptococcus species). Diabetes can increase infection risk but does not directly produce valve vegetations as a primary mechanism. Myocardial infarction and hypertension may alter cardiac function/structure but are not causes of valvular vegetations.

Question 4

The nurse cares for a client diagnosed with leftsided heart failure. The nurse knows that one of the symptoms of left-sided heart failure is?

Accepted Answer

Answer reason: Left-sided heart failure reduces left ventricular pumping ability, causing blood to back up into the pulmonary circulation and raise pulmonary capillary pressure. This increased hydrostatic pressure forces fluid into the alveoli/interstitium, producing pulmonary congestion and edema with dyspnea, crackles, and orthopnea. Findings like jugular venous distension and hepatomegaly are more typical of right-sided heart failure due to systemic venous congestion. Therefore the option reflecting pulmonary fluid overload best matches left-sided failure.

Question 5

Which landmarks are used to obtain an apical pulse?

Accepted Answer

Answer reason: The apical impulse (point of maximal impulse) is best auscultated over the mitral area, which is located at the left 5th intercostal space at the midclavicular line. This site corresponds to the left ventricular apex where heart sounds (especially S1) are typically loudest and most reliable for counting an apical pulse. The 2nd intercostal space is associated with the aortic/pulmonic areas rather than the apex, and the midaxillary line is too lateral for standard apical assessment. Using the correct landmark reduces risk of inaccurate pulse measurement when comparing apical and peripheral pulses or before administering rate-limiting medications.

Question 6

The nurse finds a client to have increased tactile fremitus. Which condition is associated with increased tactile fremitus?

Accepted Answer

Answer reason: Tactile fremitus increases when lung tissue becomes more dense and transmits vocal vibrations more efficiently. Consolidation from infection fills alveoli with inflammatory exudate, creating a solid medium that enhances vibration transmission to the chest wall. Conditions that increase pleural air (pneumothorax) or overinflate the lungs (COPD) dampen vibration transmission and reduce fremitus. Atelectasis typically decreases fremitus when there is bronchial obstruction preventing vibration from reaching the chest wall.

Question 7

In order to assess the function of a client’s optic nerve, the nurse would be required to use which equipment?

Accepted Answer

Answer reason: A Snellen chart directly assesses central visual acuity, making it an appropriate bedside tool to evaluate CN II function. Corneal reflexes and corneal sensitivity evaluate trigeminal (CN V) and facial (CN VII) function rather than the optic nerve. Testing cardinal fields is primarily an extraocular muscle/oculomotor assessment (CN III, IV, VI), not the optic nerve.

Question 8

A thin client is sitting up in bed talking on the phone and has a blood pressure of 90/50 mm Hg. Which nursing action is correct?

Accepted Answer

Answer reason: Orthostatic hypotension is suggested when a low blood pressure occurs in an upright position, especially in clients with low body mass or possible volume depletion, and the immediate nursing priority is to assess positional changes and symptoms. With the client sitting up and conversing, this reading may reflect a postural drop rather than an acute decompensation requiring emergent provider notification. The appropriate next nursing action is focused assessment: obtain orthostatic vital signs (supine, sitting, standing) and evaluate for dizziness, weakness, or syncope risk. Empirically increasing fluids is not safe without assessing for contraindications (e.g., heart failure, renal impairment) and determining whether the hypotension is truly volume-related. Documentation alone is incomplete because it fails to address the potential cause and the client’s safety risk from positional hypotension.

Question 9

The nurse is assessing the client for possible scabies infestation. Which findings should the nurse expect?

Accepted Answer

Answer reason: The described itchy, papule-like eruption is the classic assessment finding and aligns with typical distribution patterns (e.g., finger webs, wrists, waistline). Serosanguineous drainage with fever suggests secondary bacterial infection or another inflammatory process rather than uncomplicated scabies. Macules with blisters are more consistent with viral exanthems or contact dermatitis than mite infestation.

