Question 1

The nurse is obtaining a pulse oximetry reading on a client. The nurse is aware that analysis of the results will provide information regarding?

Accepted Answer

Answer reason: Pulse oximetry estimates arterial oxygen saturation (SpO2), which reflects how much hemoglobin is bound to oxygen rather than measuring dissolved oxygen content. It does not provide information about ventilation adequacy or carbon dioxide levels; CO2 assessment requires arterial blood gases or capnography. A normal or improving SpO2 suggests adequate oxygenation at the level of hemoglobin, but it can be misleading in conditions like carbon monoxide poisoning or poor peripheral perfusion. Respiratory rate is assessed by observation, not by pulse oximetry.

Question 2

During the assessment of a child with growth hormone deficiency, the nurse would expect to observe which finding?

Accepted Answer

Answer reason: The child typically has delayed bone age, increased subcutaneous fat, and a youthful facial appearance, but body proportions remain normal. Disproportionate skeletal findings suggest disorders like achondroplasia or other skeletal dysplasias rather than an endocrine growth deficiency. Limb overgrowth would be more consistent with excess growth hormone, not deficiency.

Question 3

Which condition assessed by the nurse would be an early warning sign of childhood cancer?

Accepted Answer

Answer reason: Finding a lump or swelling on exam is a specific, high-yield cue that warrants prompt evaluation because childhood cancers often present with painless masses. This assessment finding is more directly suggestive of malignancy than nonspecific symptoms like cough/hoarseness or mild bowel/bladder changes, which commonly have benign infectious or functional causes. Early identification by routine inspection and palpation supports timely diagnostic workup and reduces risk of delayed treatment.

Question 4

While caring for a 2-day-old neonate, a nurse notices the left side of the neonate becomes reddened for 2 to 3 minutes. The nurse interprets this finding as suggestive of which condition?

Accepted Answer

Answer reason: The brief duration (minutes) and unilateral reddening in a 2-day-old fits this normal newborn finding. Contact dermatitis would more typically cause localized persistent erythema with possible rash related to an irritant or allergen rather than a sudden half-body change. Tet spells cause episodic cyanosis and respiratory distress, not isolated unilateral flushing.

Question 5

Which complication involving leg length should a nurse anticipate in a client with developmental dysplasia of the hip?

Accepted Answer

Answer reason: With hip subluxation/dislocation, the femur sits higher and posterior, producing apparent limb-length discrepancy and contributing to asymmetry findings on assessment. This aligns with classic screening cues such as the Galeazzi (Allis) sign, where knee height is lower on the affected side when hips and knees are flexed. Options suggesting increased leg length or no change are inconsistent with the typical positional shortening seen in DDH, and increased abduction is the opposite of the usual limitation.

Question 6

Which history finding is the most significant related to developmental dysplasia of the hip (DDH)?

Accepted Answer

Answer reason: Breech presentation is a classic, high-yield risk factor because hip flexion with knee extension in utero can promote subluxation/dislocation. This history finding should heighten suspicion and prompt careful hip screening and follow-up imaging when indicated. Maternal activity, neonatal calcium level, and low Apgar scores are not established primary risk factors for DDH and do not specifically relate to hip joint instability.

Question 7

During the recovery stages of croup, a nurse should explain which intervention to parents?

Accepted Answer

Answer reason: Teaching parents to monitor for stridor at rest, increased work of breathing (retractions, nasal flaring), tachypnea, cyanosis, and decreased responsiveness supports prompt escalation of care before airway compromise. Oral fluids should generally be encouraged as tolerated to prevent dehydration rather than restricted. Activity and diet guidance are less safety-critical than recognizing and responding to signs of airway obstruction during recovery.

Question 8

The nurse is planning care for an infant with bronchiolitis who requires monitoring for dehydration. What is the most important intervention for the nurse to provide?

