Question 1

The nurse cares for a client with chronic kidney disease. The client has an arteriovenous fistula that is being used for dialysis. As part of the assessment, the nurse should?

Accepted Answer

Answer reason: A functioning arteriovenous fistula must have continuous blood flow to be usable for dialysis, and patency is assessed by auscultating a bruit and palpating a thrill. Absence or significant change in these findings suggests stenosis or thrombosis and requires prompt intervention to prevent loss of access. Urine output, edema, and creatinine are important in CKD monitoring, but they do not directly evaluate the integrity of the dialysis access site. Prioritizing fistula assessment reduces the risk of complications and missed access failure.

Question 2

The nurse is teaching another nurse about pulmonary capillary wedge pressure. Which response is the most accurate regarding this pressure?

Accepted Answer

Answer reason: Pulmonary capillary wedge pressure (PCWP) is an indirect estimate of left atrial pressure and, in the absence of significant mitral valve disease, correlates with left ventricular filling pressure (preload). When the pulmonary artery catheter balloon is inflated, it “wedges” and transmits downstream pressure from the pulmonary venous/left atrial side rather than the right heart. This makes PCWP clinically useful for assessing left-sided volume status and guiding fluid/diuretic/vasoactive therapy in critically ill patients. By contrast, right atrial pressure/CVP reflects right-sided preload, and systemic vascular resistance is a calculated afterload parameter, not a wedge pressure measurement.

Question 3

During an initial assessment of a neonate, the nurse notes a respiratory rate of 52 breaths/minute. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: A core newborn assessment principle is recognizing normal vital-sign ranges to avoid unnecessary escalation. A neonatal respiratory rate of about 30–60 breaths/min is expected, so 52/min alone is not an abnormal finding requiring intervention. Escalating to provider notification or preparing for intubation would be indicated only if there were signs of respiratory distress (e.g., grunting, flaring, retractions, cyanosis, apnea) or a persistently abnormal rate. Head elevation may be supportive in some conditions but is not warranted as the first action when the rate is within normal limits and no distress is described.

Question 4

Which assessment data would cause the nurse to suspect the client has atherosclerosis?

Accepted Answer

Answer reason: Atherosclerosis can narrow peripheral arteries and reduce blood flow during activity, producing intermittent claudication—exertional, cramping calf pain relieved by rest. This finding is a classic assessment clue for peripheral arterial disease and points to arterial insufficiency rather than venous congestion. Leg swelling after prolonged standing is more consistent with venous insufficiency, not arterial occlusion. The other options suggest hypoglycemia-like symptoms and gastroesophageal/peptic irritation, which do not specifically indicate atherosclerotic disease.

Question 5

The nurse is caring for a client who is receiving hemodialysis treatments. Which of the following interventions would be the most appropriate for this client?

Accepted Answer

Answer reason: A functioning AV fistula should have a palpable thrill (and an audible bruit), which indicates patency and adequate blood flow for hemodialysis access. Routine assessment of the access site helps detect early thrombosis or stenosis so complications can be addressed promptly. In contrast, an absent bruit is abnormal and suggests occlusion rather than a normal finding. Blood pressure measurements on the fistula arm are avoided because compression can reduce flow and damage the access.

Question 6

The nurse evaluates the client who is being treated for DKA. Which finding indicates that the client is responding to the treatment plan?

Accepted Answer

Answer reason: Moist skin with rapid elastic recoil indicates improved skin turgor and intravascular volume after IV fluids and insulin therapy. A potassium of 3.3 mEq/L suggests hypokalemia, which can develop during treatment and represents a complication risk rather than a positive response. The ABG shown remains significantly acidemic with low bicarbonate, indicating ongoing metabolic acidosis rather than resolution.

Question 7

The client taking NPH insulin at 0800 reports feeling anxious and shaky in the midafternoon. Which intervention is best for the nurse to initiate?

