NCLEX-RN
Assessment of a Patient Questions
Extract:
Question 1 of 5
The nurse is monitoring a client who is receiving an oxytocin infusion for the induction of labor. The nurse should suspect water intoxication if which sign or symptom is noted?
Correct Answer: D
Rationale: Oxytocin is a uterine stimulant. During an oxytocin infusion, the woman is monitored closely for signs of water intoxication, including tachycardia, cardiac dysrhythmias, shortness of breath, nausea, and vomiting. The remaining options are not associated with water intoxication.
Question 2 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 3 of 5
The nurse caring for a child diagnosed with rubeola (measles) notes that the primary health care provider has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?
Correct Answer: D
Rationale: In rubeola (measles), Koplik's spots appear approximately 2 days before the appearance of the rash. These are small, blue-white spots with a red base that are found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off. Based on this information, the remaining options are all incorrect.
Question 4 of 5
A child is admitted to the hospital with a suspected diagnosis of von Willebrand's disease. On assessment of the child, which symptom would most likely be noted?
Correct Answer: D
Rationale: The primary clinical manifestations of von Willebrand's disease are bruising and mucous membrane bleeding from the nose, mouth, and gastrointestinal tract. Prolonged bleeding after trauma and surgery, including tooth extraction, may be the first evidence of abnormal hemostasis in those with mild disease. In females, menorrhagia and profuse postpartum bleeding may occur. Bleeding associated with von Willebrand's disease may be severe and lead to anemia and shock, but unlike what is seen in clients with hemophilia, deep bleeding into joints and muscles is rare. Options 1, 2, and 3 are characteristic of those signs found in clients with hemophilia.
Question 5 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.