Accepted Answer

Answer reason: Urine output is one of the earliest and most reliable indicators of hydration and renal perfusion in infants, and diaper weights provide the most precise measurement when voids cannot be collected in a hat or urinal. This allows timely recognition of oliguria and earlier intervention (e.g., increasing oral/IV fluids) before hemodynamic compromise occurs. While overall intake and output documentation is important, it is less accurate in infants because small voids are easily missed or underestimated without diaper weighing. Routine frequent blood draws or urinalysis schedules do not monitor hydration status as directly and add unnecessary invasiveness.

Question 9

A nurse is caring for a full-term pregnant client in active labor. The electronic fetal monitor reveals a fetal heart rate of less than 70 beats/minute. The nurse interprets this as which of the following?

Accepted Answer

Answer reason: A value under 70 bpm represents profound slowing that suggests significant fetal hypoxia, cord compression, or other acute compromise and requires urgent assessment and intrauterine resuscitation measures. This finding is not normal and is the opposite of tachycardia (>160 bpm). “Moderate” bradycardia would generally refer to less extreme reductions (e.g., 80–100 bpm), making this degree best categorized as severe.

Question 10

The nurse is admitting a client diagnosed with meningitis who has AIDS. Which signs/symptoms would the nurse expect the client to exhibit?

Accepted Answer

Answer reason: Immunocompromised clients (e.g., AIDS) may not mount a typical inflammatory response, so classic meningeal findings and prominent systemic symptoms can be minimal or absent despite serious infection. This blunted presentation makes subtle or nonspecific changes (mild fever, lethargy, altered mental status) more likely than dramatic focal findings early on. A Babinski sign suggests an upper motor neuron lesion rather than meningitis as a primary expected finding. Cranial nerve-related visual or auditory deficits can occur with CNS infections but are not the most expected hallmark compared with an atypical/low-symptom presentation in advanced immunosuppression.

Question 11

A 33-year-old client complains of fatigue, anorexia, and a low-grade fever. The client also complains of joint pain. Which condition does the nurse suspect?

Accepted Answer

Answer reason: Inflammatory autoimmune arthritis commonly presents with systemic constitutional symptoms (fatigue, anorexia, low-grade fever) alongside joint pain due to active inflammation. The patient’s age (33) and the combination of fever plus arthralgia are more consistent with an inflammatory process than a degenerative one. Osteoarthritis typically causes mechanical joint pain and stiffness without fever or significant systemic symptoms. Anemia can cause fatigue but does not explain fever with joint pain as a primary syndrome, whereas RA frequently does.

Question 12

The nurse checks the carotid pulses in a client. The nurse knows to check the carotid pulse one side at a time?

Accepted Answer

Answer reason: Carotid sinus stimulation can trigger a vagal response that slows the heart rate and lowers blood pressure. Palpating both carotid arteries at the same time can also reduce cerebral perfusion by partially occluding blood flow, particularly in patients with atherosclerosis. Either mechanism can cause dizziness or fainting, creating a safety risk during assessment. The other options are not the primary physiological reason for this precaution; the key concern is preventing decreased cerebral blood flow and bradycardia-related syncope.

Question 13

The nurse assesses his client’s dorsalis pedis and posterior tibial pulses. The nurse understands that this assessment is an important part of the physical exam because?

Accepted Answer

Answer reason: Peripheral pedal pulses reflect arterial blood flow to the feet and are a key indicator of distal tissue perfusion. Assessing dorsalis pedis and posterior tibial pulses helps detect peripheral arterial disease, acute limb ischemia, or compromised circulation after vascular procedures or with edema. Heart rate and overall pulse rate are more appropriately assessed using central pulses (e.g., apical, carotid, radial) and do not specifically evaluate distal extremity perfusion. Oxygenation is primarily evaluated through respiratory assessment and oxygen saturation rather than pedal pulse palpation.

Question 14

The nurse performs an assessment on an elderly client. The nurse notes the client performs pill movement of the hand. The nurse suspects which disorder?