Accepted Answer

Answer reason: NPH is an intermediate-acting insulin with a peak several hours after administration, so midafternoon symptoms after an 0800 dose can reflect hypoglycemia. Shakiness and anxiety are adrenergic warning signs that require immediate physiologic assessment to prevent progression to neuroglycopenia and seizure/coma. A bedside glucose check is the fastest, safest way to confirm the problem and guide prompt treatment (e.g., carbohydrates if low). Giving a benzodiazepine or focusing on relaxation could mask a dangerous hypoglycemic episode and delay definitive care.

Question 8

The nurse assesses that the client with hemolytic anemia has weakness, fatigue, malaise, and skin and mucous membrane pallor. Which finding should the nurse also associate with hemolytic anemia?

Accepted Answer

Answer reason: The excess bilirubin can deposit in tissues and is often first noticeable as yellowing of the sclera. This associated finding fits hemolysis physiology, whereas a smooth, red tongue suggests B12/folate deficiency (megaloblastic anemia) rather than hemolysis. Craving ice (pagophagia) is more typical of iron-deficiency anemia, and poor fresh vegetable intake points toward folate deficiency.

Question 9

The nurse is obtaining a health history on the client with a possible left-sided varicocele. Which question is most important?

Accepted Answer

Answer reason: Varicoceles can impair spermatogenesis and are a common, potentially reversible cause of male infertility, so assessing fertility goals directly guides the urgency of evaluation and management. If the client desires future fertility or is having difficulty conceiving, prompt referral for semen analysis and urology follow-up is clinically prioritized. Symptom questions (e.g., discomfort) help characterize severity but do not address the most clinically consequential complication. Family history is not the key driver of decision-making in suspected varicocele compared with reproductive planning and fertility impact.

Question 10

The nurse is assessing the client post-hemilaryngectomy and radical neck dissection for treatment of cancer. Which finding should the nurse expect due to the surgical procedure?

Accepted Answer

Answer reason: Loss of trapezius function produces ipsilateral shoulder droop and difficulty elevating the shoulder, making a one-sided shoulder drop an expected postoperative finding. In contrast, a hemilaryngectomy typically causes hoarseness/voice change rather than complete permanent aphonia, because part of the larynx remains. The remaining options point to different cranial nerve distributions and are not classic expected consequences of this combined surgery.

Question 11

The nurse is assessing the vision of the 4-year-old and notes the child has difficulty adjusting to seeing an object as it is brought from a distance of 12 inches toward the child's eyes. What is the nurse’s correct documentation of this finding?

Accepted Answer

Answer reason: Difficulty adjusting focus when an object is moved from farther away toward the eyes indicates impaired near focusing, which is an accommodative problem. Stereopsis refers to depth perception from binocular vision and is not primarily tested by moving an object toward the face to assess focusing. A red reflex finding relates to screening for media opacities (e.g., cataract/retinoblastoma) rather than near-far focusing changes.

Question 12

The pediatric client requires clean intermittent catheterization while at home. Which early signs of infection should the nurse teach the parents to report immediately?

Accepted Answer

Answer reason: Fever is a key early indicator of infection in pediatrics and warrants prompt reporting because it may signal ascending infection. Malodorous urine is a common early UTI clue in catheterized clients due to bacterial growth. A trend toward higher heart rate (even if still within the “normal” range) can represent an early physiologic response to infection in children. Other options list nonspecific findings or patterns less consistent with early UTI related to catheterization.

Question 13

The nurse is assessing a client in the emergency room who has been experiencing black stools for the past month. The client suddenly complains of chest and stomach pain. What is the most important action for the nurse to perform?

Accepted Answer

Answer reason: Immediate nursing priority follows ABCs and rapid assessment to identify life-threatening instability. Black stools suggest GI bleeding with possible anemia/hypovolemia, and new chest pain raises concern for ischemia or hypoxia that can be worsened by low hemoglobin or shock. Vital signs quickly determine hemodynamic status (hypotension, tachycardia), oxygenation trends, and the urgency of interventions and provider notification. Oxygen, monitoring, and labs may be needed, but they should be guided by the initial objective assessment of stability to prioritize the safest next steps.

