,QUESTION 1
A nurse is assessing a client at risk for neurologic deterioration. Which finding is usually the earliest
indication of increased intracranial pressure (ICP)?
A. Severe headache
B. Change in level of consciousness
C. Projectile vomiting
D. Pupillary dilation
Answer: B. Change in level of consciousness
Detailed Rationale:
The cerebral cortex is highly sensitive to even minute changes in oxygenation and pressure. Therefore, a
subtle change in the level of consciousness (LOC)—such as restlessness, irritability, or slight confusion—
is the earliest and most sensitive indicator of rising ICP.
• Why others are wrong: Option A (Headache) and Option C (Projectile vomiting) are classic signs
but often occur as pressure continues to build. Option D (Pupillary dilation) is a late sign
indicating brainstem compression and potential herniation.
QUESTION 2
A client with suspected meningitis presents with fever and headache. Which assessment finding is most
characteristic of meningeal irritation?
A. Bradycardia
B. Nuchal rigidity
C. Hypotension
D. Hyperglycemia
Answer: B. Nuchal rigidity
Detailed Rationale:
Nuchal rigidity, or neck stiffness, occurs because the inflamed meninges (the protective membranes
covering the brain and spinal cord) are stretched during neck flexion, causing pain and muscle spasms.
• Why others are wrong: Bradycardia and hypotension are more indicative of late-stage sepsis or
Cushing’s Triad (late ICP), not specifically the irritation of the meninges themselves.
Hyperglycemia is a general stress response but not a diagnostic sign of meningitis.
QUESTION 3
,Which nursing intervention is the highest priority for a client admitted with an acute stroke?
A. Administer antihypertensives
B. Maintain airway patency
C. Provide passive range of motion
D. Encourage oral fluids
Answer: B. Maintain airway patency
Detailed Rationale:
In any acute emergency, the nurse must follow the ABC (Airway, Breathing, Circulation) priority
framework. A client with a stroke may have a decreased gag reflex, facial drooping, or altered
consciousness, putting them at high risk for airway obstruction or aspiration.
• Why others are wrong: While BP management (Option A) is important, it follows airway.
Options C and D are lower priorities and Option D (fluids) is dangerous until a swallow study
confirms the client is not at risk for aspiration.
QUESTION 4
A client with urolithiasis (kidney stones) is admitted to the medical unit. Which intervention is most
important for the nurse to implement?
A. Restrict calcium intake immediately
B. Strain all urine
C. Restrict all fluids
D. Place client on bed rest
Answer: B. Strain all urine
Detailed Rationale:
The definitive diagnosis of the stone's composition is required to determine the long-term treatment
plan (e.g., calcium oxalate vs. uric acid stones). Straining all urine through a fine mesh allows the nurse
to capture the stone for laboratory analysis.
• Why others are wrong: Fluid restriction (Option C) is contraindicated; these clients need high
intake to help "flush" the stone. Bed rest (Option D) is not required; in fact, walking often helps
the stone move through the ureter.
QUESTION 5
Which clinical manifestation is most suggestive of an acute hypoglycemic episode?
A. Fruity breath odor
B. Diaphoresis and confusion
, C. Kussmaul respirations
D. Dry skin and polyuria
Answer: B. Diaphoresis and confusion
Detailed Rationale:
Hypoglycemia triggers the sympathetic nervous system (fight-or-flight), leading to an "adrenergic"
response characterized by sweating (diaphoresis), tremors, tachycardia, and irritability. Because the
brain relies exclusively on glucose, confusion occurs rapidly.
• Why others are wrong: Options A, C, and D are classic signs of Hyperglycemia or Diabetic
Ketoacidosis (DKA). Fruity breath is caused by ketones, and dry skin indicates dehydration from
polyuria.
QUESTION 6
A client is receiving a high dose of IV furosemide for pulmonary edema. Which electrolyte imbalance
should the nurse monitor for most closely?
A. Hypernatremia
B. Hypercalcemia
C. Hypokalemia
D. Hypomagnesemia
Answer: C. Hypokalemia
Detailed Rationale:
Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in the loop of Henle. This
process also causes a significant loss of potassium in the urine.
• Critical Thinking: Low potassium (Hypokalemia) can lead to life-threatening cardiac
dysrhythmias. While other electrolytes may shift, potassium monitoring is the highest clinical
priority for loop diuretics.
QUESTION 7
The nurse is assessing a client with heart failure. Which sign most clearly indicates the development of
fluid volume overload?
A. Flat neck veins when supine
B. Tachycardia and dry mucous membranes
C. Crackles auscultated in the lung bases
D. Decreased blood pressure
Answer: C. Crackles in lungs
A nurse is assessing a client at risk for neurologic deterioration. Which finding is usually the earliest
indication of increased intracranial pressure (ICP)?