Accepted Answer

Answer reason: Pill-rolling tremor is a classic resting tremor associated with basal ganglia dysfunction due to dopamine depletion. This finding is most characteristic of Parkinsonism and commonly appears in older adults during routine neurologic assessment. Myasthenia gravis causes fatigable weakness (often ocular/bulbar) rather than a resting tremor. Huntington’s chorea produces irregular, dance-like choreiform movements, and CVA residuals more often present with focal weakness, spasticity, or unilateral deficits rather than a stereotyped pill-rolling tremor.

Question 15

The nurse notices that a client is jaundiced upon physical assessment. The nurse also notes darkcolored urine in the client’s Foley bag. The nurse suspects the client has?

Accepted Answer

Answer reason: Jaundice with dark urine most strongly suggests conjugated hyperbilirubinemia from biliary obstruction, where water-soluble bilirubin is excreted by the kidneys and darkens urine. Gallstones can obstruct the cystic duct or common bile duct, producing jaundice and bilirubinuria. A UTI typically causes cloudy, foul-smelling urine, dysuria, or fever rather than jaundice. BPH causes urinary retention and weak stream, and intestinal obstruction is characterized by abdominal distention and vomiting, not bilirubin-related urine changes.

Question 16

The nurse examines the client’s extraocular muscle movements (cranial nerve VI). Which equipment is used for this examination?

Accepted Answer

Answer reason: Extraocular movements are assessed by having the patient track a target through the six cardinal positions of gaze to evaluate cranial nerves III, IV, and VI. Cranial nerve VI innervates the lateral rectus muscle, so deficits are revealed during horizontal gaze tracking. A cotton wisp assesses corneal reflex/sensation (primarily CN V with CN VII blink), not eye muscle function. Snellen testing evaluates CN II visual acuity, and an ophthalmoscope red reflex exam screens ocular media, not extraocular motility.

Question 17

Which statement by the nurse most accurately reflects subjective data in a nursing assessment?

Accepted Answer

Answer reason: ” Subjective data are symptoms and perceptions provided by the client and cannot be directly measured or verified by the nurse at the bedside. Pain intensity ratings are self-reported and therefore represent classic subjective assessment information. In contrast, laboratory results, imaging findings, and physical exam signs (e.g., Babinski) are observable/measurable and are objective data. Accurate documentation of subjective reports supports appropriate planning and evaluation of care, especially for symptom management.

Question 18

Which assessment data should a nurse report to the physician?

Accepted Answer

Answer reason: A heart rate of 110 bpm upon awakening reflects a resting value rather than an expected physiologic rise from exertion, so it warrants provider notification and further evaluation. In contrast, blood pressures around 110–120/68–72 mm Hg are within normal limits for healthy adults. A pulse of 120 bpm after sustained aerobic exercise can be a normal, expected response to activity in many adults.

Question 19

A client is 2 days postoperative from a femoral popliteal bypass. The nurse’s assessment finds the client’s left leg cold and pale. What is the most important action by the nurse?

Accepted Answer

Answer reason: Cold, pale extremity after a femoral-popliteal bypass suggests acute arterial insufficiency (possible graft occlusion), which can rapidly threaten limb viability. The nurse’s first priority is an immediate focused neurovascular assessment to determine perfusion status, and distal pulses are a key, time-sensitive indicator (often compared bilaterally and assessed with Doppler if needed). This assessment data guides urgency and communicates objective findings for escalation and potential emergent intervention. Actions like warming the limb or changing positioning can delay recognition and may be inappropriate if perfusion is critically compromised; after confirming the assessment findings, rapid provider notification follows.

Question 20

A mother calls the pediatrician because there’s an outbreak of scabies at her child’s school. The nurse would teach the mother to check for which finding?

Accepted Answer

Answer reason: The classic distribution includes interdigital spaces of the hands and feet (finger and toe webs), wrists, and other skin folds, making these areas high-yield for assessment teaching. Linear burrows are a distinguishing feature that helps separate scabies from nonspecific allergic rashes. Options describing bite-site inflammation, nits on hair shafts (pediculosis), or diffuse wheals (urticaria) do not match the typical scabies presentation.