Question 14

A nurse is performing a neurovascular assessment. It is most important for the nurse to include which of the following in the assessment?

Accepted Answer

Answer reason: Checking capillary refill and skin warmth evaluates peripheral circulation, while palpating pulses assesses arterial blood flow adequacy. Assessing movement screens motor function and can reveal nerve compression or evolving compartment syndrome. Orientation, pupillary response, and respiratory pattern are important general assessments but do not directly evaluate distal limb perfusion/neurologic status where neurovascular compromise is most likely to present first.

Question 15

The nurse has been caring for a client who experienced a stroke and is now asking for food. What is the most important assessment for the nurse to observe before feeding the client?

Accepted Answer

Answer reason: Safe feeding after stroke depends on verifying an effective swallow and airway protection to prevent aspiration. Observing a water swallow without coughing helps screen for dysphagia and reduced laryngeal closure, which are common after stroke and can lead to silent or overt aspiration. A normal gag reflex does not reliably predict safe swallowing and may be absent in many healthy people. Speech recovery also does not confirm swallow safety, and CN III, IV, and VI relate to eye movement rather than swallowing function.

Question 16

Which method should be used to assess pupil accommodation?

Accepted Answer

Answer reason: Bringing an object toward the client and watching for constriction and convergence directly tests this near response pathway (CN II input with CN III-mediated efferent response). By contrast, following an object in multiple directions assesses extraocular movements (cranial nerves III, IV, VI) rather than accommodation. Peripheral vision testing evaluates visual fields, and corneal touch evaluates the corneal reflex (CN V and VII), neither of which measures accommodation.

Question 17

A 24-year-old client comes into the clinic complaining of sudden-onset, right-sided chest pain and shortness of breath. The nurse is assessing the client and determines that the most important intervention to implement is?

Accepted Answer

Answer reason: Immediate respiratory assessment follows the ABCs and helps rapidly identify life-threatening causes of acute pleuritic chest pain and dyspnea such as pneumothorax. Listening for unilateral decreased/absent breath sounds can quickly indicate impaired ventilation and guide urgent escalation and interventions (e.g., oxygen, provider notification, emergency response if unstable). Imaging like a chest X-ray may confirm the diagnosis but is not the first priority before completing a focused bedside assessment. Cardiac tests (ECG/echo) can be relevant for chest pain, but the presentation is strongly respiratory and requires prompt lung assessment first.

Question 18

Criteria for rheumatic fever are being discussed with parents. A nurse determines that the parents understand chorea when they make which statement?

Accepted Answer

Answer reason:  Sydenham chorea in rheumatic fever causes involuntary, purposeless movements and emotional lability that can interfere with fine motor tasks, attention, and handwriting, leading to impaired school performance. Recognizing functional/cognitive impact reflects understanding of this neurologic manifestation of the disease. Activity and stimulation should generally be reduced because fatigue and stress can worsen symptoms, making recommendations for many visitors/activities inappropriate. While gait and gross motor function can be affected, complete inability to walk is less typical than fluctuating clumsiness and poor coordination affecting daily and school activities.

Question 19

The parent of a child with diabetes asks a nurse why blood glucose monitoring is needed. What is the best response by the nurse?

Accepted Answer

Answer reason: Blood glucose monitoring provides real-time data needed to make safe day-to-day decisions about insulin dosing, food intake, and activity to prevent hypo- and hyperglycemia. Teaching families that the purpose is improved self-management addresses the clinical need for ongoing assessment and adjustment rather than convenience or cost. “Easier” and “less expensive” are not the primary health rationale and could minimize the safety importance of monitoring. A “sense of control” can be a positive psychosocial benefit, but it is secondary to the essential role of monitoring in guiding treatment and reducing complications.

Question 20

A 16-year-old African-American student visits a school nurse with complaints of nausea and fatigue. The nurse determines a need to check for jaundice. Which area of the body should the nurse examine?