A. Severe headache
B. Change in level of consciousness
C. Projectile vomiting
D. Pupillary dilation
Answer: B. Change in level of consciousness
Detailed Rationale:
The cerebral cortex is highly sensitive to even minute changes in oxygenation and pressure. Therefore, a
subtle change in the level of consciousness (LOC)—such as restlessness, irritability, or slight confusion—
is the earliest and most sensitive indicator of rising ICP.
• Why others are wrong: Option A (Headache) and Option C (Projectile vomiting) are classic signs
but often occur as pressure continues to build. Option D (Pupillary dilation) is a late sign
indicating brainstem compression and potential herniation.
QUESTION 2
A client with suspected meningitis presents with fever and headache. Which assessment finding is most
characteristic of meningeal irritation?
A. Bradycardia
B. Nuchal rigidity
C. Hypotension
D. Hyperglycemia
Answer: B. Nuchal rigidity
Detailed Rationale:
Nuchal rigidity, or neck stiffness, occurs because the inflamed meninges (the protective membranes
covering the brain and spinal cord) are stretched during neck flexion, causing pain and muscle spasms.
• Why others are wrong: Bradycardia and hypotension are more indicative of late-stage sepsis or
Cushing’s Triad (late ICP), not specifically the irritation of the meninges themselves.
Hyperglycemia is a general stress response but not a diagnostic sign of meningitis.
QUESTION 3
,Which nursing intervention is the highest priority for a client admitted with an acute stroke?
A. Administer antihypertensives
B. Maintain airway patency
C. Provide passive range of motion
D. Encourage oral fluids
Answer: B. Maintain airway patency
Detailed Rationale:
In any acute emergency, the nurse must follow the ABC (Airway, Breathing, Circulation) priority
framework. A client with a stroke may have a decreased gag reflex, facial drooping, or altered
consciousness, putting them at high risk for airway obstruction or aspiration.
• Why others are wrong: While BP management (Option A) is important, it follows airway.
Options C and D are lower priorities and Option D (fluids) is dangerous until a swallow study
confirms the client is not at risk for aspiration.
QUESTION 4
A client with urolithiasis (kidney stones) is admitted to the medical unit. Which intervention is most
important for the nurse to implement?
A. Restrict calcium intake immediately
B. Strain all urine
C. Restrict all fluids
D. Place client on bed rest
Answer: B. Strain all urine
Detailed Rationale:
The definitive diagnosis of the stone's composition is required to determine the long-term treatment
plan (e.g., calcium oxalate vs. uric acid stones). Straining all urine through a fine mesh allows the nurse
to capture the stone for laboratory analysis.
• Why others are wrong: Fluid restriction (Option C) is contraindicated; these clients need high
intake to help "flush" the stone. Bed rest (Option D) is not required; in fact, walking often helps
the stone move through the ureter.
QUESTION 5
Which clinical manifestation is most suggestive of an acute hypoglycemic episode?
A. Fruity breath odor
B. Diaphoresis and confusion
, C. Kussmaul respirations
D. Dry skin and polyuria
Answer: B. Diaphoresis and confusion
Detailed Rationale:
Hypoglycemia triggers the sympathetic nervous system (fight-or-flight), leading to an "adrenergic"
response characterized by sweating (diaphoresis), tremors, tachycardia, and irritability. Because the
brain relies exclusively on glucose, confusion occurs rapidly.
• Why others are wrong: Options A, C, and D are classic signs of Hyperglycemia or Diabetic
Ketoacidosis (DKA). Fruity breath is caused by ketones, and dry skin indicates dehydration from
polyuria.
QUESTION 6
A client is receiving a high dose of IV furosemide for pulmonary edema. Which electrolyte imbalance
should the nurse monitor for most closely?
A. Hypernatremia
B. Hypercalcemia
C. Hypokalemia
D. Hypomagnesemia
Answer: C. Hypokalemia
Detailed Rationale:
Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in the loop of Henle. This
process also causes a significant loss of potassium in the urine.
• Critical Thinking: Low potassium (Hypokalemia) can lead to life-threatening cardiac
dysrhythmias. While other electrolytes may shift, potassium monitoring is the highest clinical
priority for loop diuretics.
QUESTION 7
The nurse is assessing a client with heart failure. Which sign most clearly indicates the development of
fluid volume overload?
A. Flat neck veins when supine
B. Tachycardia and dry mucous membranes
C. Crackles auscultated in the lung bases
D. Decreased blood pressure
Answer: C. Crackles in lungs