Question 21

The intensive care nurse is caring for a client diagnosed with a myocardial infarction. Which intervention should the nurse implement?

Accepted Answer

Answer reason: Acute myocardial infarction places the client at high risk for left ventricular dysfunction and pulmonary congestion, so frequent respiratory assessment is a key early-detection strategy. Scheduled lung sound checks help identify developing crackles, worsening oxygenation, or fluid overload that may require rapid interventions (oxygen, diuretics, ventilatory support). Monitoring urine output only every shift may miss early hypoperfusion or heart failure trends that typically require more frequent trending in ICU. Keeping the head of bed flat can worsen dyspnea and pulmonary congestion, and deep breathing should be encouraged to prevent atelectasis.

Question 22

A client has recently been diagnosed with tinea corporis. The nurse would document this assessment finding as?

Accepted Answer

Answer reason: Tinea corporis (ringworm of the body) typically presents as an annular, erythematous, scaly plaque with a more active, raised border and central clearing, so documenting morphology and border characteristics is the most accurate assessment description. This option captures the classic scaly lesion with raised edges that guides recognition and treatment planning. The general statement of “fungal infection” is true but not an assessment finding description and is less specific for documentation. The foot-focused description is more consistent with tinea pedis or bromhidrosis rather than a body lesion pattern.

Question 23

An elderly client has a sore on the inside of his ankle that he says won’t heal. After noting varicosities and coarse discoloration around the sore, the nurse should suspect which condition?

Accepted Answer

Answer reason: Varicosities and brown, coarse periwound discoloration (hemosiderin staining/lipodermatosclerosis) strongly indicate long-standing venous disease rather than an acute process. Arterial occlusive disease more often causes distal toe/foot ulcers with cool skin, diminished pulses, and shiny hairless extremities rather than stasis pigmentation. The described nonhealing sore location plus stasis skin changes best fit chronic venous insufficiency.

Question 24

The nurse is assessing the client with an 8—centimeter AAA. Which finding should the nurse expect?

Accepted Answer

Answer reason: g., 8 cm). This reflects dilation of the abdominal aorta transmitting pulsations to the abdominal wall and is a classic assessment finding nurses should recognize. Chest pain is more consistent with thoracic pathology (e.g., thoracic aneurysm or cardiac ischemia) rather than an AAA. Facial/neck edema with distended neck veins suggests superior vena cava obstruction or right-sided heart failure, not an isolated AAA.

Question 25

The nurse is caring for the client with a leaking cerebral aneurysm- What is the earliest sign that would indicate to the nurse that increased ICP may be developing?

Accepted Answer

Answer reason: This finding is typically more sensitive and earlier than late brainstem signs such as pupillary dilation or sluggish reactivity, which suggest worsening compression/herniation risk. A sudden drop in blood pressure is not the expected early pattern; with worsening ICP, Cushing response tends toward hypertension with widened pulse pressure and bradycardia (a late finding). Sensory deficits can occur with focal injury but are not the classic earliest, most global indicator of increasing ICP.

Question 26

The nurse is assessing the client with polycystic kidney disease (PKD). The nurse should consider that a cyst may have ruptured when collecting which client information?

Accepted Answer

Answer reason: This is a key assessment finding suggesting an acute bleeding event rather than a chronic change in renal function. A decrease in pain would not indicate rupture, and bloody stools point to a gastrointestinal source, not urinary tract bleeding. A decreased serum creatinine suggests improved renal clearance, which is not expected with cyst rupture and does not signal acute hemorrhage.

Question 27

The home health nurse is providing care to the child with HF. Which action should be the nurse's priority when thinking that the child may have developed a dysrhythmia?