Accepted Answer

Answer reason: In darker-skinned clients, yellowing may be subtle or difficult to appreciate when assessing overall skin tone, making this approach less reliable. The sclera provides a high-contrast surface where icterus can be recognized early during assessment. Areas like the outer ears/neck are more useful for cyanosis or pallor checks, and the oral mucosa can show color change but is generally less sensitive than scleral inspection for jaundice screening.

Question 21

A child with suspected pertussis is admitted to the hospital. During assessment of the child, the nurse observes a cough with which characteristics?

Accepted Answer

Answer reason: This harsh, repetitive cough pattern is a key assessment clue that helps differentiate pertussis from routine viral URIs. A dry, hacking cough on awakening is more consistent with postnasal drip or mild bronchial irritation rather than the characteristic paroxysmal pattern. Recognizing the whooping component supports prompt isolation precautions and early treatment to reduce transmission and complications (e.g., apnea, hypoxia) in children.

Question 22

A mother is concerned that her 9-month-old infant has scabies and brings her to the pediatric clinic. The nurse assesses the infant for which findings?

Accepted Answer

Answer reason: The most typical exam findings include pruritic papules/pustules and linear burrows, especially in interdigital spaces such as finger and toe webs. Diffuse wheals more strongly suggest urticaria/allergic reaction rather than a parasitic infestation with burrows. White oval dots adherent to hair shafts are consistent with pediculosis (nits), and a focal painful erythematous area with a stinger indicates an insect sting rather than scabies.

Question 23

A 1-year-old child is treated in the clinic for a burn to the anterior surface of the left hand. What is the most accurate way for the nurse to measure burn size?

Accepted Answer

Answer reason: The child’s hand equals 1.25% of the child’s body surface area Accurate burn size estimation guides fluid needs, monitoring for complications, and decisions about referral, so a reliable bedside method is essential. For small, localized burns, using the child’s hand as a reference is the most accurate practical approach because it scales to the child’s body size. The rule of nines is less accurate in infants and young children due to different body proportion distributions compared with adults. Burn depth/type affects management and prognosis, but it is not required to calculate total body surface area involvement.

Question 24

The nurse is using an otoscope to assess a child suspected of acute otitis media. Which assessment finding would be indicative of this condition?

Accepted Answer

Answer reason: This pressure classically produces a hyperemic, opaque appearance with loss of landmarks and a bulging tympanic membrane on otoscopic exam. A dull gray membrane with visible fluid is more consistent with otitis media with effusion (serous), often following an acute infection, rather than the acute suppurative presentation. A pearl gray tympanic membrane is a normal finding and does not support the suspected diagnosis.

Question 25

A 2-month-old infant is brought to the emergency department, and a preliminary diagnosis of bronchiolitis is given. During assessment of the infant, the nurse would expect to find which of the following?

Accepted Answer

Answer reason: This leads to wheezing and sometimes crackles on lung assessment, often after an initial viral upper-respiratory prodrome. Decreased feeding is common due to increased work of breathing, making increased appetite unlikely. Bradycardia is not an expected early finding; tachypnea and tachycardia are more typical, with bradycardia suggesting severe deterioration or hypoxia.

Question 26

A child is admitted with a possible tracheal foreign body. The nurse anticipates the assessment findings will include which of the following?

Accepted Answer

Answer reason: Because the obstruction is near the larynx/trachea, the child may also have hoarseness or altered voice/phonation from irritation or impaired airflow across the vocal cords. Findings like asymmetric breath sounds and wheeze are more typical of a bronchial (lower airway) foreign body where ventilation to one lung segment is reduced. Drooling is more suggestive of esophageal obstruction or supraglottic processes rather than a tracheal object.

Question 27

When completing the morning postpartum assessment, a nurse notices a client’s perineal pad is completely saturated with lochia rubra. What is the priority action of the nurse?

