I
A client with hepatic encephalopathy is prescribed lactulose. Several hours after administration, the client tells the nurse, “This medication is making me have diarrhea, so I think I should stop taking it.”
Which response by the nurse is most appropriate?
A. “Stop taking it and I will consult your doctor because you are experiencing ammonia toxicity.”
B. “The goal is to completely eliminate bowel movements so ammonia cannot be absorbed.”
C. “It is intended for you to have several soft stools each day.”
D. “You should take an antidiarrheal medication with lactulose to prevent fluid loss.”
C. “It is intended for you to have several soft stools each day.”
A client is 12 hours post-craniotomy. The nurse notices that the client has requested water several times during the shift. The client is restless and reports feeling extremely thirsty. Vital signs are BP 94/58 mmHg and HR 112/min.
Which finding most strongly supports diabetes insipidus (DI)?
A. Urine output with a specific gravity of 1.025
B. Urine output with a specific gravity of 1.003
C. Dark amber urine with decreased output
D. Urine output with increased osmolarity
B. Urine output with a specific gravity of 1.003
A nurse suspects hepatic encephalopathy in a client with cirrhosis. Which assessment should the nurse perform to specifically assess for asterixis?
A. Ask the client to follow the nurse's finger with their eyes.
B. Ask the client to squeeze the nurse's fingers and compare hand strength bilaterally.
C. Ask the client to stand with their feet together and close their eyes.
D. Ask the client to extend both arms and dorsiflex the wrists while maintaining the position.
D. Ask the client to extend both arms and dorsiflex the wrists while maintaining the position.
A nurse is assessing a 32-year-old client who was involved in a MVA. The client only opens their eyes when the nurse applies painful stimulation. When asked where they are, the client responds with confused conversation. When the nurse applies a painful stimulus to the nail bed, the client pulls the arm away from the stimulus.
What is the client's Glasgow Coma Scale (GCS) score?
A. 9
B. 10
C. 11
D. 12
B. 10
A 46-year-old client presents to the clinic with several days of fatigue, decreased appetite, and nausea. The client reports noticing that their urine has become darker than usual and that the whites of their eyes appear yellow.
Which statement best explains the pathophysiological process responsible for the client's condition?
A. Hepatic inflammation increases bilirubin production, causing excess bilirubin to accumulate in the bloodstream.
B. Decreased bile production causes bilirubin to be converted into excess hemoglobin, resulting in yellow discoloration of the skin.
C. Hepatic inflammation impairs the liver's ability to effectively process and clear bilirubin, causing bilirubin to accumulate in the blood and tissues.
D. Viral infection causes the kidneys to retain bilirubin, allowing it to accumulate in the bloodstream and produce jaundice.
C. Hepatic inflammation impairs the liver's ability to effectively process and clear bilirubin, causing bilirubin to accumulate in the blood and tissues.
A 41-year-old client is admitted following a high-speed MVA. During the neurological assessment, the nurse notes that the client is unable to move the lower extremities and reports being unable to feel pain or temperature below the level of the injury. The client can, however, identify when the nurse moves the toes into different positions and can distinguish vibration.
Which spinal cord injury pattern should the nurse suspect?
A. Anterior cord syndrome
B. Complete spinal cord lesion
C. Brown-Séquard syndrome
D. Central cord syndrome
A. Anterior cord syndrome
A nurse is reviewing the progress of four clients diagnosed with viral hepatitis. Which client is demonstrating findings most consistent with the icteric stage?
A. A client reporting fatigue, anorexia, nausea, and generalized muscle aches
B. A client reporting improved appetite and energy while jaundice gradually fades
C. A client with yellow sclera, dark urine, pale stools, and mild RUQ discomfort
D. A client with persistent fatigue but gradually improving liver function tests
C. A client with yellow sclera, dark urine, pale stools, and mild RUQ discomfort
A nurse is assessing a client with a spinal cord injury at T4 who is experiencing autonomic dysreflexia. The nurse documents profuse sweating and flushing of the face while the client's lower extremities are pale, cool, and covered with goosebumps.
Which explanation best describes these findings?
A. Vasoconstriction occurs above the injury while vasodilation occurs below the injury.
B. Vasodilation occurs above the injury while vasoconstriction occurs below the injury.
C. Vasodilation occurs both above and below the injury.
D. Vasoconstriction occurs both above and below the injury.
B. Vasodilation occurs above the injury while vasoconstriction occurs below the injury.
A client with known cholelithiasis tells the nurse that the abdominal pain usually begins shortly after eating a high-fat meal. The client asks why the pain does not occur as frequently after eating a small meal of vegetables and rice.
Which explanation by the nurse is most accurate?