Accepted Answer

Answer reason: In suspected dysrhythmia, the first priority is rapid bedside assessment of perfusion and pulse regularity to identify an immediate threat. Comparing apical to radial rates helps detect a pulse deficit (some cardiac beats are not generating effective peripheral pulses), supporting the suspicion of an arrhythmia and guiding urgency of escalation. A Holter monitor is diagnostic but not an immediate priority action in the home setting when instability is possible. Administering digoxin without assessing for bradycardia/irregular rhythm is unsafe because digoxin can worsen certain dysrhythmias or reflect toxicity, and applying ice to the face is a vagal maneuver used for SVT only and is not indicated without confirming the rhythm and stability.

Question 28

The nurse completes an assessment of the 2-month-old infant during a well-child checkup. The nurse should report which finding to the HCP?

Accepted Answer

Answer reason: A stronger femoral pulse than brachial is atypical and warrants follow-up because extremity pulse differences may reflect congenital heart disease or measurement/assessment error that could mask pathology. In contrast, an apical rate of 140 bpm is within the expected infant range, and an oxygen saturation of 97% is acceptable for a well infant. Heart sound splitting can be a normal physiologic finding in infants when related to respiration, but unequal peripheral pulses require provider notification.

Question 29

The preschool-aged child who has purulent, foul-smelling drainage from both nares is brought to an urgent care clinic- What action should be taken by the nurse first?

Accepted Answer

Answer reason: Purulent, foul-smelling nasal drainage in a preschooler strongly suggests a retained nasal foreign body, which can cause local infection and risk aspiration if it dislodges. The nurse’s priority is to rapidly assess airway/breathing status, degree of obstruction, unilateral vs bilateral findings, presence of respiratory distress, fever, and any signs of complications to guide immediate interventions and provider notification. A focused assessment also helps identify red flags (e.g., button battery insertion) that require emergent management to prevent tissue necrosis. Vital signs are important but do not replace the targeted airway/ENT assessment needed to determine urgency and safest next steps, and relying on the child’s history is often unreliable at this age.

Question 30

Prior to administration of Lanoxin (digoxin), the nurse must obtain the apical pulse. Where does the nurse place the stethoscope?

Accepted Answer

Answer reason: The apical impulse (PMI) is normally auscultated at the mitral area, located at the left 5th intercostal space on the midclavicular line. This location best reflects the left ventricular apex, making it the most accurate site for counting a full minute prior to administration. Alternatives describe sites that correspond to other valve areas or are anatomically incorrect for PMI, increasing risk of missing clinically important rate/rhythm changes.

Question 31

When auscultating the abdominal region of a client with abdominal aortic aneurysm, the nurse hears a bruit. How does the nurse interpret this finding?

Accepted Answer

Answer reason: A bruit is a vascular sound created by turbulent blood flow, most commonly from narrowing/stenosis or irregularity within an artery. In an abdominal aortic aneurysm, altered vessel geometry and possible atherosclerotic plaque can create turbulence that is consistent with partial obstruction or stenotic flow. This is not considered a normal assessment finding and should prompt focused vascular assessment and monitoring for worsening perfusion or aneurysm complications. Lung fluid would be suggested by crackles on lung auscultation, and peritoneal inflammation is associated with abdominal guarding/rigidity and rebound tenderness rather than a vascular bruit.

Question 32

The nurse is performing a cardiac assessment on her client and auscultates a fourth heart sound (S4). The nurse interprets this as indicative of which of the following?

Accepted Answer

Answer reason: This scenario is often associated with impaired ventricular filling and can coexist with systolic dysfunction, where increased end-systolic volume reflects incomplete emptying. The option describing incomplete ejection best aligns with the pathophysiologic context of a poorly functioning ventricle in which abnormal filling dynamics and elevated residual volume contribute to abnormal heart sounds. A “normally functioning heart” is incorrect because S4 is typically pathologic in adults, whereas a dilated aorta does not characteristically generate an S4.

Question 33

The nurse is reviewing lab results on a postoperative client. Upon analysis of the lab work, the nurse notes the client is immunocompromised. The nurse should assess the client for which of the following?

