Question 1
The nurse hears short, high-pitched sounds just before the end of inspiration in the right
and left lower lobes when auscultating a client's lungs. How should this finding be
recorded?
-Inspiratory wheezes in both lungs.
-Crackles in the right and left lower lobes.
-Abnormal lung sounds in the bases of both lungs.
-Pleural friction rub in the right and left lower lobes.
CORRECT ANSWER
Crackles in the right and left lower lobes.
Rationale: Fine crackles are short, high-pitched sounds heard just before the end of
inspiration that are the result of rapid equalization of pressure when collapsed alveoli or
terminal bronchioles suddenly snap open.
Question 2
The nurse is planning care for a client who has a right hemispheric stroke. Which nursing
diagnosis should the nurse include in the plan of care?
-Impaired physical mobility related to right-sided hemiplegia.
-Risk for injury related to denial of deficits and impulsiveness.
-Impaired verbal communication related to speech-language deficits.
-Ineffective coping related to depression and distress about disability.
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@THE STUDY VAULT
,CORRECT ANSWER
Risk for injury related to denial of deficits and impulsiveness.
Rationale: With right-brain damage, a client experience difficulty in judgment and spatial
perception and is more likely to be impulsive and move quickly, which places the client at
risk for falls.
Question 3
The nurse is assessing a postmenopausal woman who is complaining of urinary urgency
and frequency and stress incontinence. She also reports difficulty in emptying her bladder.
These complaints are most likely due to which condition?
-Cystocele.
-Bladder infection.
-Pyelonephritis.
-Irritable bladder.
CORRECT ANSWER
Cystocele
Rationale: This constellation of signs in a postmenopausal woman are characteristic of a
cystocele. These symptoms are not characteristic of the other options.
Question 4
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone
(SIADH), which is manifested by which symptoms?
-Loss of thirst, weight gain.
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@THE STUDY VAULT
,-Dependent edema, fever.
-Polydipsia, polyuria.
-Hypernatremia, tachypnea.
CORRECT ANSWER
Loss of thirst, weight gain
Rationale: SIADH occurs when the posterior pituitary gland releases too much ADH, causing
water retention, a urine output of less than 20 ml/hour, and dilutional hyponatremia. Other
indications of SIADH are loss of thirst, weight gain, irritability, muscle weakness, and
decreased level of consciousness.
Question 5
The nurse is teaching a client with maple syrup urine disease (MSUD), an autosomal
recessive disorder, about the inheritance pattern. Which information should the nurse
provide?
-This recessive disorder is carried only on the X chromosome.
-Occurrences mainly affect males and heterozygous females.
-Both genes of a pair must be abnormal for the disorder to occur.
-One copy of the abnormal gene is required for this disorder.
CORRECT ANSWER
Both genes of a pair must be abnormal for the disorder to occur
Rationale: Maple syrup urine disease (MSUD) is a type of autosomal recessive inheritance
disorder in which both genes of a pair must be abnormal for the disorder to be expressed.
Question 6
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@THE STUDY VAULT
, What information should the nurse include in a teaching plan about the onset of
menopause? (Select all that apply).
-Smoking.
-Oophorectomy with hysterectomy.
-Early menarche.
-Cardiac disease.
-Genetic influence.
-Chemotherapy exposure.
CORRECT ANSWER
-Smoking
-early menarche
-genetic influence
-chemotherapy exposure
Rationale: Menopausal symptoms are related to the cessation of ovarian function. Factors
influencing the onset of menopause include smoking, genetic influences, early men
Question 7
The nurse reviews the complete blood count (CBC) findings of an adolescent with acute
myelogenous leukemia (AML). The hemoglobin is 13.8 g/dl, hematocrit is 36.7%, white
blood cell count is 8,200 mm3, and platelet count is 115,000 mm3. Based on these
findings, what is the priority nursing diagnosis for this client's plan of care?
-Impaired gas exchange.
-Risk for infection.
-Risk for injury.
-Risk for activity intolerance.
