Free Adult Health Clinical Nurse Specialist MCQ Questions and Answers — Questions and Answers
Question 1: A new patient admitted for a rapid change in the degree of awareness has been evaluated by Carla, the new nurse (ALOC). Additionally, she went over the most recent lab findings, which are as follows: <br>
<br>
Na+ 156 <br>
CL- 100 <br>
K+ 4.0 <br>
HCO 21 <br>
BUN 86 <br>
Bild. Glucose 100 <br>
<br>
Based on the data she has acquired, Nina, the new nurse, is entering a nursing diagnosis on the care plan. Which nursing diagnosis fits the situation best?
- Self-care deficit: feeding
- Fluid volume deficit (Correct answer)
- Trick question! There isn’t enough information provided in the above scenario to determine a nursing diagnosis!
- Alteration in urinary elimination
Correct answer: Fluid volume deficit
The patient's lab results show a sodium level of 156 mEq/L (hypernatremia) and an elevated BUN of 86 mg/dL. These findings, especially in conjunction with an altered level of consciousness, are strong indicators of dehydration or fluid volume deficit. Hypernatremia occurs when there is a relative lack of water compared to sodium, and an elevated BUN often reflects decreased renal perfusion due to insufficient fluid volume.
Question 2: After a complete bowel rest, a client has been prescribed a clear liquid diet. The nurse making the dietary plan for the client keeps in mind that a clear liquid diet consists of the following:
- Coffee
- Milk (Correct answer)
- Gelatin
- Bouillon
Correct answer: Milk
A clear liquid diet is specifically designed to include only liquids that are transparent and leave minimal residue, such as broth, gelatin, and clear juices. Milk, being an opaque liquid with fat and protein content, does not meet the criteria for a clear liquid diet and is instead classified under a full liquid diet. Therefore, among the given options, milk is the item that would typically be *excluded* from a clear liquid diet.
Question 3: A nurse is evaluating a recently admitted client. According to the assessment, the client exhibits muscle stiffness, weakness, and an unstable stride. Which of the following nursing diagnoses is most appropriate in light of the findings?
- Impaired physical mobility (Correct answer)
- Activity intolerance
- Self-care deficit
- Risk for impaired skin integrity
Correct answer: Impaired physical mobility
The assessment findings of muscle stiffness, weakness, and an unstable stride directly indicate a problem with the client's ability to move freely and purposefully. 'Impaired physical mobility' is a nursing diagnosis that accurately reflects these signs and symptoms, focusing on the limitation of independent, purposeful physical movement. This diagnosis guides interventions aimed at improving strength, balance, and range of motion.
Question 4: It is believed that a high-fiber diet lowers the risk of colon cancer because of it:
- Promotes the excretion of bile (Correct answer)
- Absorbs water from the intestinal wall
- It is low in kilocalories
- Stops diarrhea
Correct answer: Promotes the excretion of bile
A high-fiber diet is believed to lower the risk of colon cancer partly because it promotes the excretion of bile acids. Fiber binds to bile acids in the intestine, preventing their reabsorption and increasing their elimination from the body. This reduces the exposure of the colon lining to potentially harmful secondary bile acids, thereby contributing to a lower risk of colon cancer.
Question 5: Which of the diets mentioned above is advised for an AIDS client?
- High-calorie, high carbohydrate
- High-calorie, high fat
- High-calorie, high protein (Correct answer)
- Low-calorie, low protein
Correct answer: High-calorie, high protein
Patients with AIDS often experience significant weight loss, muscle wasting (cachexia), and malabsorption due to the disease and opportunistic infections. A high-calorie, high-protein diet is essential to combat these issues, support immune function, and maintain body mass. Adequate caloric and protein intake helps prevent further wasting, promotes tissue repair, and provides the energy needed for overall well-being and recovery.
Question 6: Nina, the New Nurse, loves her job! She is working on the medical/surgical. Unit, and has received reports on the clients she will care for from the off-going shift. She is prioritizing her first rounds of the day. Which of the following clients should Nina, the New Nurse see first?
- 55-year-old female, right mastectomy two days ago; Jackson-Pratt draining serosanguineous fluid, 23cc for last shift
- 25-year-old male, gunshot wound to left thigh; 2.5cm area of dark drainage observed on dressing
- 58-year-old male, abdominal-perineal resection four days ago; complaining of chills (Correct answer)
- A 30-year-old female, a hysterectomy three days ago; complaining of pain
Correct answer: 58-year-old male, abdominal-perineal resection four days ago; complaining of chills
A patient complaining of chills post-surgery (abdominal-perineal resection four days ago) is a priority concern because chills can be an early indicator of a serious infection, fever, or even sepsis. These conditions can rapidly deteriorate and require immediate assessment and intervention to prevent further complications. The other clients' complaints, while important, do not suggest such an acute and potentially life-threatening situation.
Question 7: Mr. Clive, a 56-year-old patient admitted due to esophageal cancer, is being cared for by a nurse. Six weeks ago, a gastrostomy tube (PEG) was placed. The nurse observes a reddish color and edema near the insertion site while assessing. The nurse's best course of action is to:
- Notify the physician immediately. (Correct answer)
- Clean the insertion site with normal saline solution and cover it with sterile gauze
- Flush the PEG with cold water to soothe the irritated insertion site
- This is expected during the first few weeks after the creation of PEG, and she can continue feeding
Correct answer: Notify the physician immediately.
Redness and edema around a gastrostomy tube insertion site, especially six weeks post-placement, are signs of inflammation or potential infection. This is not an expected finding and indicates a complication that requires immediate medical evaluation. Notifying the physician promptly allows for timely diagnosis and intervention to prevent more serious issues like cellulitis or peritonitis.