Accepted Answer

Answer reason: An acquired immune disorder (e.g., HIV/AIDS, immunosuppressive therapy, malignancy-related immunodeficiency) is a primary, high-yield etiology that would explain abnormal immune parameters and would immediately change infection-prevention measures, monitoring, and provider notifications. Family history is more relevant to primary (congenital) immunodeficiencies and is less likely to newly present as postoperative lab abnormalities. While nutrition and substance use can contribute to immune suppression, they are indirect contributors and do not as directly account for an immunocompromised lab profile as an acquired immune disorder.

Question 34

A nurse is assigned to care for a 70-year-old client with acute rheumatoid arthritis. Which assessment finding should the nurse expect to find during the physical examination?

Accepted Answer

Answer reason: This option describes the classic inflammatory symptom cluster expected on exam during an acute episode. In contrast, Heberden’s and Bouchard’s nodes are bony enlargements of the DIP and PIP joints that are characteristic of osteoarthritis rather than rheumatoid arthritis. Radial deviation of distal phalanges is not the typical deformity pattern for rheumatoid arthritis, which more commonly produces ulnar deviation and MCP involvement over time.

Question 35

The nurse is evaluating the effectiveness of therapy with acetylcysteine (Mucomyst) in a child with acetaminophen poisoning. It is most important for the nurse to monitor which value?

Accepted Answer

Answer reason: The most direct way to evaluate treatment effectiveness is to trend liver transaminases, which reflect ongoing hepatocyte injury and should stabilize or improve with timely therapy. PT can also worsen with severe hepatic failure, but it is a later/synthetic-function marker and less direct for early response to antidote therapy compared with AST/ALT. Calcium and glucose are not primary indicators of antidote effectiveness in acetaminophen toxicity.

Question 36

When assessing a client suspected of having pyloric stenosis, which finding should the nurse expect?

Accepted Answer

Answer reason: This mass is typically felt in the epigastrium/right upper quadrant near the pylorus, especially after feeding when the stomach is distended. A “sausage-shaped” mass is more characteristic of intussusception rather than pyloric obstruction. The expected assessment finding aligns with the classic physical exam hallmark used to support suspicion before confirmatory imaging.

Question 37

The nurse is assessing a child with suspected roseola. The nurse determines the child has a roseola rash when she observes which finding?

Accepted Answer

Answer reason: Blanching with pressure supports a benign viral exanthem pattern typical of roseola rather than petechiae/purpura. Vesicles with pruritus suggest varicella or contact dermatitis, not roseola. A rash that begins on the face is more characteristic of measles or rubella patterns than roseola.

Question 38

A child is admitted to the hospital with a diagnosis of severe combined immunodeficiency disease (SCID). During the admission interview and assessment, the nurse should observe the child for which symptom?

Accepted Answer

Answer reason: The most expected assessment finding is recurrent, severe, or opportunistic infections (e.g., persistent thrush, pneumonia, chronic diarrhea, poor wound healing). Bruising and prolonged bleeding are more consistent with platelet/coagulation disorders rather than primary immunodeficiency. Failure to thrive can occur in SCID, but it is less specific than the hallmark pattern of frequent and serious infections.

Question 39

The nurse is planning care for a child admitted to the pediatric unit with neonatal chronic lung disease (bronchopulmonary dysplasia). Which symptom is the nurse most likely to assess?

Accepted Answer

Answer reason: A typical assessment finding is persistent tachypnea with signs of increased work of breathing and dyspnea, especially with feeding or agitation. Minimal work of breathing would be unexpected because these infants often have reduced pulmonary compliance and higher oxygen/ventilatory demands. Hypotension is not a hallmark feature of this respiratory disorder and would suggest a separate circulatory problem (e.g., sepsis, dehydration, shock).

Question 40

A nurse is working with a female client with anorexia nervosa who has acrocyanosis in her extremities. Which short-term goal is most important for the client?

