CORRECT ANSWERS GRADED A+
FOR 2026 ASSURED EXCEL!!
Which assessment is most important for the nurse to perform on a client who is hospitalized for
Guillain-Barre syndrome that is rapidly progressing?
Respiratory effort.
Unsteady gait.
Intensity of pain.
Ability to eat. - CORRECT ANSWERS-Respiratory effort.
Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and
progresses upwards. As the condition progresses, the nurse must ensure that the client is able
to breathe effectively.
A male client comes into the clinic with a history of penile discharge with painful, burning
urination. Which action should the nurse implement?
Collect a culture of the penile discharge.
Palpate the inguinal lymph nodes gently.
Observe for scrotal swelling and redness.
Express the discharge to determine color. - CORRECT ANSWERS-Collect a culture of the penile
discharge.
,Penile discharge with painful urination is commonly associated with gonorrhea. The nurse
should collect a culture of the penile discharge to determine the cause of these symptoms. The
cause must be determined or confirmed through culture to identify the organism and ensure
effective treatment.
A client with history of atrial fibrillation is admitted to the telemetry unit with sudden onset of
shortness of breath. The nurse observes a new irregular heart rhythm and should perform
which assessment at this time?
Check for a pulse deficit.
Palpate the apical impulse.
Inspect jugular vein pulse.
Examine for a carotid bruit. - CORRECT ANSWERS-Check for a pulse deficit.
A client with a past history of atrial fibrillation may return to that rhythm. Any signs of atrial
fibrillation, such as sudden onset shortness of breath, requires further investigation. The nurse
should assess this client for a pulse deficit because this condition occurs with atrial fibrillation.
Which client should be further assessed for an ectopic pregnancy?
A 24-year-old with shoulder and lower abdominal quadrant pain.
A 33-year-old with intermittent lower abdominal cramping.
A 20-year-old with fever and right lower abdominal colic.
A 40-year-old with jaundice and right lower abdominal pain. - CORRECT ANSWERS-A 24-year-
old with shoulder and lower abdominal quadrant pain.
A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for an
ectopic pregnancy. The pain can also be referred to the shoulder and may be associated with
vaginal bleeding.
,Which dietary assessment finding is most important for the nurse to address when caring for a
client with diabetic nephropathy?
Drinks a six pack of beer every day.
Enjoys a hamburger once a month.
Eats fortified breakfast cereal daily.
Consumesfbeansfandfricefeveryfday.f-ffCORRECTfANSWERS-Drinksfafsixfpackfoffbeerfeveryfday.
Drinkingfsixfbeersfeveryfdayfisfthefdietaryfassessmentffindingfmostfimportantfforfthefnurseftofaddre
ssfwhenfcaringfforfafclientfwithfdiabeticfnephropathy.fThefusualfcanfoffbeerfisf12founcesf(355fmL).fCl
ientsfwithfdiabetesfarefrecommendedftofdrinkfnofmorefthanf12founcesfoffbeerfperfdayfbecausefbee
rfcontainsfcarbohydratesfthatfcanfcreatefunhealthyffluctuationsfinfbloodfglucosefandfpromotefpoorf
glucosefcontrol.fNephropathyfisfexacerbatedfbyfpoorfbloodfglucosefcontrol.
Whichfassessmentffindingfisfoffgreatestfconcernftofthefnursefwhofisfcaringfforfafclientfwithfstomatiti
s?
Coughfbroughtfonfbyfswallowing.
Sorefthroatfcausedfbyfspeaking.
Painfulfandfdryforalfcavity.
Unintendedfweightfloss.f-ffCORRECTfANSWERS-Coughfbroughtfonfbyfswallowing.
Afcoughfbroughtfonfbyfswallowingfisfafsignfoffdysphagia,fwhichfisfaffindingfoffparticularfconcernfinfaf
clientfwithfstomatitis.fDysphagiafcanfcausefnumerousfproblems,fincludingfairwayfobstruction,fandf
shouldfbefreportedftofthefhealthcarefproviderfimmediately.
Thefnursefisfteachingfafclientfdiagnosedfwithfperipheralfarterialfdisease.fWhichfgenitourinaryfsyste
mfcomplicationfshouldfthefnursefincludefinfthefteaching?
, Alteredfsexualfresponse.
Sterility.
Urinaryfincontinence.
Decreasedfpelvicfmuscleftone.f-ffCORRECTfANSWERS-Alteredfsexualfresponse.f
Peripheralfarterialfdiseasef(PAD)fisfafcardiovascularfconditionfcharacterizedfbyfnarrowingfoffthefart
eriesfandfreducedfbloodfflowftofthefextremities.fPADfisfknownftofalterfthefbloodfflowftofthefmale'sfp
enisfandfisfassociatedfwithferectilefdysfunctionfinfmen.
Af40-year-
oldffemalefclientfhasfafhistoryfoffsmoking.fWhichffindingfshouldfthefnursefidentifyfasfafriskffactorffor
fmyocardialfinfarction?
Oralfcontraceptives.
Senilefosteopenia.
Levothyroxineftherapy.
Perniciousfanemia.f-ffCORRECTfANSWERS-Oralfcontraceptives.
Womenfolderfthanf35fyearsfoldfwhofsmokefandftakeforalfcontraceptivesfhavefanfincreasedfriskfoffm
yocardialfinfarctionforfstroke.
Afclientfhasfbeenftoldfthatftherefisfcataractfformationfoverfbothfeyes.fWhichffindingfshouldfthefnurs
efexpectfwhenfassessingfthefclient?
Decreasedfcolorfperception.
Presencefofffloaters.
Lossfoffcentralfvision.