NCLEX-RN
Assessment of a Patient Questions
Extract:
Question 1 of 5
A pregnant client diagnosed with diabetes mellitus arrives at the primary health care clinic for a follow-up visit. What best assessment should the nurse perform to assess insulin function?
Correct Answer: C
Rationale: In a pregnant client with diabetes mellitus, assessing insulin function is critical to ensure glycemic control and prevent complications. Testing urine for glucose and ketones is the best assessment, as it directly indicates whether insulin is effectively managing blood glucose levels (glucose in urine suggests hyperglycemia) and whether the client is at risk for ketoacidosis (ketones indicate fat metabolism due to insufficient insulin). Urine specific gravity reflects hydration status, not insulin function. Edema assessment is relevant for preeclampsia or fluid overload, not insulin function. Vital signs like blood pressure, pulse, and respirations provide general health information but are not specific to insulin function.
Question 2 of 5
On assessment of the client diagnosed with stage III Lyme disease, which clinical manifestation should the nurse expect to note?
Correct Answer: D
Rationale: Stage III Lyme disease develops within a month to several months after initial infection. It is characterized by arthritic symptoms such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. A rash occurs during stage I, and cardiac and neurological dysfunction occur during stage II.
Question 3 of 5
A client who has been receiving long-term diuretic therapy is admitted to the hospital with a diagnosis of dehydration. The nurse should assess for which sign that correlates with this fluid imbalance?
Correct Answer: D
Rationale: Assessment findings with fluid volume deficit are increased pulse and respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine output, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The assessment findings in the remaining options are not associated with dehydration.
Question 4 of 5
The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. Which sign/symptom should the nurse observe with this electrolyte imbalance?
Correct Answer: B
Rationale: The inadequate production of aldosterone in clients with Addison's disease causes the inadequate excretion of potassium and results in hyperkalemia. The clinical manifestations of hyperkalemia are the result of altered nerve transmission. The most harmful consequence of hyperkalemia is its effect on cardiac function. Based on this information, none of the remaining options are manifestations that are associated with Addison's disease or hyperkalemia.
Question 5 of 5
The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which sign/symptom indicates the presence of an opportunistic respiratory infection?
Correct Answer: B
Rationale: Fever and exertional dyspnea are signs of Pneumocystis jiroveci pneumonia, which is a common, life-threatening opportunistic infection that afflicts those with AIDS. Option 1 is not associated with respiratory infection. Options 3 and 4 are normal findings.