Accepted Answer

Answer reason: Acrocyanosis reflects peripheral vasoconstriction and poor tissue perfusion, which in anorexia nervosa is commonly driven by malnutrition, hypothermia, bradycardia, and low cardiac output. The most urgent short-term goal is to support and monitor perfusion to prevent ischemic complications and detect deterioration (e.g., worsening cyanosis, cool extremities, delayed cap refill). Interventions aimed at circulation (warming measures, avoiding constrictive clothing, monitoring vital signs/perfusion, gradual activity as tolerated) address the immediate physiologic risk. Range-of-motion can help mobility but does not target the primary perfusion problem, and dietary changes are longer-term and must be structured for refeeding safety. Neurologic reflex checks are not the priority unless new neurologic deficits are present.

Question 41

The nurse is caring for a client with a C-6 SCI in the neurological intensive care unit. Which nursing intervention should be implemented?

Accepted Answer

Answer reason: Spinal cord injury care prioritizes frequent, systematic neuro assessment to detect deterioration early (e.g., worsening motor/sensory function, ascending level, emerging complications) and to guide timely escalation of care. Regular neuro checks are a core nursing responsibility in the neuro ICU and directly address the ongoing risk for secondary injury. A heparin drip is not an expected universal intervention for all C6 SCI patients and would be based on a specific prescription/indication. Ice saline infusion and intrathecal corticosteroids are not standard, routine nursing interventions for SCI and are not broadly supported as general care measures.

Question 42

The 18-year-old client is admitted to the medical floor with a diagnosis of meningitis. Which priority intervention should the nurse assess?

Accepted Answer

Answer reason: Meningitis can rapidly increase intracranial pressure and cause acute neurologic deterioration, so frequent global neurologic assessment is the most safety-critical priority. A focused neuro check (level of consciousness/mental status, pupillary response, motor/sensory changes, signs of seizures) provides the earliest detection of worsening cerebral edema or impending herniation. The other choices are narrower assessments (a single cranial nerve, one deep tendon reflex) or target peripheral perfusion, which do not capture the life-threatening neurologic trajectory of meningitis as effectively. Prioritizing a broad neurologic assessment supports timely escalation and interventions when status changes occur.

Question 43

Which clinical manifestations would the nurse expect to assess in the client diagnosed with Parkinson disease (PD)?

Accepted Answer

Answer reason: Parkinson disease is defined by degeneration of dopaminergic neurons in the substantia nigra, producing an imbalance between dopamine and acetylcholine in the basal ganglia and resulting in characteristic motor findings. The classic triad expected on assessment is resting tremor, muscular rigidity, and bradykinesia (slowness/poverty of movement), often with shuffling gait and postural instability. The other options point to gastrointestinal illness (A), diabetes mellitus (B), or cerebellar dysfunction with scanning speech (C), which are not the hallmark manifestations of PD. Recognizing these expected findings guides focused neurologic assessment and early safety planning to reduce fall risk.

Question 44

The nurse is performing a physical assessment on a client. The nurse places the client in a sitting position and observes that the extension of the knee is limited due to pain. Which sign is associated with limited extension of the knee when the hip is flexed?

Accepted Answer

Answer reason: Pain and resistance to knee extension with the hip flexed reflects meningeal irritation, classically seen in meningitis or subarachnoid hemorrhage. This maneuver stretches the inflamed meninges and nerve roots, producing hamstring spasm and limiting extension due to pain. Brudzinski’s involves involuntary hip and knee flexion with passive neck flexion rather than inability to extend the knee. Homan’s relates to calf pain with dorsiflexion and is associated with suspected DVT, not meningeal signs.

Question 45

The nurse cares for a client with a diagnosis of chronic kidney disease. Which nursing intervention is appropriate for this client?

Accepted Answer

Answer reason: Daily weights are the most sensitive, practical bedside indicator of fluid status changes in chronic kidney disease, where impaired excretion predisposes to fluid volume excess. Keeping the time consistent improves reliability by controlling for normal diurnal variation, meals, and clothing, allowing earlier detection of edema and worsening heart failure or hypertension. Encouraging routine fluid intake is not universally appropriate because many CKD patients require fluid restriction based on urine output, edema, and dialysis status. High phosphorus foods are typically limited in CKD to reduce hyperphosphatemia and renal bone disease risk.

