Revised Answers, 100% Verified
1. A female client presents in the emergency department and tells the nurse
that she was raped last night. Which question is most important for the nurse
to ask?
A. Has she taken a bath since the rape occurred?
B. Is the place where she lives a safe place?
C. Does she know the person who raped her?
D. Did she report the rape to the police department? ANS > A. Has she taken a
bath since the rape occurred?
2. The nurse is completing the admission assessment of a 3-year old who
is admitted with bacterial meningitis and hydrocephalus. Which assessment
finding is evidence that the child is experiencing increased intracranial pres-
sure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope ANS > B. Sluggish and unequal
pupillary responses
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, 3. A client with acute pancreatitis is admitted with severe, piercing abdominal
pain and an elevated serum amylase. Which additional information is the client
most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly. ANS > A. Abdominal
pain decreases when lying supine
4. A child newly diagnosed with sickle cell anemia (SCA) is being discharged
from the hospital. Which information is most important for the nurse to provide
the parents prior to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family ANS > A. Instructions about
how much fluid the child should drink daily
5. To auscultate for a carotid bruit, the nurse places the stethoscope at what
location. (Select the location on the image with a red dot). ANS > I placed the
red dot on the base of the neck on the right side
6. After receiving report on an inpatient acute care unit, which client should
the nurse assess first?
A. The client with an obstruction of the large intestine who is experiencing
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, abdominal distention
B. The client who had surgery yesterday and is experiencing a paralytic ileus
with absent bowel sounds
C. The client with a small bowel obstruction who has a nasogastric tube that
is draining greenish fluid
D. The client with a bowel obstruction due to a volvulus who is experiencing
abdominal rigidity ANS > D. The client with a bowel obstruction due to a volvulus
who is experiencing abdominal rigidity
7. A teenager presents to the emergency department with palpitations after
vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse
anticipates the client developing which acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis ANS > D. Respiratory alkalosis
8. A client with dyspnea is being admitted to the medical unit. To best prepare
for the client's arrival, the nurse should ensure that the client's bed is in which
position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers ANS > Fowlers
9. The nurse is taking the blood pressure measurement of a client with Parkin-
son's disease. Which information in the client's admission assessment is
relevant to the nurse's plan for taking the blood pressure reading? (Select all
the apply)
A. Frequent syncope
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, B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling ANS > A. Frequent syncope
C. Flat affect
D. Blurred vision
10. While caring for a client's postoperative dressing, the nurse observes
purulent drainage at the wound. Before reporting this finding to the healthcare
provider, the nurse should review which of the client's laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
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