ADN Exam 3 / Test 3 | Med-Surg II, Maternity, Peds & Psych |
2026/2027 UPDATE |Galen College
1. A client with schizophrenia is experiencing auditory hallucinations. Which
nursing intervention is most appropriate initially?
A. Tell the client that the voices are not real.
B. Leave the client alone in a quiet room to reduce stimulation.
C. Ask the client, ‘What are the voices telling you?’
D. Agree with the client so they feel supported.
Answer: C
Rationale: Safety is the priority; the nurse must determine if the hallucinations are
‘command hallucinations’ which could lead to self-harm or harm to others.
2. A patient is admitted with Diabetes Insipidus (DI). Which clinical
manifestation should the nurse expect to find?
A. High urine specific gravity
B. Weight gain and edema
C. Hyperglycemia
D. Excessive thirst and large amounts of diluted urine
Answer: D
Rationale: DI is characterized by a deficiency of ADH, leading to polydipsia and polyuria
(diluted urine with low specific gravity).
,3. A nurse is caring for a child with Tetralogy of Fallot who suddenly becomes
cyanotic and dyspneic. What is the priority action?
A. Administer 100% oxygen via mask.
B. Prepare for immediate intubation.
C. Place the child in a knee-chest position.
D. Administer a dose of morphine.
Answer: C
Rationale: The knee-chest position increases systemic vascular resistance, which
decreases the right-to-left shunt and improves oxygenation during a ‘tet’ spell.
4. Which assessment finding is a hallmark sign of Placenta Previa?
A. Hard, board-like abdomen
B. Severe abdominal pain
C. Painless, bright red vaginal bleeding
D. Frequent uterine contractions
Answer: C
Rationale: Placenta previa is characterized by painless bright red bleeding, whereas
abruptio placentae involves painful dark red bleeding and a rigid abdomen.
5. A client taking Lithium Carbonate for Bipolar Disorder reports vomiting and
diarrhea. What is the nurse’s priority concern?
A. Dehydration from the GI symptoms
B. Lithium toxicity due to electrolyte imbalance
C. Development of a viral infection
D. The client is entering a manic phase
Answer: B
Rationale: Vomiting and diarrhea cause sodium depletion, which can lead to toxic levels of
Lithium in the bloodstream.
, 6. A nurse is caring for a patient with End-Stage Renal Disease (ESRD). Which lab
value would indicate the need for immediate intervention?
A. Creatinine of 2.5 mg/dL
B. Hemoglobin of 10 g/dL
C. Potassium of 6.8 mEq/L
D. BUN of 40 mg/dL
Answer: C
Rationale: Hyperkalemia (Potassium > 5.0) in renal patients can lead to life-threatening
cardiac arrhythmias.
7. Which developmental task is associated with Erikson’s stage for a 4-year-old
child?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Answer: C
Rationale: Preschool-aged children (3-6 years) fall into the Initiative vs. Guilt stage.
8. An antepartum client at 34 weeks gestation has a blood pressure of 160/110
and 3+ proteinuria. Which medication does the nurse anticipate administering?
A. Oxytocin
B. Terbutaline
C. Magnesium Sulfate
D. Warfarin
Answer: C
Rationale: Magnesium Sulfate is used to prevent seizures in patients with severe
preeclampsia.
2026/2027 UPDATE |Galen College
1. A client with schizophrenia is experiencing auditory hallucinations. Which
nursing intervention is most appropriate initially?
A. Tell the client that the voices are not real.
B. Leave the client alone in a quiet room to reduce stimulation.
C. Ask the client, ‘What are the voices telling you?’
D. Agree with the client so they feel supported.
Answer: C
Rationale: Safety is the priority; the nurse must determine if the hallucinations are
‘command hallucinations’ which could lead to self-harm or harm to others.
2. A patient is admitted with Diabetes Insipidus (DI). Which clinical
manifestation should the nurse expect to find?
A. High urine specific gravity
B. Weight gain and edema
C. Hyperglycemia
D. Excessive thirst and large amounts of diluted urine
Answer: D
Rationale: DI is characterized by a deficiency of ADH, leading to polydipsia and polyuria
(diluted urine with low specific gravity).
,3. A nurse is caring for a child with Tetralogy of Fallot who suddenly becomes
cyanotic and dyspneic. What is the priority action?
A. Administer 100% oxygen via mask.
B. Prepare for immediate intubation.
C. Place the child in a knee-chest position.
D. Administer a dose of morphine.
Answer: C
Rationale: The knee-chest position increases systemic vascular resistance, which
decreases the right-to-left shunt and improves oxygenation during a ‘tet’ spell.
4. Which assessment finding is a hallmark sign of Placenta Previa?
A. Hard, board-like abdomen
B. Severe abdominal pain
C. Painless, bright red vaginal bleeding
D. Frequent uterine contractions
Answer: C
Rationale: Placenta previa is characterized by painless bright red bleeding, whereas
abruptio placentae involves painful dark red bleeding and a rigid abdomen.
5. A client taking Lithium Carbonate for Bipolar Disorder reports vomiting and
diarrhea. What is the nurse’s priority concern?
A. Dehydration from the GI symptoms
B. Lithium toxicity due to electrolyte imbalance
C. Development of a viral infection
D. The client is entering a manic phase
Answer: B
Rationale: Vomiting and diarrhea cause sodium depletion, which can lead to toxic levels of
Lithium in the bloodstream.
, 6. A nurse is caring for a patient with End-Stage Renal Disease (ESRD). Which lab
value would indicate the need for immediate intervention?
A. Creatinine of 2.5 mg/dL
B. Hemoglobin of 10 g/dL
C. Potassium of 6.8 mEq/L
D. BUN of 40 mg/dL
Answer: C
Rationale: Hyperkalemia (Potassium > 5.0) in renal patients can lead to life-threatening
cardiac arrhythmias.
7. Which developmental task is associated with Erikson’s stage for a 4-year-old
child?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Answer: C
Rationale: Preschool-aged children (3-6 years) fall into the Initiative vs. Guilt stage.
8. An antepartum client at 34 weeks gestation has a blood pressure of 160/110
and 3+ proteinuria. Which medication does the nurse anticipate administering?
A. Oxytocin
B. Terbutaline
C. Magnesium Sulfate
D. Warfarin
Answer: C
Rationale: Magnesium Sulfate is used to prevent seizures in patients with severe
preeclampsia.