Question 46

A client presents to the emergency department with a cough. The nurse’s assessment reveals the client is also experiencing chills, fever, night sweats, and hemoptysis. The nurse suspects the client may have which illness?

Accepted Answer

Answer reason: This symptom cluster is classic for pulmonary TB: chronic cough with constitutional “B symptoms” (fever, night sweats, chills/weight loss) and hemoptysis from cavitary lung disease and airway erosion. The combination of night sweats and hemoptysis is more suggestive of TB than routine acute bronchitis or a simple upper respiratory infection. Pneumonia can cause fever and cough, but night sweats and hemoptysis as a prominent pattern should raise concern for TB, prompting airborne precautions and diagnostic evaluation (e.g., sputum AFB/NAAT, chest imaging). Early recognition is critical to reduce transmission risk in the ED setting.

Question 47

A client presents to the emergency department complaining of large amounts of bright red blood in the stool. The client is currently in no apparent distress. Which intervention should be the nurse’s first action?

Accepted Answer

Answer reason: Large-volume bright red blood per rectum can rapidly progress to hypovolemia, so immediate assessment must focus on physiologic stability and early shock detection. Checking blood pressure, heart rate, respiratory rate, oxygen saturation, and mental status establishes baseline hemodynamics and guides urgency of interventions (e.g., IV access, fluids, labs, transfusion readiness). A history and abdominal exam are important but are secondary once potential active bleeding is reported because they do not quickly determine stability. Nasogastric tube insertion is not a first-line nursing action for hematochezia and would be based on provider direction and further assessment findings.

Question 48

A client has a history of left-sided heart failure. The nurse knows that one of the complications of this type of heart failure is pulmonary congestion. What should the nurse expect to find upon assessment?

Accepted Answer

Answer reason: Left-sided heart failure causes backup of blood into the pulmonary veins, raising pulmonary capillary pressures and leading to pulmonary congestion. Ongoing elevation in pulmonary vascular pressures can manifest as pulmonary hypertension as the lungs are exposed to chronically increased left-sided filling pressures. Jugular venous distension is more typical of right-sided heart failure from systemic venous congestion, not an early hallmark of isolated left-sided failure. Skin tenting suggests dehydration rather than fluid overload, and hypotension may occur in severe low-output states but is less directly tied to pulmonary congestion than elevated pulmonary pressures.

Question 49

The nurse auscultates breath sounds in a client. The nurse knows an incorrect method for auscultation is?

Accepted Answer

Answer reason: Accurate lung sound assessment requires positioning that maximizes chest expansion and access to posterior lung fields, typically sitting upright. Lying flat can reduce lung expansion, alter ventilation distribution, and make it harder to compare symmetric lung areas, decreasing reliability of findings. Using the diaphragm and placing it on bare skin are correct techniques because they improve transmission of high-frequency breath sounds and reduce artifact from clothing. Instructing the client to breathe slowly and deeply through the mouth helps standardize airflow and makes adventitious sounds easier to detect while reducing nasal turbulence.

Question 50

The nurse cares for a client who is complaining of nausea, vomiting, and back pain. Upon assessment, the nurse notices a pulsation left of midline in the upper abdomen. The nurse auscultates a bruit at this same site. Which illness does the nurse suspect?

Accepted Answer

Answer reason: A prominent pulsation in the upper abdomen with an audible bruit indicates turbulent blood flow through a large abdominal vessel, most concerning for an abdominal aortic aneurysm. Back pain with nausea/vomiting can occur as the aneurysm expands or irritates adjacent structures, and these findings warrant urgent evaluation due to rupture risk. Renal colic from urolithiasis typically presents with flank pain radiating to the groin and does not produce an epigastric pulsatile mass or bruit. Cholecystitis and pancreatitis can cause upper abdominal pain and vomiting, but neither explains a focal pulsation with a bruit over the aorta.

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