Accepted Answer

Answer reason: A saturated pad can indicate either normal postpartum bleeding over time or abnormal heavy bleeding, so the priority is to quantify the amount and rate of lochia before initiating interventions. Determining when the pad was last changed establishes whether this represents rapid blood loss (e.g., soaking a pad in an hour) versus expected lochia rubra. If bleeding is rapid or accompanied by a boggy uterus or large clots, then immediate uterine assessment and fundal massage and escalation would be indicated. Acting first without clarifying timing risks unnecessary intervention, while delaying quantification could miss developing postpartum hemorrhage.

Question 28

The client is being admitted with rule-out (R/O) brain tumor. Which signs/symptoms support the diagnosis of a brain tumor?

Accepted Answer

Answer reason: Brain tumors commonly produce signs of increased intracranial pressure and focal neurologic deficits due to mass effect and impaired CSF flow. Headache (often worse in the morning), vomiting (sometimes projectile), and diplopia (from cranial nerve involvement or papilledema-related visual disturbance) fit this pattern well. In contrast, the Cushing triad constellation in option A is more suggestive of significant, late intracranial hypertension/herniation physiology rather than the typical presenting cluster used to support suspicion. Options C and D describe systemic shock-like findings or unrelated GI/sensory symptoms that do not characteristically point to an intracranial mass.

Question 29

The nurse is assessing the client diagnosed with bacterial meningitis. In addition to nuchal rigidity, which clinical manifestations would the nurse assess?

Accepted Answer

Answer reason: Bacterial meningitis causes meningeal inflammation, producing classic meningeal irritation findings and sensory hypersensitivity. Brudzinski sign reflects meningeal irritation (involuntary hip/knee flexion with neck flexion), and photophobia is a common accompanying symptom due to irritation and increased sensitivity to light. Cushing response is associated with markedly increased intracranial pressure and herniation physiology rather than being a typical primary presenting sign set for meningitis, and “ascending paralysis” suggests Guillain-Barré syndrome. Trousseau sign relates to hypocalcemia, and patterns of descending/ascending paralysis are not characteristic assessment targets for uncomplicated meningitis.

Question 30

The client is diagnosed with acute otitis media. Which statement would cause the nurse to suspect the client had a ruptured tympanic membrane?

Accepted Answer

Answer reason: " In acute otitis media, increasing middle-ear pressure causes significant otalgia; if the tympanic membrane perforates, that pressure is suddenly relieved and pain often decreases abruptly. This “pain that suddenly resolves” is a classic clue for rupture, often accompanied by new otorrhea and transient hearing change. Fever with ear pain more strongly reflects ongoing infection/inflammation rather than perforation. Earwax buildup and a preceding sinus infection are not specific indicators of a tympanic membrane rupture.

Question 31

The nurse cares for a client who is 2 days postop femoral popliteal bypass. While assessing the client, the nurse notes that the client’s right leg is cool and pale. Which action should the nurse take first?

Accepted Answer

Answer reason: A cool, pale extremity after a femoral-popliteal bypass suggests decreased distal perfusion and possible graft occlusion, which requires immediate focused neurovascular assessment. The nurse should first validate and quantify perfusion by checking distal pulses (and comparing bilaterally) to determine severity and urgency. This assessment provides essential data to guide rapid escalation and potential limb-saving intervention. Calling the provider may be necessary next, but doing so before completing the key circulation check delays critical objective findings. Positioning changes or getting the client up could worsen perfusion or delay recognition of acute ischemia.

Question 32

Which nursing intervention is used during assessment of a pediatric client?

Accepted Answer

Answer reason: A core pediatric assessment principle is to validate data by documenting who provided it and judging its reliability because children’s developmental level, anxiety, and caregiver perspectives can change accuracy and completeness. This action strengthens clinical judgment by clarifying whether findings are subjective vs observed and whether corroboration is needed from another informant. It also supports safer follow-up decisions when symptoms are vague or inconsistently reported. Asking parents to leave is not routinely appropriate and can increase distress or reduce essential history, while keeping the child on the exam table at all times is unsafe and increases fall risk.

Question 33

The nurse is caring for a client who was diagnosed with a myocardial infarction 24 hours ago. The client has developed an audible S3 heart sound. Which action should the nurse implement first?

