NCLEX-RN
Assessment of a Patient Questions
Extract:
Question 1 of 5
A client diagnosed with cirrhosis of the liver is receiving oral triamterene daily. Which sign/symptom would indicate to the nurse that the client is experiencing an adverse effect of the medication?
Correct Answer: D
Rationale: Triamterene is a potassium-retaining diuretic. Adverse effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this is a potassium-retaining medication, which means that the concern with the administration of this medication is hyperkalemia. Other effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever.
Question 2 of 5
The nurse is performing an assessment on a pregnant client with a history of cardiac disease. Which body area will venous congestion most commonly be noted in?
Correct Answer: A
Rationale: Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, the vulva, or the rectum. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion. It would be difficult to assess for edema in the abdominal area of a client who is pregnant.
Question 3 of 5
A client prescribed dextroamphetamine reports to the nurse difficulty falling asleep at night. The nurse instructs the client on how to minimize sleep disorders. Which statement by the client indicates that teaching has been effective?
Correct Answer: D
Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from the nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep.
Therefore, the remaining options are incorrect.
Question 4 of 5
A client at 35 weeks of gestation reports a sudden discharge of fluid from the vagina. Based on the data provided, which condition should the nurse suspect?
Correct Answer: D
Rationale: Premature rupture of the membranes is usually manifested by a sudden discharge of fluid from the vagina before 37 weeks of gestation. Miscarriage is typically manifested by vaginal bleeding and abdominal pain. Preterm labor is typically manifested by uterine contractions, cramping, and pressure before 37 weeks of gestation. Intrauterine fetal demise is usually manifested by an absence of fetal movements and heartbeat.
Question 5 of 5
Which data should the nurse expect to obtain during the admission assessment of a child to support the diagnosis of irritable bowel syndrome?
Correct Answer: D
Rationale: Irritable bowel syndrome causes diffuse abdominal pain unrelated to meals or activity. Alternating constipation and diarrhea with the presence of undigested food and mucus in the stools may also be noted. Option 1 is a clinical manifestation of lactose intolerance. Option 2 is a clinical manifestation of Hirschsprung's disease. Option 3 is a clinical manifestation of celiac disease.