NUR 355 Exam 4: Acute & Chronic Health Disruptions In
Adults I V3 - Arizona College Updated and Latest Questions
and Correct Answers with Rationale
1. A patient with chronic kidney disease (CKD) presents with a glomerular filtration rate (GFR) of 22 mL/min.
Which stage of CKD should the nurse document?
A. Stage 2
B. Stage 3
C. Stage 4
D. Stage 5
Ans: C
Explanation: Chronic kidney disease is staged based on the level of kidney function measured by GFR.
Stage 4 CKD is defined by a GFR ranging from 15 to 29 mL/min. This stage indicates a severe decrease in
kidney function and requires close monitoring for complications. Preparation for renal replacement
therapy usually begins at this level of decline. The nurse must assess the patient for signs of uremia and
electrolyte imbalances.
2. Following a hemodialysis session, a patient complains of a headache, nausea, and becomes increasingly
restless. Which complication does the nurse suspect?
A. Disequilibrium syndrome
B. Air embolism
C. Hypovolemic shock
D. Septicemia
Ans: A
,Explanation: Disequilibrium syndrome is caused by a rapid shift of solutes and fluids from the blood into
brain cells during dialysis. This often occurs during the first few sessions when urea levels are extremely
high. Clinical manifestations include headache, vomiting, restlessness, and potentially seizures. The nurse
should slow the blood flow rate or stop the treatment if symptoms become severe. Future treatments
may be shortened to prevent recurrence of this neurological emergency.
3. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which laboratory finding is most
characteristic of this condition?
A. Serum bicarbonate level of 24 mEq/L
B. Arterial pH of 7.25
C. Blood glucose level of 180 mg/dL
D. Negative urine ketones
Ans: B
Explanation: Diabetic Ketoacidosis is characterized by hyperglycemia, metabolic acidosis, and ketonuria.
An arterial pH below 7.35 indicates an acidotic state resulting from the accumulation of ketone bodies.
The bicarbonate level is usually low because it is consumed in an attempt to buffer the acid. Blood
glucose levels in DKA are typically above 250 mg/dL but are lower than those seen in HHNS. Immediate
insulin therapy and fluid resuscitation are the primary treatments for these patients.
4. The nurse is caring for a patient with cirrhosis who has developed hepatic encephalopathy. What is the
primary goal of administering lactulose?
A. To reduce the risk of gastrointestinal bleeding
B. To decrease the production of bile salts
C. To promote the excretion of ammonia through the stool
, D. To increase serum potassium levels
Ans: C
Explanation: Hepatic encephalopathy is caused by the accumulation of ammonia which crosses the
blood-brain barrier. Lactulose works by trapping ammonia in the gut and facilitating its removal via its
laxative effect. The nurse monitors the patient for two to three soft bowel movements per day to ensure
effectiveness. A decrease in confusion and improved mental status are clinical indicators of successful
therapy. Electrolytes must be monitored as frequent stools can lead to dehydration or hypokalemia.
5. A patient with acute pancreatitis exhibits a bluish discoloration around the periumbilical area. How
should the nurse document this finding?
A. Cullen’s sign
B. Murphy’s sign
C. Chvostek’s sign
D. Turner’s sign
Ans: A
Explanation: Cullen’s sign is characterized by periumbilical ecchymosis and suggests intra-abdominal or
retroperitoneal bleeding. This finding is often associated with severe necrotizing pancreatitis. The
discoloration results from blood tracking along the falciform ligament to the umbilicus. Turner’s sign, in
contrast, involves bruising of the flanks or loin area. The nurse must report these signs immediately as
they indicate a high risk of hemorrhage and clinical deterioration.
6. Which clinical manifestation is expected in a patient diagnosed with Cushing’s syndrome?
A. Truncal obesity and moon face
B. Hypotension and weight loss
Adults I V3 - Arizona College Updated and Latest Questions
and Correct Answers with Rationale
1. A patient with chronic kidney disease (CKD) presents with a glomerular filtration rate (GFR) of 22 mL/min.
Which stage of CKD should the nurse document?
A. Stage 2
B. Stage 3
C. Stage 4
D. Stage 5
Ans: C
Explanation: Chronic kidney disease is staged based on the level of kidney function measured by GFR.
Stage 4 CKD is defined by a GFR ranging from 15 to 29 mL/min. This stage indicates a severe decrease in
kidney function and requires close monitoring for complications. Preparation for renal replacement
therapy usually begins at this level of decline. The nurse must assess the patient for signs of uremia and
electrolyte imbalances.
2. Following a hemodialysis session, a patient complains of a headache, nausea, and becomes increasingly
restless. Which complication does the nurse suspect?
A. Disequilibrium syndrome
B. Air embolism
C. Hypovolemic shock
D. Septicemia
Ans: A
,Explanation: Disequilibrium syndrome is caused by a rapid shift of solutes and fluids from the blood into
brain cells during dialysis. This often occurs during the first few sessions when urea levels are extremely
high. Clinical manifestations include headache, vomiting, restlessness, and potentially seizures. The nurse
should slow the blood flow rate or stop the treatment if symptoms become severe. Future treatments
may be shortened to prevent recurrence of this neurological emergency.
3. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which laboratory finding is most
characteristic of this condition?
A. Serum bicarbonate level of 24 mEq/L
B. Arterial pH of 7.25
C. Blood glucose level of 180 mg/dL
D. Negative urine ketones
Ans: B
Explanation: Diabetic Ketoacidosis is characterized by hyperglycemia, metabolic acidosis, and ketonuria.
An arterial pH below 7.35 indicates an acidotic state resulting from the accumulation of ketone bodies.
The bicarbonate level is usually low because it is consumed in an attempt to buffer the acid. Blood
glucose levels in DKA are typically above 250 mg/dL but are lower than those seen in HHNS. Immediate
insulin therapy and fluid resuscitation are the primary treatments for these patients.
4. The nurse is caring for a patient with cirrhosis who has developed hepatic encephalopathy. What is the
primary goal of administering lactulose?
A. To reduce the risk of gastrointestinal bleeding
B. To decrease the production of bile salts
C. To promote the excretion of ammonia through the stool
, D. To increase serum potassium levels
Ans: C
Explanation: Hepatic encephalopathy is caused by the accumulation of ammonia which crosses the
blood-brain barrier. Lactulose works by trapping ammonia in the gut and facilitating its removal via its
laxative effect. The nurse monitors the patient for two to three soft bowel movements per day to ensure
effectiveness. A decrease in confusion and improved mental status are clinical indicators of successful
therapy. Electrolytes must be monitored as frequent stools can lead to dehydration or hypokalemia.
5. A patient with acute pancreatitis exhibits a bluish discoloration around the periumbilical area. How
should the nurse document this finding?
A. Cullen’s sign
B. Murphy’s sign
C. Chvostek’s sign
D. Turner’s sign
Ans: A
Explanation: Cullen’s sign is characterized by periumbilical ecchymosis and suggests intra-abdominal or
retroperitoneal bleeding. This finding is often associated with severe necrotizing pancreatitis. The
discoloration results from blood tracking along the falciform ligament to the umbilicus. Turner’s sign, in
contrast, involves bruising of the flanks or loin area. The nurse must report these signs immediately as
they indicate a high risk of hemorrhage and clinical deterioration.
6. Which clinical manifestation is expected in a patient diagnosed with Cushing’s syndrome?
A. Truncal obesity and moon face
B. Hypotension and weight loss