Question 10

The client is experiencing vocal cord paralysis after extubation from prolonged ET intubation. Which symptom should prompt the nurse to conclude that only one vocal cord is affected?

Accepted Answer

Answer reason: With only one cord affected, the airway usually remains patent enough for adequate ventilation, so the dominant finding is a breathy or weak voice. Bilateral vocal cord paralysis is more likely to narrow the glottic opening significantly, producing stridor and potentially severe respiratory distress. Apnea would not be the expected distinguishing symptom of isolated unilateral cord dysfunction and would suggest a different or more severe process.

Question 11

The nurse is assessing the client who just arrived by ambulance following an MVA. Which assessment finding should the nurse associate with a possible pulmonary contusion?

Accepted Answer

Answer reason: Hemoptysis can occur because the bruised lung tissue leaks blood into the airways, making bloody sputum a key assessment clue after blunt chest trauma such as an MVA. Stridor points to upper-airway obstruction (e.g., laryngeal edema) rather than lung parenchymal injury. Increased breath sounds are not typical for contusion, which more often produces crackles and/or diminished breath sounds as edema and hemorrhage progress.

Question 12

The client presents with vaginal bleeding at 7 weeks. Which action should be taken by the nurse first?

Accepted Answer

Answer reason: Obtaining vital signs quickly identifies tachycardia and hypotension that suggest significant blood loss and guides the urgency of escalation and interventions. Oxygen is not routinely indicated without evidence of respiratory distress or shock, and preparing equipment can follow once stability is assessed. Psychosocial assessment is important, but it comes after physiologic assessment and stabilization.

Question 13

The nurse is assessing a client for an abdominal aortic aneurysm. Which area does the nurse palpate?

Accepted Answer

Answer reason: The abdominal aorta is most accessible to palpation in the midline of the abdomen, typically around the level of the umbilicus in most adults. This location best allows detection of an abnormal pulsatile mass while avoiding unrelated quadrant-based organ findings. Options describing right or left of midline are less anatomically appropriate because the aorta lies primarily midline, with bifurcation occurring lower in the abdomen.

Question 14

A nurse is teaching a client about cardiomyopathy and determines further teaching is needed when the client states?

Accepted Answer

Answer reason: ” Cardiomyopathy is a primary disease of the heart muscle that leads to impaired contractility, relaxation, or electrical stability rather than a problem originating from coronary artery plaque. Atherosclerotic plaque causes coronary artery disease and myocardial ischemia/infarction, which can secondarily weaken the myocardium (ischemic cardiomyopathy), but plaque itself is not the direct cause of cardiomyopathy as taught in general patient education. Viral infection is a well-known cause of myocarditis that can progress to dilated cardiomyopathy, and certain drugs (e.g., anthracyclines, alcohol, cocaine) can be cardiotoxic and cause cardiomyopathy. Bacterial processes are more classically associated with infective endocarditis; while severe infection can affect the heart, it is not a typical primary teaching point for cardiomyopathy etiology compared with viral and drug/toxin causes.

Question 15

Which finding suggests to the nurse that fluid resuscitation has been effective for a 23-year-old client admitted in hypovolemic shock?

Accepted Answer

Answer reason: In adults, a common target is at least about 0.5 mL/kg/hr, which often approximates ≥30 mL/hr for many patients, signaling improving circulating volume and cardiac output. Lower hourly outputs suggest ongoing hypoperfusion and risk of acute kidney injury despite interventions. Therefore, this value best reflects an effective response to volume replacement.

Question 16

The nurse is aware that a client with a diagnosis of thrombocytopenia would be likely to complain of which of the following?

Accepted Answer

Answer reason: This commonly presents as easy bruising (ecchymoses) and petechiae from capillary bleeding with minimal or no trauma. In contrast, weakness and fatigue are more characteristic of anemia from reduced oxygen-carrying capacity rather than low platelets. Nausea, light-headedness, and vomiting are nonspecific symptoms and do not directly reflect a platelet-related bleeding tendency.

