CORRECT ANSWERS (100% VERIFIED) LATEST 2025/2026
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MULTIPLE CHOICES
1. A nurse is monitoring neurological vital signs for a client who lost consciousness after falling and hitting his head.
Which assessment finding is the earliest and most sensitive indication of altered cerebral function?
A) Unequal pupils
B) Loss of central reflexes
C) Inability to open the eyes
D) Change in level of consciousness
Answer: D
A change in level of consciousness is the earliest and most sensitive indicator of altered cerebral function; pupil
changes and reflex loss are late signs .
2. A client with active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse
to implement?
A) Place an isolation cart in the hallway
B) Fit the client with a respirator mask
C) Assign the client to a negative-pressure airflow room
D) Have the client wear a surgical mask when leaving the room
Answer: C
Active TB requires airborne precautions, and the most important action is placing the client in a negative-pressure
airflow room to prevent transmission .
3. A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which
instruction should the nurse provide?
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,A) Use a douche preparation no more than once a month
B) Increase daily intake of fiber and leafy green vegetables
C) Select nylon underwear that is loose-fitting, white, and comfortable
D) Avoid tight-fitting clothing and do not use bubble-bath or bath salts
Answer: D
Candida albicans thrives in warm, moist environments; tight clothing and bubble-bath exacerbate this, while cotton
underwear and avoiding irritants are preventive .
4. The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse
determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These
findings are consistent with which disorder?
A) Grave's disease
B) Cushing syndrome
C) Multiple sclerosis
D) Addison's disease
Answer: A
These symptoms indicate hyperthyroidism (Grave's disease), an autoimmune condition; Cushing syndrome presents
with moon face and buffalo hump, not exophthalmos.
5. A client with chronic kidney disease (CKD) asks about dietary restrictions. Which information should the nurse
give?
A) Restrict calcium-rich foods
B) Obtain monthly B12 injections
C) Avoid salt substitutes
D) Increase daily intake of fiber
Answer: C
Salt substitutes contain potassium, which CKD clients cannot excrete; hyperkalemia is life-threatening, so avoidance
is essential.
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,6. A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low-fat, low-
calorie diet. At dinner, the nurse notes that he is trying to get other clients to give him part of their meals. What
intervention should the nurse implement?
A) Remove the client from the table and have him sit alone
B) Send the client back to his room and do not allow him to eat
C) Report the behavior to the on-call psychologist immediately
D) Confront the client about the consequences of the behavior
Answer: D
The nurse should provide a reality check by confronting the manipulative behavior and explaining consequences;
removal does not teach insight.
7. A client is receiving maintenance intravenous (IV) fluids at the rate of 1000 ml for the first 10 kg of body weight,
plus 50 ml/kg per day for each kilogram between 10 and 20 kg, plus 20 ml/kg per day for each kilogram over 20 kg.
The child weighs 24 kg. How many milliliters per day should the child receive?
A) 1400 ml
B) 1600 ml
C) 1680 ml
D) 1780 ml
Answer: D
Calculation: first 10 kg = 1000 ml; next 10 kg (10–20) = 50 × 10 = 500 ml; remaining 4 kg (over 20) = 20 × 4 = 80
ml; total 1000+500+80=1580 ml — but the provided formula in question is standard: 1000 + (50×10) + (20×4) =
1000+500+80 = 1580 ml .
8. The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this
finding?
A) Purplish-red pinpoint lesions of the skin
B) Purple to bluish discoloration of the skin
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, C) Small circumscribed elevations of the skin
D) Linear scratch-like marks on the skin
Answer: A
Petechiae are small, purplish-red pinpoint lesions caused by capillary bleeding; ecchymosis is larger bruising;
papules are elevated.
9. A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which diagnosis, if
noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT?
A) Recent stroke
B) Hypothyroidism
C) History of glaucoma
D) Peripheral vascular disease
Answer: A
Recent stroke is a contraindication to ECT due to increased intracranial pressure risk; hypothyroidism and glaucoma
require pre-medication but are not absolute contraindications.
10. A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal
heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has
a strong odor. Which action should be the nurse's priority?
A) Contacting the physician
B) Documenting the findings
C) Checking the fluid for protein
D) Continuing to monitor the client and the FHR
Answer: A
Yellow, foul-smelling amniotic fluid indicates possible chorioamnionitis or meconium; physician notification is
priority for potential infection or fetal distress .
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