A. “Fat causes the pancreas to release enzymes that directly irritate the gallbladder.”
B. “Fat causes the liver to produce excessive bilirubin, increasing gallbladder pressure.”
C. “Fat stimulates CCK release, causing the gallbladder to contract against the obstruction.”
D. “Fat temporarily blocks bile production, causing the gallbladder to become inflamed.”
C. “Fat stimulates CCK release, causing the gallbladder to contract against the obstruction.”
A nurse is assessing a client who sustained a severe traumatic brain injury. The client is unresponsive and develops abnormal posturing when painful stimulation is applied. The nurse observes extension of both arms, internal rotation of the shoulders, and pronation of the forearms.
Which interpretation by the nurse is most accurate?
A. decorticate posturing, indicating damage in the cerebral cortex.
B. decerebrate posturing, indicating damage involving the medulla oblongata.
C. decorticate posturing, indicating damage to the cerebellum and pons.
D. decerebrate posturing, indicating damage to the cerebral cortex.
B. decerebrate posturing, indicating damage involving the medulla oblongata.
A nurse is assessing a client following a head injury. The client opens their eyes when spoken to, answers questions with inappropriate words, and when the nurse applies a painful stimulus, the client moves their hand toward the stimulus in an attempt to push it away.
What is the client's Glasgow Coma Scale (GCS) score?
A. 9
B. 10
C. 11
D. 12
C. 11
A client with acute pancreatitis has been hospitalized for several days. During a reassessment, the nurse notices bluish-purple discoloration around the client’s umbilicus. The client reports worsening abdominal pain and weakness. Vital signs show BP 92/58 mmHg and HR 118/min.
Which finding is the nurse most likely identifying?
A. Turner’s sign
B. Cullen’s sign
C. Grey-Turner syndrome
D. Murphy’s sign
B. Cullen’s sign
A client with acute pancreatitis has severe abdominal inflammation and requires aggressive fluid management. The nurse notes that the client's blood pressure is trending downward despite the client having received some IV fluids.
Which explanation best describes why the client may require significant fluid resuscitation?
A. Pancreatic inflammation causes fluid to shift out of the vascular space into surrounding tissues.
B. Pancreatic inflammation causes the kidneys to retain excessive fluid inside the bloodstream.
C. Digestive enzymes prevent the client from absorbing any oral fluids.
D. Elevated lipase causes fluid to move from the tissues into the vascular space.
A. Pancreatic inflammation causes fluid to shift out of the vascular space into surrounding tissues.
A client with acute hepatitis reports nausea, decreased appetite, and fatigue. The client tells the nurse, “I haven't really wanted to eat, so I've mostly been drinking water.” The client has no vomiting at this time. The nurse is developing a nutrition plan.
Which dietary recommendation is most appropriate?
A. High-fat, high-protein meals to prevent muscle wasting
B. High-carbohydrate, high-calorie meals with moderate protein and low fat
C. Low-carbohydrate, high-protein meals to reduce the liver's workload
D. A fat-free, protein-free diet until liver enzymes normalize
B. High-carbohydrate, high-calorie meals with moderate protein and low fat
A client with spinal cord injury has severe focal spasticity involving several muscles in one extremity. The provider wants to target the affected muscles rather than provide medication throughout the body.
Which treatment would the nurse expect?
A. Oral diazepam
B. Oral baclofen
C. Botulinum toxin injection
D. Intrathecal baclofen pump
C. Botulinum toxin injection
A nurse is reinforcing dietary teaching with a client diagnosed with hepatitis. Which client statement indicates a need for further teaching?
A. “I'll try eating smaller meals if large meals make me nauseated.”
B. “I'll avoid alcohol while my liver is recovering.”
C. “I'll focus on getting enough calories and carbohydrates.”
D. “Since I fatigue easily, I'll increase the amount of fatty foods I eat because they're high in calories.”
D. “Since I fatigue easily, I'll increase the amount of fatty foods I eat because they're high in calories.”
A client with small-cell lung cancer is admitted with worsening headache, nausea, and confusion. The nurse notes that the client has gained 3 kg since admission without significant peripheral edema. Laboratory results show a serum sodium of 116 mEq/L. The provider orders 3% NaCl (hypertonic saline).
Which pathophysiological process best explains why 3% NaCl is being administered?
A. Excess ADH causes excessive water retention, diluting the sodium concentration in the blood; 3% NaCl increases serum sodium and helps correct severe hyponatremia.
B. Excess ADH causes excessive sodium excretion, so 3% NaCl replaces the sodium that was directly lost through the kidneys.
C. SIADH causes severe dehydration, so 3% NaCl rapidly replaces the large amount of fluid lost from the vascular space.
D. Hypertonic saline suppresses ADH release, allowing the kidneys to excrete the excess water responsible for the client's symptoms.