Accepted Answer

Answer reason: An S3 after an MI can indicate new or worsening left ventricular failure with decreased cardiac output and fluid volume overload risk. The priority is to assess hemodynamic stability immediately by obtaining vital signs, with blood pressure giving rapid, actionable information about perfusion and potential shock. This focused assessment guides urgency and subsequent actions such as escalation of care, oxygenation, and diuretic/vasodilator considerations per orders. Telemetry may identify dysrhythmias but does not directly evaluate perfusion status as quickly or comprehensively as blood pressure in this context. Documentation is important but is not a first action when a potentially significant new finding appears.

Question 34

The client diagnosed with endocarditis is complaining of increased dyspnea and nausea. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: Worsening dyspnea in a client with endocarditis can signal acute heart failure from valvular dysfunction, so the nurse should first perform an immediate focused assessment to determine severity and urgency. Lung auscultation helps detect pulmonary congestion (e.g., crackles) and guides rapid escalation (oxygen, provider notification, further diagnostics). Peripheral assessment for edema and perfusion provides additional evidence of fluid overload or compromised cardiac output. Delegating evaluation to another discipline delays initial nursing assessment, and catheterization or sputum collection does not address the immediate cardiopulmonary risk.

Question 35

The nurse caring for clients on a medical unit thinks she hears a murmur while assessing the client. After determining that no other HCP have documented a murmur, which action should the nurse implement next?

Accepted Answer

Answer reason: A newly suspected heart murmur can signal an acute or previously unrecognized valvular problem and warrants prompt provider evaluation. The nurse’s priority is to communicate a potentially significant new assessment finding so the client can receive timely diagnostic follow-up (e.g., focused cardiac exam, echocardiogram) and management if needed. Simply documenting without notifying can delay care when the finding may represent an evolving condition. Asking about history may provide context, but it does not replace reporting a new or undocumented abnormal cardiovascular assessment finding.

Question 36

The client diagnosed with a grade II aortic murmur is admitted to the telemetry unit. Which symptoms should the nurse expect to assess?

Accepted Answer

Answer reason: Aortic valve sounds are best assessed at the aortic area (2nd intercostal space, right sternal border), making location a key system-specific assessment finding for an aortic murmur. A grade II murmur indicates a soft but clearly audible murmur, so an expected assessment is the characteristic auscultation finding rather than overt heart failure signs. Findings like JVD, peripheral edema, or pink frothy sputum suggest decompensated right- or left-sided heart failure/pulmonary edema and are not expected solely from a mild murmur. Dyspnea and weakness can occur with significant aortic valve disease but are less specific and not the most directly expected assessment tied to identifying an aortic murmur.

Question 37

During a routine physical examination, a firm mass is palpated in the right breast of a 35-year-old female client. Which finding or client history would suggest cancer of the breast as opposed to fibrocystic disease?

Accepted Answer

Answer reason: Fibrocystic breast changes more characteristically produce tenderness and lumpiness that fluctuates with the menstrual cycle, reflecting hormone-responsive cystic changes. A history of anovulatory cycles is more relevant to altered estrogen/progesterone balance and benign breast symptoms, not a classic discriminator for malignancy on exam. Increased vascularity can be seen with several benign and inflammatory conditions and is less specific than location pattern for cancer risk.

Question 38

A nurse is performing a skin assessment on a recently admitted client. The nurse analyzes the assessment findings and determines that which is the most important risk factor?

Accepted Answer

Answer reason: Existing ulcers also signal the client has already experienced breakdown under their present physiologic and care conditions, placing them at immediate risk for worsening or additional lesions. In contrast, family history is not a primary clinical risk driver for pressure injuries compared with modifiable factors and current skin status. Identifying existing ulcers prompts urgent preventive and therapeutic actions (pressure redistribution, wound care, and reassessment) to reduce complications.

Question 39

The nurse is assessing the client newly diagnosed with endometrial cancer. Which common findings would the nurse expect?

