2023 EXAM QUESTIONS AND ANSWERS
100% CORRECT!!!
,A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2
days ago. Which of the following findings is associated with this diagnosis?
A. Increased appetite
B. Elevated Temperature
C. Bradycardia
D. Drowsiness - ANSWER Elevated Temperature
Rationale: The content of this question emphasizes the concept of client-centered care
through identifying findings associated with a client's diagnosis. Client-centered care
focuses on the client and emphasizes the client's cultural, ethnic, and social values. The
identification of expected and unexpected findings associated with a client's diagnosis
assists the nurse to distinguish possible unrelated complications the client might be
experiencing, which indicates the need for further investigation. The specific focus on
the client enhances the provision of safe, quality nursing care. An elevated temperature
is a finding associated with acute alcohol delirium.
A nurse working in a hospice facility is talking to a client's son who is distressed
because his mother cries frequently and says she wants to die. Which of the following
responses by the nurse is appropriate?
A. "I know this must be difficult, but your mother will calm down soon."
B. "Lets discuss some strategies you can use when this happens again."
C. Individuals near death are ready to let go toward the end."
D. "Have you determined why she is crying and saying she is ready to die?" - ANSWER
" Let's discuss some strategies you can use when this happens again."
Rationale: This response by the nurse offers to provide information, which can reduce
anxiety and enhance decision making. This response creates a safe environment,
fosters trust and respect, and is appropriate.
A nurse is caring for a client who had cerebrovascular accident 2 days ago. Which of
the following is the first sign of increased intracranial pressure (ICP)?
A. pupil dilation
, B. Ataxia
C. Lethargy
D Bradycardia - ANSWER Lethargy
rationale: Lethargy occurs when pressure is placed on the reticular activating system
within the brainstem. Along with other indicators of a change in level of consciousness,
such as restlessness, irritability, and disorientation. Lethargy is the first sign of
increased ICP.
A nurse working in a provider's office is reinforcing teaching with a client who is 14
weeks of gestation. The nurse should instruct the client to immediately notify the
provider if she experiences which of the following?
A. facial edema
b. urinary frequency
c. acid indigestion
d. breast leakage - ANSWER Facial edema
rationale: facial edema is an indication of pregnancy-induced hypertension and should
be reported immediately to the provider.
A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled
central venous catheter and reports hearing a gurgling sound on the side of the
catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the
following actions should the nurse take first?
A. Notify the provider
B. Obtain a chest x-ray
C. Flush the catheter.
D. Stop the infusion. - ANSWER Stop the infusion
Rationale: This prevents further damage to vessel and minimizes any additional harm to
the client
A nurse is caring for a client who has an acid-base imbalance. For which of the
following manifestations is metabolic alkalosis a possible complications?
A. Hyperkalemia
B. Severe diarrhea
C. Atelectasis
D. Excessive vomiting - ANSWER Excessive vomiting
rationale: Metabolic alkalosis is a potential complication of excessive vomiting because
of loss of acid from the body.