Question 17

The trauma nurse is caring for a client who was involved in an automobile accident. The trauma nurse would assess the client for which of the following classic fractures?

Accepted Answer

Answer reason: The clavicle is frequently fractured with shoulder seatbelt or direct impact mechanisms, and proximal humerus fractures also occur with falls/impact or transmitted forces to the shoulder. A focused trauma assessment prioritizes likely injury patterns to prevent missed fractures and neurovascular compromise around the shoulder. Options using “brachial” are anatomically imprecise for a bone fracture label, and an occipital fracture is not a classic paired musculoskeletal fracture pattern for this context.

Question 18

A nurse is caring for a client with homonymous hemianopia. The most important information for the nurse to teach the client is?

Accepted Answer

Answer reason: Homonymous hemianopia causes loss of the same visual field in both eyes, creating a major safety risk from unseen hazards on the affected side. Teaching systematic scanning and turning the head toward the impaired side reduces collisions, falls, and missed objects during ambulation and ADLs. This strategy is a direct compensatory technique that improves functional vision and environmental awareness immediately. The other choices address cognitive support, fatigue, or general decision-making, but they do not target the primary deficit or its highest-risk complication (injury).

Question 19

The nurse views the term “pink puffer” on a client’s chart. This assessment finding leads the nurse to suspect that the client may be experiencing?

Accepted Answer

Answer reason: “Pink puffer” classically describes an emphysema-predominant COPD presentation, where alveolar destruction leads to air trapping and increased work of breathing. Clients often compensate with tachypnea and pursed-lip breathing to maintain oxygenation longer, so they may appear relatively well oxygenated (“pink”) despite significant dyspnea (“puffer”). Chronic bronchitis is more associated with “blue bloater” due to prominent hypoxemia and hypercapnia with productive cough. ARDS and asthma are acute inflammatory processes and are not the classic context for this chronic COPD phenotype label.

Question 20

The nurse determines that a child with Kawasaki disease has entered the subacute phase when the assessment includes which of the following?

Accepted Answer

Answer reason: The subacute phase commonly features periungual peeling/desquamation of the hands and feet after the acute febrile period begins to resolve. Polymorphous rash and cervical lymphadenopathy are more characteristic of the acute phase criteria rather than the transition into subacute. “Normal blood values” is inconsistent because inflammatory markers and platelet count can remain abnormal (often thrombocytosis) during the subacute period, reinforcing that peeling is the key phase indicator.

Question 21

In the neonatal intensive care unit, the nurse is assessing the neonate of a mother with poorly controlled diabetes. The nurse would assess the neonate for which condition?

Accepted Answer

Answer reason: Congenital heart defects (e.g., VSD, transposition of the great arteries) are among the most common and clinically significant malformations associated with poorly controlled pregestational diabetes, so targeted cardiovascular assessment and screening are priority. This aligns with newborn risk assessment in the NICU to identify complications requiring prompt intervention. By contrast, findings like low-set ears are more classically associated with chromosomal syndromes, and cataracts are more linked to congenital infections (e.g., rubella) rather than maternal diabetes.

Question 22

On assessment of a child’s skin, the nurse notes a papular, pruritic rash with some vesicles. The rash is profuse on the trunk and sparse on the distal limbs. Based on this assessment, which illness does the client have?

Accepted Answer

Answer reason: The presence of vesicles along with itching strongly supports this diagnosis compared with other childhood exanthems. Measles usually presents with a morbilliform (maculopapular), nonvesicular rash that begins on the face and spreads downward and is accompanied by cough, coryza, and conjunctivitis. Roseola classically features high fever that resolves before a nonpruritic rash appears, and mumps is characterized primarily by parotitis rather than a vesicular rash.

Question 23

The nurse is assessing a client with leukemia. What assessment findings would indicate that the cancer has invaded the brain?

