RPN Client Assessment and Planning 5

Question 1

Which finding MOST suggests increased intracranial pressure (ICP) in a client following a head injury?

Accepted Answer

Widening pulse pressure and bradycardia

Answer

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?

Accepted Answer

Client will walk 50 feet without dyspnea within 3 days

Answer

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?

Accepted Answer

Auscultate before palpating to avoid altering bowel activity

Answer

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?

Accepted Answer

Heart rate of 52 bpm with peaked T waves on ECG

Answer

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?

Accepted Answer

Client rates pain as 2/10 and participates in deep-breathing exercises

Answer

Effective pain management results in tolerable pain levels that allow the client to participate in recovery activities such as breathing exercises.

RPN - Registered Practical Nurse Practice Test