2025 | Actual Exam
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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 - ANS✔✔---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?" - ANS✔✔---" 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 - ANS✔✔---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