EXAM
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 pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope - CORRECT ANSWER -B. Sluggish and unequal pupillary
responses
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. |- |CORRECT |ANSWER |-A.
|Abdominal |pain|decreases |when |lying |supine
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 |- |CORRECT |ANSWER |-A. |Instructions
|about |how|much |fluid |the |child |should |drink |daily
,To |auscultate |for |a |carotid |bruit, |the |nurse |places |the |stethoscope |at |what |location. |(Select
|the |location|on |the |image |with |a |red |dot). |- |CORRECT |ANSWER |-I |placed |the |red |dot |on |the
|base |of |the |neck |on |the |right |side
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 |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 |- |CORRECT |ANSWER |-D. |The |client |with |a |bowel |obstruction |due |to |a |volvulus
|who |is |experiencing|abdominal |rigidity
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 |- |CORRECT |ANSWER |-D. |Respiratory |alkalosis
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 |- |CORRECT |ANSWER |-Fowlers
,The |nurse |is |taking |the |blood |pressure |measurement |of |a |client |with |Parkinson'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
B. Occasional |nocturia
C. Flat |affect
D. Blurred |vision
E. Frequent |drooling |- |CORRECT |ANSWER |-A. |Frequent |syncope
C. |Flat |affect
D. |Blurred |vision
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
C. Serum |blood |glucose |level
D. Creatinine |level |- |CORRECT |ANSWER |-B. |Culture |for |sensitive |organisms
A |preschool-aged |boy |is |admitted |to |the |pediatric |unit |following |successful |resuscitation
|from |a |near-|drowning |incident. |While |providing |care |to |the |child, |the |nurse |begins |talking
|with |his |preadolescent |brother |who |rescued |the |child |from |the |swimming |pool |and |initiated
|resuscitation. |The |nurse |notices|the |older |boy |becomes |withdrawn |when |asked |about |what
|happened. |Which |action |should |the |nurse|take?
A. Develop |a |water |safety |teaching |plan |for |the |family
B. Ask |the |older |brother |how |he |felt |during |the |incident
C. Tell |the |older |brother |that |he |seems |depressed
D. Commend |the |older |brother |for |his |heroic |actions |- |CORRECT |ANSWER |-B. |Ask |the |older
|brother |how|he |felt |during |the |incident
, A |male |client |with |cirrhosis |has |jaundice |and |pruritus. |He |tells |the |nurse |that |he |has |been
|soaking |in |hot|baths |at |night |with |no |relief |of |his |discomfort. |Which |action |should |the |nurse
|take?
A. Encourage |the |client |to |use |cooler |water |and |apply |calamine |lotion |after |soaking
B. Obtain |a |PRN |prescription |for |an |analgesic |that |the |client |can |use |for |symptom |relief
C. Suggest |that |the |client |take |brief |showers |and |apply |oil-based |lotion |after |showering
D. Explain |that |the |symptoms |are |caused |by |liver |damage |and |cannot |be |relieved |- |CORRECT
|ANSWER |-A.|Encourage |the |client |to |use |cooler |water |and |apply |calamine |lotion |after |soaking
An |older |client |with |a |long |history |of |coronary |artery |disease |(CAD), |hypertension |(HTN), |and
|heart |failure |(HF) |arrives |in |the |Emergency |Department |(ED) |in |respiratory |distress. |The
|healthcare |provider |prescribes |furosemide |IV. |Which |therapeutic |response |to |furosemide
|should |the |nurse |expected |in |the|client |with |acute |HF?
A. Increased |cardiac |contractility
B. Reduced |preload
C. Relaxed |vascular |tone
D. Decreased |afterload |- |CORRECT |ANSWER |-B. |Reduced |preload
Which |intervention |should |the |nurse |include |in |the |plan |of |care |for |a |child |with |tetanus?
A. Encourage |coughing |and |deep |breathing
B. Minimize |the |amount |of |stimuli |in |the |room
C. Reposition |from |side |to |side |every |hour
D. Open |window |shades |to |provide |natural |light |- |CORRECT |ANSWER |-B. |Minimize |the |amount
|of |stimuli|in |the |room
An |adolescent |who |was |diagnosed |with |diabetes |mellitus |Type |1 |at |the |age |of |9, |is
|admitted |to |the|hospital |in |diabetic |ketoacidosis. |Which |occurrence |is |the |most |likely
|cause |of |the |ketoacidosis?
A. Ate |an |extra |peanut |butter |sandwich |before |gym |class