Accepted Answer

Answer reason: g., CNS infiltration/meningeal involvement) commonly presents with signs of increased intracranial pressure. Headache with vomiting is a classic symptom cluster suggesting elevated ICP and warrants urgent evaluation. The other options reflect nonspecific anxiety or cardiovascular changes that are more consistent with stress, anemia, infection, or hypovolemia rather than direct brain invasion. A key nursing assessment focus is recognizing new neurologic symptoms early to prompt rapid diagnostic workup and treatment.

Question 24

A 6-year-old child has been diagnosed with Rocky Mountain spotted fever. In teaching the parents about the cause of the illness, a nurse would be correct in telling them that a bite by which animal or insect caused the illness?

Accepted Answer

Answer reason: Knowing the vector is key to prevention teaching, including prompt tick removal and use of protective clothing and repellents in endemic areas. A mosquito is a common distractor because it transmits other febrile illnesses, but it is not the typical vector for this disease. Early recognition of tick exposure supports timely evaluation and treatment to reduce severe complications.

Question 25

A child is admitted with severe dehydration. The nurse would assess the child for which finding?

Accepted Answer

Answer reason: Markedly decreased tissue turgor leads to skin “tenting,” a classic sign of substantial fluid loss, especially when accompanied by other perfusion abnormalities. A capillary refill time under 2 seconds indicates adequate perfusion and is inconsistent with severe dehydration. Dry mucous membranes and pallor can occur with dehydration, but the combination of mottling plus tenting is more suggestive of advanced volume depletion.

Question 26

A child has a desquamation rash of the hands and feet. Which additional findings should the nurse expect to observe with this rash?

Accepted Answer

Answer reason: g., post-scarlet fever or Kawasaki-related changes). This finding is a direct description of the expected morphology of a desquamating rash. The other options describe different dermatologic patterns (atrophy/translucency, burrows, or raw erythematous epidermal loss) that are more consistent with conditions like scabies, chronic steroid/aging changes, or severe blistering disorders. Therefore the most consistent additional finding is superficial peeling.

Question 27

A child is suspected of having cellulitis. What classic signs should the nurse expect to see in a child?

Accepted Answer

Answer reason: The expected assessment includes erythema with warmth, swelling/edema, and tenderness/pain, and children may also have fever from the infectious process. Vesicular blisters suggest herpes/varicella or bullous disorders rather than typical cellulitis. Well-defined borders are more consistent with erysipelas, whereas cellulitis commonly has more diffuse, poorly demarcated margins.

Question 28

A child has a healed wound from a traumatic injury. His mother is concerned because a lesion formed over the wound is pink, thickened, smooth, and rubbery in nature. The nurse should use what term to discuss this condition with the mother?

Accepted Answer

Answer reason: This overgrowth produces a thickened scar that can extend beyond the original wound margins and is more common in some children and after trauma. Erosion and fissure describe active skin breakdown (superficial loss of epidermis or a linear crack), not a healed, raised scar. Striae are linear atrophic bands from skin stretching (e.g., growth spurts, steroids) rather than a localized post-traumatic thick scar.

Question 29

The school nurse is providing instructions on scoliosis screening for the student nurses. The nurse explains that which structure is best to observe when screening a child?

Accepted Answer

Answer reason: The vertebral spinous processes form a visible and palpable midline reference; deviation from a straight vertical line suggests abnormal curvature. Iliac crests and posterior superior iliac spines primarily help assess pelvic tilt or leg-length discrepancy, which can contribute to posture but are less direct for identifying spinal curvature. Shoulder (acromion) asymmetry may be present, but it is less specific because it can reflect muscular imbalance or posture rather than vertebral alignment. Therefore, observing the spinous processes provides the most direct screening indicator for scoliosis.

Question 30

Which condition would alert the nurse that a child might be suffering from muscular dystrophy?

