Comprehensive Review with High-Yield Questions,
Rationales, and Test-Taking Strategies for Guaranteed
Success
Question: A nurse completes the assessment of a female client who cannot function
because of an impending divorce. What is the most effective nursing intervention at this
time?
Answer: 2. Assisting her in exploring new coping abilities ✅ Rationale:
• Encouraging new coping strategies helps the client actively manage emotional
distress. Other options focus too much on analysis rather than action.
Question: A client is admitted with a diagnosis of Cushing syndrome. Which clinical
manifestations should the nurse expect the client to exhibit? Select all that apply. Choices:
1. Polyuria
2. Weakness ✅
3. Hypertension ✅
4. Truncal obesity ✅
5. Intermittent tonic spasms Rationale:
• Weakness, hypertension, and truncal obesity are classic signs of Cushing syndrome
due to excess corticosteroids.
• Polyuria and tonic spasms are not typical.
Question: Which conservation exercises should the nurse include in the assessment
process of a child who is 6 years of age? Select all that apply. Choices:
1. Comparing the mass of two balls ✅
2. Comparing the weight of two balls
3. Comparing the length of pencils ✅
4. Comparing the volume in two cups
, 5. Comparing the number of marbles ✅ Rationale:
• Conservation tasks involving mass, number, and length are developmentally
appropriate for a 6-year-old, according to Piaget’s concrete operational stage.
Question: Listening to a client's heart sounds, the nurse hears a characteristic sound.
What should the nurse document? Answer: 4. Pericardial friction rubs ✅ Rationale:
• A pericardial friction rub produces a high-pitched, scratchy sound associated with
pericarditis.
2. Wound Dressing Asepsis
Question: Which statement by a new nurse about wound dressing indicates the need for
further teaching?
Answer: 2. "I should take the cotton swab placed on the table." ✅
Rationale:
• Once a cotton swab is placed on a non-sterile surface, it is no longer sterile.
3. Malaria Clinical Indicators
Question: Which clinical indicators are important in a client with malaria? Select all that
apply. Choices:
1. Polyuria
2. Leukopenia
3. Hyperthermia ✅
4. Splenomegaly ✅
5. Erythrocytosis Rationale:
• Hyperthermia (due to fever) and splenomegaly (due to RBC destruction) are common
in malaria.
4. Very Low Birth Weight (VLBW)
, Question: What birth weight indicates that the infant is VLBW?
Answer: 1. 900 g ✅ Rationale:
• VLBW is defined as a birth weight less than 1500 grams.
5. Caput Succedaneum Explanation
Question: A newborn has caput succedaneum. What is the cause?
Answer: 2. Swelling of soft tissue from labor pressure ✅ Rationale:
• Caput is soft tissue swelling that crosses suture lines due to pressure during vaginal
delivery.
6. Burns - Most Concerning Finding
Question: A child rescued from a fire has burns. What is most concerning?
Answer: 3. Burns around the mouth ✅ Rationale:
• This suggests possible inhalation injury, which is life-threatening.
7. Systemic Lupus Erythematosus (SLE)
Question: Which responses are common in SLE? Select all that apply. Choices:
1. Butterfly facial rash ✅
2. Firm skin fixed to tissue
3. Inflammation of the joints ✅
4. Muscle mass degeneration
5. Inflammation of small arteries Rationale:
• Rash and arthritis are hallmark signs of SLE.
Question:
During a follow-up office visit, an older client who has been undergoing treatment for the
last 5 months for osteomyelitis notes perianal itching and diarrhea. Which other finding does
the nurse correlate with this information?
1. Whitish-yellow lesions in the oral cavity