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@THE STUDY VAULT
The nurse hears short, high-pitched sounds just before the end of inspiration in the right
and left lower lobes when auscultating a client's lungs. How should this finding be
recorded?
-Inspiratory wheezes in both lungs.
-Crackles in the right and left lower lobes.
-Abnormal lung sounds in the bases of both lungs.
-Pleural friction rub in the right and left lower lobes.
CORRECT ANSWER
Crackles in the right and left lower lobes.
Rationale: Fine crackles are short, high-pitched sounds heard just before the end of
inspiration that are the result of rapid equalization of pressure when collapsed alveoli or
terminal bronchioles suddenly snap open.
Question 2
The nurse is planning care for a client who has a right hemispheric stroke. Which nursing
diagnosis should the nurse include in the plan of care?
-Impaired physical mobility related to right-sided hemiplegia.
-Risk for injury related to denial of deficits and impulsiveness.
-Impaired verbal communication related to speech-language deficits.
-Ineffective coping related to depression and distress about disability.
1
@THE STUDY VAULT
,CORRECT ANSWER
Risk for injury related to denial of deficits and impulsiveness.
Rationale: With right-brain damage, a client experience difficulty in judgment and spatial
perception and is more likely to be impulsive and move quickly, which places the client at
risk for falls.
Question 3
The nurse is assessing a postmenopausal woman who is complaining of urinary urgency
and frequency and stress incontinence. She also reports difficulty in emptying her bladder.
These complaints are most likely due to which condition?
-Cystocele.
-Bladder infection.
-Pyelonephritis.
-Irritable bladder.
CORRECT ANSWER
Cystocele
Rationale: This constellation of signs in a postmenopausal woman are characteristic of a
cystocele. These symptoms are not characteristic of the other options.
Question 4
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone
(SIADH), which is manifested by which symptoms?
-Loss of thirst, weight gain.
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@THE STUDY VAULT
,-Dependent edema, fever.
-Polydipsia, polyuria.
-Hypernatremia, tachypnea.
CORRECT ANSWER
Loss of thirst, weight gain
Rationale: SIADH occurs when the posterior pituitary gland releases too much ADH, causing
water retention, a urine output of less than 20 ml/hour, and dilutional hyponatremia. Other
indications of SIADH are loss of thirst, weight gain, irritability, muscle weakness, and
decreased level of consciousness.
Question 5
The nurse is teaching a client with maple syrup urine disease (MSUD), an autosomal
recessive disorder, about the inheritance pattern. Which information should the nurse
provide?
-This recessive disorder is carried only on the X chromosome.
-Occurrences mainly affect males and heterozygous females.
-Both genes of a pair must be abnormal for the disorder to occur.
-One copy of the abnormal gene is required for this disorder.
CORRECT ANSWER
Both genes of a pair must be abnormal for the disorder to occur
Rationale: Maple syrup urine disease (MSUD) is a type of autosomal recessive inheritance
disorder in which both genes of a pair must be abnormal for the disorder to be expressed.
Question 6
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@THE STUDY VAULT
, What information should the nurse include in a teaching plan about the onset of
menopause? (Select all that apply).
-Smoking.
-Oophorectomy with hysterectomy.
-Early menarche.
-Cardiac disease.
-Genetic influence.
-Chemotherapy exposure.
CORRECT ANSWER
-Smoking
-early menarche
-genetic influence
-chemotherapy exposure
Rationale: Menopausal symptoms are related to the cessation of ovarian function. Factors
influencing the onset of menopause include smoking, genetic influences, early men
Question 7
The nurse reviews the complete blood count (CBC) findings of an adolescent with acute
myelogenous leukemia (AML). The hemoglobin is 13.8 g/dl, hematocrit is 36.7%, white
blood cell count is 8,200 mm3, and platelet count is 115,000 mm3. Based on these
findings, what is the priority nursing diagnosis for this client's plan of care?
-Impaired gas exchange.
-Risk for infection.
-Risk for injury.
-Risk for activity intolerance.
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@THE STUDY VAULT