Accepted Answer

Answer reason: As disease progresses, pelvic discomfort or pain can occur from local invasion or uterine enlargement. Night sweats and unexplained fevers are more characteristic of hematologic malignancies or systemic infection rather than a typical initial presentation of endometrial cancer. Supraclavicular lymphadenopathy and splenomegaly suggest more systemic or lymphoproliferative processes and are not expected as common early assessment findings in this condition.

Question 40

The client has right homonymous hemianopia following an ischemic stroke. The nurse asks the NA to help the client with meals knowing that this problem may result in which client response?

Accepted Answer

Answer reason: During meals this commonly presents as leaving food untouched on the side of the plate that falls within the blind visual field, unless cued to scan. Falling to the contralateral side is more consistent with balance/vestibular or motor deficits rather than a primary visual field loss. Choking on liquids reflects dysphagia from cranial nerve/bulbar involvement, not a visual field deficit, and inappropriate utensil use suggests apraxia or significant cognitive impairment.

Question 41

The nurse is obtaining a hospital admission history for the client. Which statement should prompt the nurse to consider that the client has chronic prostatitis?

Accepted Answer

Answer reason: " Chronic prostatitis commonly presents with pelvic/perineal discomfort and genitourinary symptoms related to prostatic inflammation. Painful ejaculation is a classic, fairly specific symptom because the prostate contributes to seminal fluid and is compressed during ejaculation, provoking pain when inflamed. In contrast, difficulty sustaining an erection is nonspecific and more often points to vascular, endocrine, medication, or psychogenic causes rather than prostatitis. While incomplete bladder emptying can occur with prostatic conditions, it is more suggestive of obstructive pathology (e.g., BPH) than a hallmark indicator of chronic prostatitis.

Question 42

During an assessment, the nurse covers the client’s right eye and then observes a shift in the client’s gaze after the eye is uncovered. Which conclusion should the nurse make about the results of the test?

Accepted Answer

Answer reason: A cover-uncover observation assesses ocular alignment and the ability of the eyes to maintain fixation with coordinated extraocular muscle activity. A shift in gaze when the covered eye is uncovered indicates the eye was not aligned while covered and must refixate when binocular vision is restored, consistent with a phoria/strabismus-type misalignment from extraocular muscle imbalance. Lens opacity would affect visual clarity (e.g., cataract) but does not cause a refixation movement on cover testing. Increased intraocular pressure and absence of the blink reflex are assessed with different findings/tests and would not specifically produce this cover-uncover refixation response.

Question 43

The malnourished child has cheilosis of the lips, burning and itching eyes, and seborrheic dermatitis. The child is diagnosed with a vitamin B2 (riboflavin) deficiency. Which additional findings on the assessment should the nurse consider consistent with the diagnosis?

Accepted Answer

Answer reason: In addition to cheilosis and seborrheic dermatitis, angular fissures and cracking around facial orifices (e.g., at the corners of the mouth and nose) are consistent assessment findings. Paresthesia is more typical of other B-vitamin deficiencies affecting peripheral nerves, and irregular heart rate is not a hallmark feature of this deficiency. Acanthosis nigricans is more associated with insulin resistance than with riboflavin deficiency.

Question 44

The nurse assesses that the client with an eating disorder is taking 20 laxative products daily, diuretics twice daily, and is self-inducing vomiting. What should the nurse do next?

Accepted Answer

Answer reason: The priority “next” action is immediate cardiovascular assessment for instability by checking the apical pulse for rate and rhythm changes. Notifying the provider is important, but it follows rapid assessment findings so the urgency and needed interventions can be communicated accurately. Gathering product names or stool patterns is less time-sensitive and does not address the most immediate life-threatening risk.

Question 45

The nurse determines further teaching is necessary when a client with cardiomyopathy states?

