SAUNDERS FINAL EXAM ELITE REVIEW
WITH ACTUAL QUESTIONS AND VERIFIED
ANSWERS FULL SOLUTION 2026
‣ The nurse notes documentation that a client is exhibiting Cheyne-
Stokes respirations. On assessment of the client, the nurse should expect
to note which finding? Answer: Rhythmic respirations with periods of
apnea/can indicate a metabolic dysfunction in the cerebral hemisphere or
basal ganglia
‣ Neurogenic hyperventilation Answer: a regular, rapid and deep,
sustained respiration that can indicate a dysfunction in the low midbrain
and middle pons
‣ Ataxic respirations Answer: totally irregular in rhythm and depth and
indicate a dysfunction in the medulla
‣ Apneustic respirations Answer: irregular respirations with pauses at the
end of inspiration and expiration and can indicate a dysfunction in the
middle or caudal pons.
‣ The nurse notes documentation that a client has conductive hearing
loss. The nurse understands that this type of hearing loss is caused by
which problem? Answer: A physical obstruction to the transmission of
sound waves
, ‣ A sensorineural hearing loss occurs as a result of a pathological
process where? Answer: 1) in the inner ear
2) a defect in the 8th cranial nerve
3) a defect of the sensory fibers that lead to the cerebral cortex
‣ A pericardial friction rub is described as what heart sound? Answer: a
scratchy, leathery heart sound
‣ While performing a cardiac assessment on a client with an incompetent
heart valve, the nurse auscultates a murmur. Which describes the sound
of a heart murmur? Answer: Gentle blowing or swooshing noise
‣ The nurse is assessing a client for meningeal irritation and elicits a
positive Brudzinski's sign. Which finding did the nurse observe?
Answer: The client passively flexes the hip and knee in response to neck
flexion and reports pain in the vertebral column.
‣ Kernig's sign positive response Answer: tests for meningeal irritation
and is positive when the client flexes the legs at the hip and knee and
complains of pain along the vertebral column when the leg is extended.
‣ Decorticate posturing Answer: abnormal flexion and is noted when the
client's upper arms are flexed and held tightly to the sides of the body
and the legs are extended and internally rotated.
WITH ACTUAL QUESTIONS AND VERIFIED
ANSWERS FULL SOLUTION 2026
‣ The nurse notes documentation that a client is exhibiting Cheyne-
Stokes respirations. On assessment of the client, the nurse should expect
to note which finding? Answer: Rhythmic respirations with periods of
apnea/can indicate a metabolic dysfunction in the cerebral hemisphere or
basal ganglia
‣ Neurogenic hyperventilation Answer: a regular, rapid and deep,
sustained respiration that can indicate a dysfunction in the low midbrain
and middle pons
‣ Ataxic respirations Answer: totally irregular in rhythm and depth and
indicate a dysfunction in the medulla
‣ Apneustic respirations Answer: irregular respirations with pauses at the
end of inspiration and expiration and can indicate a dysfunction in the
middle or caudal pons.
‣ The nurse notes documentation that a client has conductive hearing
loss. The nurse understands that this type of hearing loss is caused by
which problem? Answer: A physical obstruction to the transmission of
sound waves
, ‣ A sensorineural hearing loss occurs as a result of a pathological
process where? Answer: 1) in the inner ear
2) a defect in the 8th cranial nerve
3) a defect of the sensory fibers that lead to the cerebral cortex
‣ A pericardial friction rub is described as what heart sound? Answer: a
scratchy, leathery heart sound
‣ While performing a cardiac assessment on a client with an incompetent
heart valve, the nurse auscultates a murmur. Which describes the sound
of a heart murmur? Answer: Gentle blowing or swooshing noise
‣ The nurse is assessing a client for meningeal irritation and elicits a
positive Brudzinski's sign. Which finding did the nurse observe?
Answer: The client passively flexes the hip and knee in response to neck
flexion and reports pain in the vertebral column.
‣ Kernig's sign positive response Answer: tests for meningeal irritation
and is positive when the client flexes the legs at the hip and knee and
complains of pain along the vertebral column when the leg is extended.
‣ Decorticate posturing Answer: abnormal flexion and is noted when the
client's upper arms are flexed and held tightly to the sides of the body
and the legs are extended and internally rotated.
