NUR185/NUR 185 Exam 2 V2 | Concepts of
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with a history of Chronic Kidney Disease (CKD) who is
scheduled for hemodialysis. Which assessment finding should the nurse prioritize reporting to
the healthcare provider?
A. A serum potassium level of 4.2 mEq/L
B. A blood pressure of 168/94 mmHg
C. Absence of a thrill or bruit over the AV fistula
D. Weight gain of 1.5 kg since the last treatment
Correct Answer: C
Rationale: The absence of a thrill or bruit indicates that the arteriovenous (AV) fistula may
be clotted or obstructed, which is a medical emergency for a dialysis patient. A thrill is a
palpable vibration and a bruit is an audible rushing sound heard with a stethoscope.
Immediate intervention is required to save the access site for life-sustaining treatments.
2. A client with Gastroesophageal Reflux Disease (GERD) is being discharged. Which
instruction should the nurse include in the teaching plan to prevent symptoms?
A. Eat three large meals a day to keep the stomach full
,B. Lie down flat for 30 minutes after eating
C. Drink orange juice every morning to increase acidity
D. Avoid caffeine, chocolate, and peppermint
Correct Answer: D
Rationale: Caffeine, chocolate, and peppermint are known to relax the lower esophageal
sphincter (LES), which allows gastric acid to flow back into the esophagus. Clients should
be encouraged to eat small, frequent meals rather than large ones to reduce gastric
pressure. Elevation of the head of the bed after meals is also a critical component of non-
pharmacological management.
3. The nurse is monitoring a client with an acute spinal cord injury at the T6 level. The client
suddenly reports a severe, throbbing headache and has a blood pressure of 190/110 mmHg.
What is the priority nursing action?
A. Administer an analgesic for the headache
B. Check the client for bladder distention
C. Lower the head of the bed to the flat position
D. Request an order for a STAT CT scan
Correct Answer: B
Rationale: These symptoms indicate Autonomic Dysreflexia, a life-threatening
complication in clients with spinal cord injuries above T6. The most common trigger is a
, full bladder or fecal impaction causing a sympathetic response. The nurse must
immediately sit the client up to lower blood pressure and then identify/remove the
stimulus, such as checking for a kinked catheter.
4. A client is diagnosed with suspected bacterial meningitis. Which clinical manifestation
should the nurse expect to find during the physical assessment?
A. Nuchal rigidity and a positive Kernig’s sign
B. Flaccid paralysis of the lower extremities
C. Hypotension and bradycardia
D. Increased appetite and polyuria
Correct Answer: A
Rationale: Nuchal rigidity (neck stiffness) and Kernig’s sign (pain when extending the leg
from a flexed hip) are classic signs of meningeal irritation. Clients may also present with
photophobia, high fever, and a severe headache. Prompt recognition is vital as bacterial
meningitis can lead to rapid neurological decline or death if untreated.
5. Which laboratory value is most indicative of acute pancreatitis in a client presenting with
severe epigastric pain radiating to the back?
A. Elevated serum amylase and lipase
B. Decreased White Blood Cell (WBC) count
C. Decreased serum glucose levels
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with a history of Chronic Kidney Disease (CKD) who is
scheduled for hemodialysis. Which assessment finding should the nurse prioritize reporting to
the healthcare provider?
A. A serum potassium level of 4.2 mEq/L
B. A blood pressure of 168/94 mmHg
C. Absence of a thrill or bruit over the AV fistula
D. Weight gain of 1.5 kg since the last treatment
Correct Answer: C
Rationale: The absence of a thrill or bruit indicates that the arteriovenous (AV) fistula may
be clotted or obstructed, which is a medical emergency for a dialysis patient. A thrill is a
palpable vibration and a bruit is an audible rushing sound heard with a stethoscope.
Immediate intervention is required to save the access site for life-sustaining treatments.
2. A client with Gastroesophageal Reflux Disease (GERD) is being discharged. Which
instruction should the nurse include in the teaching plan to prevent symptoms?
A. Eat three large meals a day to keep the stomach full
,B. Lie down flat for 30 minutes after eating
C. Drink orange juice every morning to increase acidity
D. Avoid caffeine, chocolate, and peppermint
Correct Answer: D
Rationale: Caffeine, chocolate, and peppermint are known to relax the lower esophageal
sphincter (LES), which allows gastric acid to flow back into the esophagus. Clients should
be encouraged to eat small, frequent meals rather than large ones to reduce gastric
pressure. Elevation of the head of the bed after meals is also a critical component of non-
pharmacological management.
3. The nurse is monitoring a client with an acute spinal cord injury at the T6 level. The client
suddenly reports a severe, throbbing headache and has a blood pressure of 190/110 mmHg.
What is the priority nursing action?
A. Administer an analgesic for the headache
B. Check the client for bladder distention
C. Lower the head of the bed to the flat position
D. Request an order for a STAT CT scan
Correct Answer: B
Rationale: These symptoms indicate Autonomic Dysreflexia, a life-threatening
complication in clients with spinal cord injuries above T6. The most common trigger is a
, full bladder or fecal impaction causing a sympathetic response. The nurse must
immediately sit the client up to lower blood pressure and then identify/remove the
stimulus, such as checking for a kinked catheter.
4. A client is diagnosed with suspected bacterial meningitis. Which clinical manifestation
should the nurse expect to find during the physical assessment?
A. Nuchal rigidity and a positive Kernig’s sign
B. Flaccid paralysis of the lower extremities
C. Hypotension and bradycardia
D. Increased appetite and polyuria
Correct Answer: A
Rationale: Nuchal rigidity (neck stiffness) and Kernig’s sign (pain when extending the leg
from a flexed hip) are classic signs of meningeal irritation. Clients may also present with
photophobia, high fever, and a severe headache. Prompt recognition is vital as bacterial
meningitis can lead to rapid neurological decline or death if untreated.
5. Which laboratory value is most indicative of acute pancreatitis in a client presenting with
severe epigastric pain radiating to the back?
A. Elevated serum amylase and lipase
B. Decreased White Blood Cell (WBC) count
C. Decreased serum glucose levels