Accepted Answer

Answer reason: Hypertrophic obstructive cardiomyopathy causes dynamic left ventricular outflow tract obstruction and impaired diastolic filling, which commonly reduces stroke volume and can lower cardiac output, especially with decreased preload or increased contractility. An assertion that output increases reflects misunderstanding of the pathophysiology and would prompt the nurse to reinforce teaching about obstruction-related symptoms (syncope, exertional dyspnea) and triggers that worsen obstruction. By contrast, dilated cardiomyopathy typically decreases systolic function and lowers output, and restrictive cardiomyopathy limits ventricular filling leading to reduced stroke volume and output. A common distractor is thinking “stronger, thicker muscle pumps more,” but in HOCM the thickened septum and obstruction impair forward flow.

Question 46

A nurse is assessing a client who is experiencing new-onset signs and symptoms of paresthesia. What is the most appropriate question for the nurse to ask the client?

Accepted Answer

Answer reason:  Paresthesia is an abnormal sensory complaint that is classically described as numbness, tingling, “pins and needles,” or burning, so the assessment should directly characterize these sensory changes. This focused question validates the symptom, helps quantify severity and distribution, and guides a targeted neurovascular assessment for possible nerve compression or evolving complications. Asking about ROM is more consistent with musculoskeletal limitation rather than a primary sensory disturbance. Pain with blanching points more toward vascular compromise, and fever/chills suggests infection, neither of which best matches the defining feature of paresthesia.

Question 47

A client comes to the emergency department complaining of dull, deep bone pain unrelated to movement. The client asks the nurse if this could be a fracture. The best response by the nurse is?

Accepted Answer

Answer reason:  Fracture pain is typically localized, sharp, and worsens with movement or weight-bearing because bone ends and injured periosteum/soft tissues are mechanically stimulated. Dull, deep pain that is not affected by movement is less characteristic of an acute fracture and can suggest other etiologies (e.g., bone tumor, osteomyelitis, or referred pain), so the nurse should not affirm it as “classic” for fracture. A key assessment discriminator is that fractures usually have pain exacerbated by motion plus tenderness, swelling, and decreased function. Therefore, describing fracture pain as sharp and movement-related best aligns with expected fracture presentation and supports appropriate further evaluation (e.g., immobilization and imaging).

Question 48

A nurse is collecting a health history from the parents of a 12-month-old infant being evaluated for possible hypopituitarism. What is the most important question for the nurse to ask?

Accepted Answer

Answer reason:  Hypopituitarism in infants commonly presents with growth hormone deficiency, so the hallmark history clue is poor linear growth or growth deceleration on the growth chart. Asking about the growth pattern helps determine timing, severity, and trajectory (e.g., dropping percentiles), which directly supports or argues against an endocrine cause. It also guides what focused assessments and diagnostics are needed (anthropometrics, endocrine labs, and possible imaging). In contrast, prenatal alcohol exposure and multivitamin use are not primary indicators of pituitary hormone deficiency, and prematurity is a risk factor for some complications but is less specific than documented growth failure for this evaluation.

Question 49

A client newly diagnosed with diabetes insipidus asks the nurse about what method is best to monitor the condition. What is the best response by the nurse?

Accepted Answer

Answer reason: The most direct way to monitor disease control is to trend urine volume and concentration along with fluid balance, which is reflected by accurate intake/output and urine specific gravity. Daily weights can help assess overall fluid status, but without urine concentration it is less specific for DI control. Abdominal girth and dependent edema monitoring are more relevant to fluid overload states rather than the classic fluid deficit pattern seen in DI.

Question 50

The nurse is teaching parents how to feed their infant who has a cleft palate. The nurse teaches the parents to apply gentle steady pressure to the base of the bottle. The nurse explains that this will?

Accepted Answer

Answer reason: Infants with a cleft palate often cannot generate adequate suction, which disrupts coordinated suck–swallow–breathe and increases aspiration risk. Gentle, steady pressure on the bottle helps deliver milk in a controlled way despite poor suction, promoting a smoother swallow and better airway protection. This feeding support is aimed at preventing coughing, gagging, and choking episodes during feeds. A common pitfall is focusing on reducing leakage or noise, but those are secondary effects and do not address the primary safety concern of airway compromise.

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