VERSION WITH REAL COMPLETE QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES||
VERIFIED 100% ACTUAL FINAL EXAM WITH
VERIFIED ANSWERS & QUESTIONS || LATEST
UPDATE 2026-2027
A 25-year-old client was admitted yesterday after a motor vehicle
collision. Neurodiagnostic studies have shown a basal skull
fracture in the middle fossa. Assessment on admission revealed
both halo and Battle signs. Which new symptom indicates that the
client is likely to be experiencing a common life-threatening
complication associated with a basal skull fracture?
A. Bilateral jugular venous distention
B.Oral temperature of 102° F
C.Intermittent focal motor seizures
D.Intractable pain in the cervical region
B. Oral temperature of 102° F
Rationale:
Clients with basilar skull fractures are at high risk for infection of the
brain, as indicated by an increased oral temperature, because the
fracture leaves the meninges open to bacterial invasion. Clients may
experience options C and D, but these findings do not pose as great a
life-threatening risk as infection. Jugular distention is not a typical
complication of basal skull fractures.
,Which statement reflects the highest priority nursing diagnosis for
an older client recently admitted to the hospital for a new-onset
cardiac dysrhythmia?
A.Diarrhea related to medication side effects
B.Anxiety related to fear of recurrent anginal episodes
C.Altered nutrition related to high serum lipid levels
D.Risk for injury related to syncope and confusion
D.Risk for injury related to syncope and confusion
Rationale:
The loss of cardiac function in aging decreases cardiac output, so
dysrhythmias, particularly tachycardias, are poorly tolerated. With onset
of a tachycardic or bradycardic dysrhythmia, cardiac output is
compromised further, placing the client at risk of syncope and falling,
as well as confusion. Option A is of high priority but less so than
maintaining client safety. Clients may experience option B as a result of
a newly diagnosed cardiac condition, but this nursing diagnosis does
not have the priority of option D. Option C also does not have the
priority of option D.
,A client is admitted to the hospital with a diagnosis of severe
acute diverticulitis. Which nursing intervention has the highest
priority?
A.Place the client on NPO status.
B. Assess the client's temperature.
C. Obtain a stool specimen.
D.Administer IV fluids.
A.Place the client on NPO status.
Rationale:
A client with acute severe diverticulitis is at risk for peritonitis and
intestinal obstruction and should be made NPO to reduce risk of
intestinal rupture. Options B, C, and D are important but are less of a
priority than option A, which is implemented to prevent a severe
complication.
, The nurse notes that a client who is scheduled for surgery the
next morning has an elevated blood urea nitrogen (BUN) level.
Which condition is most likely to have contributed to this finding?
A. Myocardial infarction 2 months ago
B.Anorexia and vomiting for the past 2 days
C.Recently diagnosed type 2 diabetes mellitus
D.Skeletal traction for a right hip fracture
B.
Anorexia and vomiting for the past 2 days
Rationale:
The blood urea nitrogen (BUN) level indicates the effectiveness of the
kidneys in filtering waste from the blood. Dehydration, which could be
caused by vomiting, would cause an increased BUN level. Option A
would affect serum enzyme levels, not the BUN level. Option C would
primarily affect the blood glucose level; renal failure that could
increase the BUN level would be unlikely in a client newly diagnosed
with type 2 diabetes. Effects of option D might affect the complete
blood count (CBC) but would not directly increase the BUN level.