ADN Exam Questions With Answers and detailed Rationales
Question 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.
Correct Answer: C. Ask the client, ‘What are the voices telling you?’
Explanation: Safety is the priority; the nurse must determine if the hallucinations are
‘command hallucinations’ which could lead to self-harm or harm to others.
Question 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
Correct Answer: D. Excessive thirst and large amounts of diluted urine
Explanation: DI is characterized by a deficiency of ADH, leading to polydipsia and
polyuria (diluted urine with low specific gravity).
Question 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.
Correct Answer: C. Place the child in a knee-chest position.
Explanation: The knee-chest position increases systemic vascular resistance, which
decreases the right-to-left shunt and improves oxygenation during a ‘tet’ spell.
, Question 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
Correct Answer: C. Painless, bright red vaginal bleeding
Explanation: Placenta previa is characterized by painless bright red bleeding, whereas
abruptio placentae involves painful dark red bleeding and a rigid abdomen.
Question 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
Correct Answer: B. Lithium toxicity due to electrolyte imbalance
Explanation: Vomiting and diarrhea cause sodium depletion, which can lead to toxic
levels of Lithium in the bloodstream.
Question 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
Correct Answer: C. Potassium of 6.8 mEq/L
Explanation: Hyperkalemia (Potassium > 5.0) in renal patients can lead to
life-threatening cardiac arrhythmias.
Question 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
Correct Answer: C. Initiative vs. Guilt
Explanation: Preschool-aged children (3-6 years) fall into the Initiative vs. Guilt stage.
Question 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.
Correct Answer: C. Ask the client, ‘What are the voices telling you?’
Explanation: Safety is the priority; the nurse must determine if the hallucinations are
‘command hallucinations’ which could lead to self-harm or harm to others.
Question 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
Correct Answer: D. Excessive thirst and large amounts of diluted urine
Explanation: DI is characterized by a deficiency of ADH, leading to polydipsia and
polyuria (diluted urine with low specific gravity).
Question 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.
Correct Answer: C. Place the child in a knee-chest position.
Explanation: The knee-chest position increases systemic vascular resistance, which
decreases the right-to-left shunt and improves oxygenation during a ‘tet’ spell.
, Question 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
Correct Answer: C. Painless, bright red vaginal bleeding
Explanation: Placenta previa is characterized by painless bright red bleeding, whereas
abruptio placentae involves painful dark red bleeding and a rigid abdomen.
Question 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
Correct Answer: B. Lithium toxicity due to electrolyte imbalance
Explanation: Vomiting and diarrhea cause sodium depletion, which can lead to toxic
levels of Lithium in the bloodstream.
Question 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
Correct Answer: C. Potassium of 6.8 mEq/L
Explanation: Hyperkalemia (Potassium > 5.0) in renal patients can lead to
life-threatening cardiac arrhythmias.
Question 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
Correct Answer: C. Initiative vs. Guilt
Explanation: Preschool-aged children (3-6 years) fall into the Initiative vs. Guilt stage.