Accepted Answer

Answer reason: Weak hip and trunk extensors contribute to an exaggerated lumbar curve as the child shifts the center of gravity to maintain balance while standing and walking. Spasticity, hypertonia, and hyperreflexia are more consistent with central nervous system involvement (upper motor neuron lesions), not primary muscle fiber degeneration. Recognizing this posture change helps prompt further evaluation for associated findings such as Gower’s sign and delayed motor milestones.

Question 31

Which sign should alert a nurse that an 18-month-old child with croup is experiencing increased respiratory distress?

Accepted Answer

Answer reason: Intercostal retractions are an objective sign of worsening respiratory distress and can precede fatigue and respiratory failure if not addressed. A barking cough is a common hallmark of croup but does not by itself indicate deterioration. Clubbing and increased anterior-posterior diameter suggest chronic hypoxemia or long-standing obstructive disease rather than an acute worsening episode of croup.

Question 32

The nurse is caring for the postoperative client who reports an inability to void. Which initial action by the nurse is most appropriate?

Accepted Answer

Answer reason: Determining when the client last voided helps gauge urgency and risk of bladder overdistention and guides next steps such as bladder scanning and provider notification thresholds. This is the least invasive, safest initial action and establishes a baseline for ongoing monitoring. Noninvasive comfort measures can be attempted after assessment, while catheterization is invasive and increases infection risk, so it should not be the first step unless retention is confirmed and significant.

Question 33

The nurse monitors a client who receives treatment for an asthma attack. The nurse knows the client’s respiratory status has worsened if which occurs?

Accepted Answer

Answer reason: Worsening asthma can progress from bronchospasm with audible wheeze to critical airflow limitation where very little air moves, causing quiet or absent breath sounds (“silent chest”). This finding signals impending respiratory failure because decreased ventilation reflects severe obstruction, fatigue, or poor air exchange despite treatment. Wheezing or rhonchi can occur with ongoing bronchoconstriction/secretions and may still be compatible with some airflow, whereas reduced sounds indicate markedly reduced air movement. Clear breath sounds would generally indicate improved airway patency and response to therapy.

Question 34

A client is diagnosed with iron-deficiency anemia. The nurse expects which complaint from the client?

Accepted Answer

Answer reason: Iron-deficiency anemia lowers hemoglobin, reducing oxygen-carrying capacity and causing tissue hypoxia. Hypoxia commonly presents with fatigue, exertional dyspnea, and can progress to dyspnea at rest in more significant anemia. Flushing is not typical because anemia more often causes pallor. Altered taste can occur with some conditions, but a primary expected complaint in iron-deficiency anemia is shortness of breath related to decreased oxygen delivery.

Question 35

The nurse examines a client’s external auditory canal and tympanic membrane with an otoscope. Which is the best way to position the ear for the examination?

Accepted Answer

Answer reason: Straightening the external auditory canal is the key principle for safe, accurate otoscopic visualization of the canal and tympanic membrane. In adults and older children, pulling the auricle up and back aligns the S-shaped canal to allow insertion of the speculum with less discomfort and a clearer view of the eardrum. Pulling downward is generally used for infants/toddlers because their canal angle differs, making it less appropriate as the best general approach here. Manipulating the tragus is more relevant to assessing tenderness (e.g., otitis externa) than optimizing the canal for otoscopy.

Question 36

The nurse cares for a client diagnosed with bronchial obstruction. Which assessment finding should the nurse expect to find?

Accepted Answer

Answer reason: Bronchial obstruction increases airway resistance and traps secretions, so assessment commonly reveals cough with mucus as the body attempts to clear the obstructed airways. Obstructive processes are more consistent with abnormal breath sounds (e.g., wheezes/rhonchi) than with normal auscultation findings. Rust-colored sputum is classically associated with pneumococcal pneumonia rather than obstruction as the primary issue. Clients with obstruction typically show increased work of breathing, so reduced accessory muscle use would be unexpected.

Question 37

A client at a routine blood glucose screening for diabetes mellitus tells a nurse he has excessive urination and excessive thirst. The priority question by the nurse would address which of the following?