A. Excess ADH causes excessive water retention, diluting the sodium concentration in the blood; 3% NaCl increases serum sodium and helps correct severe hyponatremia.
A nurse is teaching a client about anterior pituitary hormones. Which statement correctly describes the function of follicle-stimulating hormone (FSH)?
A. It stimulates ovulation and testosterone production.
B. It stimulates breast milk production after childbirth.
C. It stimulates sperm production and estrogen and egg development.
D. It stimulates the adrenal gland to release cortisol.
C. It stimulates sperm production and estrogen and egg development.
The nurse receives report on four clients. Which client would most likely benefit from vasopressin rather than desmopressin based on the information provided?
A. A client with central DI and BP 122/76 mmHg
B. A client with nocturnal enuresis and stable vital signs
C. A client with central DI who needs primarily water retention
D. A client experiencing shock with severe hypotension
D. A client experiencing shock with severe hypotension
A client is admitted after sustaining a spinal cord injury. During the initial assessment, the nurse notes hypotension, bradycardia, flaccid paralysis, and loss of spinal reflexes below the level of injury. Which pathophysiologic change best explains these findings?
A. Increased parasympathetic activity causing widespread vasodilation and increased cardiac output
B. Increased parasympathetic activity causing severe vasoconstriction and increased blood pressure
C. Temporary increase in spinal reflex activity causing muscle rigidity and hypertension
D. Decreased sympathetic activity with dominant parasympathetic activity
D. Decreased sympathetic activity with dominant parasympathetic activity
The nurse is assessing a client admitted with suspected cholecystitis. The client has been complaining of RUQ pain and states that the pain became worse after breakfast. The nurse positions the client supine and prepares to perform a test for the Murphy's sign.
Which finding indicates a positive Murphy's sign?
A. The client stops inhaling because of sudden RUQ pain
B. The client reports increased pain when pressure is released
C. The client develops bruising around the umbilicus
D. The client reports pain radiating toward the left shoulder
A. The client stops inhaling because of sudden RUQ pain
A nurse educator is providing a group of nursing students with education regarding elevated intracranial pressure (ICP). The educator asks the students which findings would indicate that the client has progressed to a late stage of increased ICP.
Which response by the students is most accurate?
A. Headache, nausea, vomiting, and restlessness
B. Irritability, tachycardia, and decreased diastolic blood pressure
C. Increased systolic blood pressure, bradycardia, and irregular respirations
D. Widened mean arterial pressure, pupillary changes, tachycardia
C. Increased systolic blood pressure, bradycardia, and irregular respirations
A 47-year-old client comes to the clinic reporting several days of right upper quadrant pain and yellowing of the eyes. The client says, “My urine has been really dark lately, and my bowel movements have looked almost white.” Laboratory results show an elevated direct bilirubin level.
Which type of jaundice is the client most likely experiencing, and which pathophysiological process best explains the findings?
A. Hemolytic jaundice; rapid destruction of RBCs produces excessive unconjugated bilirubin that exceeds the liver's processing capacity.
B. Hepatocellular jaundice; damaged hepatocytes are unable to properly take up, conjugate, and excrete bilirubin.
C. Obstructive jaundice; blockage of bile flow prevents conjugated bilirubin from reaching the intestines, causing bilirubin to accumulate in the blood.
D. Hemolytic jaundice; impaired renal excretion causes conjugated bilirubin to accumulate in the bloodstream and prevents normal stool formation.
C. Obstructive jaundice; blockage of bile flow prevents conjugated bilirubin from reaching the intestines, causing bilirubin to accumulate in the blood.
A client with a spinal cord injury is admitted following a motor vehicle collision. The nurse is developing the initial plan of care. Which intervention is the priority to help prevent additional spinal cord and brain injury?
A. Reposition the client frequently on a pressure-relief mattress
B. Administer a muscle relaxant to decrease muscle spasms
C. Maintain spinal alignment and ensure a patent airway
D. Prepare the client for a laminectomy to relieve pressure on the spinal cord
C. Maintain spinal alignment and ensure a patent airway
A client sustains a left-sided spinal cord injury following a motor vehicle collision. During the neurological assessment, the nurse is comparing the client's motor and sensory function on both sides of the body.
Which assessment finding is most consistent with Brown-Séquard syndrome?
A. Right-sided loss of motor function, vibration, and proprioception with left-sided loss of pain and temperature
B. Left-sided loss of motor function, vibration, and proprioception with right-sided loss of pain and temperature
C. Bilateral arm weakness that is greater than weakness of the legs, with possible sensory and bowel/bladder changes
D. Left-sided loss of motor function, temperature, and proprioception with right-sided loss of pain sensation and vibration
B. Left-sided loss of motor function, vibration, and proprioception with right-sided loss of pain and temperature