RPN Client Assessment and Planning 5 — Questions and Answers
Question 1: Which finding MOST suggests increased intracranial pressure (ICP) in a client following a head injury?
- Bilateral miosis and diaphoresis
- Widening pulse pressure and bradycardia (Correct answer)
- Hypotension and tachycardia
- Symmetric pupil reaction to light
Correct answer: Widening pulse pressure and bradycardia
Cushing's triad — widening pulse pressure, bradycardia, and irregular respirations — is a late sign of dangerously increased ICP.
Question 2: A client recently diagnosed with heart failure has a new nursing diagnosis of 'Activity intolerance.' Which expected outcome is MOST measurable?
- Client will feel better during activity
- Client will walk 50 feet without dyspnea within 3 days (Correct answer)
- Client will understand the importance of rest
- Client will avoid strenuous exercise
Correct answer: Client will walk 50 feet without dyspnea within 3 days
A measurable outcome includes a specific distance, timeframe, and observable criterion such as absence of dyspnea.
Question 3: Which technique should the RPN use when assessing bowel sounds?
- Percuss before auscultating to stimulate sounds
- Auscultate before palpating to avoid altering bowel activity (Correct answer)
- Palpate deeply first to assess organ position
- Inspect only if the client reports abdominal pain
Correct answer: Auscultate before palpating to avoid altering bowel activity
Auscultation precedes palpation and percussion in abdominal assessment to prevent artificially altering bowel sounds.
Question 4: A client with chronic kidney disease has a potassium level of 6.2 mEq/L. Which assessment finding is MOST concerning?
- Mild muscle weakness in the legs
- Heart rate of 52 bpm with peaked T waves on ECG (Correct answer)
- Slight decrease in urine output
- Client reports mild nausea
Correct answer: Heart rate of 52 bpm with peaked T waves on ECG
Bradycardia with peaked T waves on ECG indicates severe hyperkalemia affecting cardiac conduction, requiring immediate intervention.
Question 5: Which assessment finding is an expected outcome of effective pain management planning for a post-operative client?
- Client is sedated and unresponsive to stimuli
- Client rates pain as 2/10 and participates in deep-breathing exercises (Correct answer)
- Client requests opioid analgesics every 2 hours
- Client avoids all movement to prevent pain
Correct answer: Client rates pain as 2/10 and participates in deep-breathing exercises
Effective pain management results in tolerable pain levels that allow the client to participate in recovery activities such as breathing exercises.
Question 6: When collecting a health history, the RPN uses open-ended questions. Which question is an example of this technique?
- 'Is your pain sharp or dull?'
- 'Do you smoke cigarettes?'
- 'Tell me what brings you to the hospital today.' (Correct answer)
- 'Have you had surgery before?'
Correct answer: 'Tell me what brings you to the hospital today.'
Open-ended questions invite the client to elaborate in their own words, providing richer subjective assessment data.
Question 7: A client on a medical unit has a new onset of confusion and agitation at night but is oriented during the day. The RPN suspects:
- Dementia progression
- Sundowning or delirium (Correct answer)
- Depression with psychotic features
- Medication non-compliance
Correct answer: Sundowning or delirium
Fluctuating confusion that worsens in the evening and at night is characteristic of delirium (sundowning) and requires further assessment and physician notification.
RPN Client Assessment and Planning 5
Which finding MOST suggests increased intracranial pressure (ICP) in a client following a head injury?