Accepted Answer

Answer reason: Acute or progressive visual changes can indicate significant glucose elevations causing lens swelling or diabetic retinopathy, which has immediate implications for driving, falls, and urgent referral. Asking about vision helps gauge severity and potential end-organ involvement during screening. Other symptoms like weakness, weight loss, and increased hunger are common in diabetes but are less immediately safety-critical than potential vision impairment.

Question 38

Following electroconvulsive therapy (ECT), which nursing intervention would be implemented?

Accepted Answer

Answer reason: Vital signs and cardiopulmonary status can change after ECT due to transient autonomic instability, so monitoring provides immediate data to identify hypotension/hypertension, dysrhythmias, or respiratory depression. The client should not be left alone because postictal confusion and sedation increase risk for aspiration and injury. Family visitation is typically delayed until the client is stable and oriented, and restraints are not routine—used only if absolutely necessary for safety and with the least restrictive approach.

Question 39

The nurse administers tamsulosin (Flomax) to a client with benign prostatic hyperplasia (BPH)? The nurse is aware that which of the following is a priority assessment?

Accepted Answer

Answer reason: The priority is to assess whether the medication is achieving its intended outcome, which is reduced obstructive urinary symptoms and improved urine flow. Monitoring the client’s urinary frequency, hesitancy, weak stream, nocturia, and sense of incomplete emptying directly evaluates treatment effectiveness and detects worsening retention. Prostate size and testosterone levels are not immediate nursing priorities for evaluating response to this therapy, and renal function testing is typically guided by broader clinical context rather than being the primary assessment specific to this medication’s effect.

Question 40

A client admitted for acute pyelonephritis is about to start antibiotic therapy. Which symptom would the nurse expect this client to present?

Accepted Answer

Answer reason: This presentation is typically accompanied by costovertebral angle tenderness, making localized flank discomfort on the involved side an expected finding. Hypertension is not a typical acute presenting symptom and is more associated with chronic renal disease or specific renal vascular/endocrine etiologies. The absence of costovertebral angle tenderness would argue against acute pyelonephritis rather than support it.

Question 41

The client returns to a hospital unit after undergoing placement of a vena cava filter. Which intervention should the nurse implement?

Accepted Answer

Answer reason: After vena cava filter placement, the immediate nursing priority is monitoring for access-site complications from venous catheterization, especially bleeding or hematoma. The femoral (groin) puncture site is a common entry point, and early assessment can prevent occult blood loss and detect complications requiring prompt intervention. Restarting anticoagulation is provider-directed and depends on bleeding risk and procedure details, so it is not the first universal nursing action on return to the unit. An abdominal incision is not expected for typical percutaneous filter placement, and routine “dye excretion” hydration is not the key postprocedure safety focus compared with puncture-site assessment and hemodynamic monitoring.

Question 42

The nurse is assessing the client who is to have a closed reduction for a right elbow dislocation. Which should be the nurse’s priority?

Accepted Answer

Answer reason: g., brachial artery, median/ulnar nerve), and early detection prevents ischemia and permanent nerve injury. The priority pre-reduction assessment is neurovascular status distal to the injury, especially pulses and sensation, to establish a baseline and identify emergent compromise. Pain scoring is important but does not supersede limb perfusion and neurologic function. Bruising and handedness are relevant history details but are not time-critical compared with assessing circulation and sensation.

Question 43

The client, who had a stroke, follows the nurse’s instructions without problems, but an attempt to verbally respond to the nurse’s question was garbled. The nurse should identify that the client has which type of aphasia?

Accepted Answer

Answer reason: Garbled, impaired verbal output with preserved understanding is characteristic of expressive (Broca) aphasia after stroke. Global aphasia would significantly impair both comprehension and expression, which does not match the scenario. Anomic aphasia primarily causes word-finding difficulty with otherwise fluent speech, not markedly garbled responses.

Question 44

The nurse reviews the chart of the client diagnosed with closed-angle glaucoma. Which documented finding should the nurse question with the HCP?

Accepted Answer

Answer reason: The classic presentation includes severe eye pain with decreased vision and systemic symptoms such as nausea and vomiting from the vagal response to intense pain. Therefore, documenting a normal intraocular pressure is inconsistent with the expected pathophysiology and should prompt the nurse to clarify whether the diagnosis or measurement is incorrect or whether the condition has resolved/was treated. While decreased visual acuity can occur in glaucoma, the key defining acute feature that should align with the diagnosis is elevated intraocular pressure.

Question 45

The client is receiving treatment with gentamicin ophthalmic solution for bacterial conjunctivitis. Which symptom, described by the client, indicates that the medication is ineffective?

Accepted Answer

Answer reason: An effective topical aminoglycoside should reduce bacterial load, leading to decreased discharge and redness over time. Eye strain and difficulty reading small print are more consistent with refractive/visual issues or irritation rather than treatment failure for conjunctivitis. Eyelid/eye twitching is typically benign myokymia and is not a reliable indicator of persistent ocular infection.

Question 46

The ED nurse is assessing the pediatric client with a tentative diagnosis of acute pericarditis. Which assessment finding should the nurse conclude supports acute pericarditis?

Accepted Answer

Answer reason: This rub is a classic, high-yield bedside finding that directly supports the diagnosis during auscultation. A pleural friction rub points instead to pleural inflammation (pleuritis) rather than pericardial disease. Bilateral leg pain is not a typical indicator of pericardial inflammation and would suggest a different process (e.g., musculoskeletal pain or vascular issues).

Question 47

The nurse is caring for a client with skeletal traction to the right leg. The client complains of severe right leg pain. Which action should the nurse perform first?

Accepted Answer

Answer reason: Severe pain in a client in skeletal traction can signal loss of traction effectiveness or neurovascular compromise, so the nurse should assess for correct traction setup and body alignment first. Malalignment (not centered in bed, sliding down, improper counter-traction) can increase muscle spasm and pain and is a common, correctable cause. Removing weights is contraindicated without a prescription because it disrupts traction and can worsen injury. After ensuring alignment/traction is functioning and completing a focused neurovascular check, the nurse would then escalate care (e.g., notify the provider) if pain remains severe or assessment suggests complication.

Question 48

Which of the following clinical manifestations would lead the nurse to suspect that the client has a dislocation of the left hip?

Accepted Answer

Answer reason: An apparent limb-length discrepancy is a key assessment cue that the joint is no longer anatomically aligned, and it should prompt urgent evaluation due to neurovascular risk. In contrast, groin pain with an abnormal gait is more consistent with chronic hip pathology (e.g., arthritis) and is not specific for an acute dislocation. Positioning findings for dislocation are classically abnormal and fixed, and limb length/deformity is more discriminating than nonspecific pain descriptors.

Question 49

The nurse is performing an assessment on a client with a suspected diagnosis of asthma. Which assessment finding supports the diagnosis?

Accepted Answer

Answer reason: This commonly manifests on auscultation as diffuse wheezing, which may be heard during expiration and, in more significant obstruction, also during inspiration. An increased forced expiratory volume would be inconsistent because obstructive disease decreases expiratory flow rates (e.g., reduced FEV1). Circumoral cyanosis is a late, severe sign of hypoxemia and is not the typical supportive finding for diagnosing asthma during routine assessment, while normal breath sounds do not support airway narrowing.

Question 50

A client experienced smoke inhalation and developed pulmonary edema. The nurse auscultates the client's breath sounds and anticipates hearing which of the following?

Accepted Answer

Answer reason: This classic finding is heard as crackles (rales), often beginning at the lung bases and potentially progressing as edema worsens. Wheezing is more characteristic of bronchospasm from airway narrowing (e.g., asthma or irritant-induced bronchoconstriction) rather than alveolar flooding. Rhonchi suggest larger-airway secretions and may improve with coughing, which is less specific for edema than crackles.

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