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2025 Concept-Based Assessment Test Level 3 Actual
Exams Questions with 100% Correct Verified Answers
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A nurse is counseling a client who has experienced intimate partner violence. Which of the following instructions is the priority for the nurse to include in the teaching? Develop a safety plan. A nurse in a mental health facility is assessing a client who has a hx of alcohol use disorder. The client states their last drink was 24 hr ago. For which of the following manifestation of alcohol withdrawal should the nurse monitor? Tremors A nurse is teaching a client who has epilepsy and a prescription for valproic acid. The nurse should instruction the client to report which of the following as an adverse effect of the medication? Yellow sclera a nurse is obtaining a history for a client who has major depressive disorder. Which of the following findings should the nurse identify
- Family history of obsessive compulsive disorder
- Attends weekly religious services
- Schedules monthly appointments with a health care provider
- Recent move across the country to look for work Recent move across the country to look for work rationale: loss of employment and isolation
A nurse is assessing a 2 YO toddler at a well-child visit. For which if the following findings should the nurse refer the toddler for an eval for ASD?
- Reluctance to make eye contact
- Plays alongside but not with other children
- Speaks using only two- to three-word phrases
- Displays temper tantrums Reluctance to make eye contact A nurse is caring for a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse plan to administer?
- Methylergonovine
- Magnesium sulfate
- Terbutaline
- Betamethasone Methylergonovine rationale: causes contraction of the uterine muscle, which decreases bleeding A nurse at a crisis center is meeting with a client who reports that his adolescent daughter has been increasingly defiant since the divorce 2 years ago. the client states, "i'm so stressed that i can't take this anymore" Which of the following actions should the nurse take first?
- Refer the client and his daughter for family therapy.
- Recommend that the client attend a support group for guardians of adolescents.
- Identify the client's current coping strategies.
- Teach the client stress-reduction techniques.
- Offer the infant small, frequent feedings.
- Position the infant supine or side-lying.
- Assess the infant's radial pulse every 2 hr. Offer the infant small, frequent feedings. rationale: decreased cardiac output lowers tolerance to activity. small, frequent feedings can enable overall increased caloric intake A nurse is planning care for a newborn who was born at 33 wks gestation and 2 day old. which of the following interventions should the nurse include? position the newborn side-lying or prone while in the nursery 1 week ago, 1000:Client reports unexplained weight loss of about 4.53 kg (10 lb) over the last 2 months and heat intolerance. Client also states difficulty sleeping and increased anxiety. Client is pacing the room. Actions to Take:
- Prepare to administer propranolol.
- Prepare the client for a parathyroid scan. Potential Condition:
- Hyperthyroidism Parameters to monitor:
- serum calcium
- edema of the glottis Nurses' Notes1 month ago: 40-year-old client in office for an annual physical. Client has been concerned about their weight and feeling tired. Return in 1 month for follow-up after visiting with nutritionist. Will continue to monitor weight and blood pressure. Client education
regarding new prescription for lisinopril completed. Discussed dietary modifications for weight reduction.
- advise the client that fasting is not necessary prior to their hemo A1C lab work
- take the glyburide if the bg is above 200
- monitor BP
- keep daily food dairy
- obtain colonoscopy this year A nurse is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication to an oral contraceptive? Migraine the aura Nurses' NotesYesterday, 1000:Client who has a history of hypertension is admitted for disorganized thinking, paranoia, and hallucinations. Client is unable to stay seated during examination. They repeat questions when asked and continue to look around and gesture during assessment. Client is unkempt and malodorous. The nurse should monitor for airway patency due to the possible development of an acute dystonic reaction Nurses' Notes1525:Client was admitted to the ED following itching and difficulty swallowing and breathing. Client states a coworker sprayed an aerosol product into the air. Sclera are red with periorbital swelling, tearing is noted, and pupils are equal, round, and reactive to light and accommodation. Skin is warm and dry, pruritus noted. Breath sounds are noted with inspiratory and expiratory wheezing throughout. The client is at risk of developing anaphylactic shock as evidenced by the clients BP A nurse is teaching a client who is at 22 wk of gestation and has gestational HTN. which of the following information should the nurse include in the teaching? Gestational HTN usually resolves during the first postpartum wk.
A nurse is caring for a newborn who has hyperbilirubinemia. The newborn is prescribed phototherapy to treat this newborn complication. C a nurse is reviewing the medication record of a client who was recently dx with Alzheimer disease and has a new prescription for memantine. The nurse should instruct the client which of the following medications can interact adversely with memantine? Sodium bicarb a nurse is assessing a client who has schizophrenia. which of the following manifestations should the nurse identify as positive symptoms.
- magical thinking
- clang association
- auditory hallucinations A hospice nurse is caring for a client who has end-stage cancer. The client's partner asked about ways to help reduce the client's pain. Which of the following palliative actions should the nurse recomment for the tactile distraction applying warm compresses A nurse is caring for a client who is at 33 wk of gestation and has a new diagnosis of preeclampsia. Which of the following medications should the nurse expect the provider to prescribe? Nifedipine A nurse is planning care for a client who has a gambling disorder. Which of the following interventions should the nurse include in the plan? recommend joining a self-help group A nurse is caring for a client who has moderate dementia and is experiencing frequent episodes of confusion. Which of the following actions should the nurse take?
use a large calendars that are easy for the client to read A nurse is assessing a client who has amyotrophic lateral sclerosis ALS which of the following findings should the nurse identify as an early manifestation of this illness? fasciculations of the face a nurse is providing teaching to a client who has preeclampsia without severe features. Which of the following instructions should the nurse include? use a side-lying position when resting in bed or on the couch a nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take? give the client short, firm directions when communicating A nurse is teaching about self-management of STIs with a client who has genital herpes. Which of the following instructions should the nurse include in the teaching?
- "Begin topical antiviral medication during an outbreak."
- "Wear gloves when applying anesthetic ointments."
- "Use natural membrane condoms during sexual activity."
- "Take a sitz bath once daily." "Wear gloves when applying anesthetic ointments." A nurse is preparing dc instructions for a client who experienced an anaphylactic reaction to seafood. which of the following instructions should the nurse plan to include regarding the clients new prescription for epi? Use the injector pen regardless of severity of manifestations. a nurse is updating the meal plan for a client who has resolving diverticulitis and is being advanced to a high-fiber diet. The nurse should recognize that which of the following foods is best source of fiber?
Position the client's head in a midline position. rationale: increases cerebral perfusion A nurse is preparing to administer phenytoin via intermittent IV bolus to a client who is having a tonic-clonic seizure caused by epilepsy. Which of the following factors should the nurse consider when administering IV phenytoin? Administer phenytoin at a rate no greater than 50 mg/min. rationale: to prevent from developing hypotension and bradycardia History and Physical The client admitted with a diagnosis of chronic pancreatitis Reports increased abdominal pain Reports dark urine... A nurse is performing an admission assessment on a client. Which of the following findings should the nurse expect? foul-smelling bulky stool A nurse assessing an adolescent client who has Ewing sarcoma. Which of the following manifestations should the nurse expect? Client reports pain in the upper thigh A nurse is admitting a toddler who has Wilms' tumor. Which of the following actions is the nurse's priority? Avoid palpation of the abdomen. rationale: risk of rupture which would spread cancer cells
A nurse is assessing a newly admitted client following a stroke. Which of the following findings should indicate to the nurse the client has experienced a left hemispheric stroke? Difficulty reading rationale: deficits to right visual field, inability to discriminate letters and words, aphasia, memory deficits History and Physical1500:Client reports to ED and states, "My stomach is hurting."The client states abdominal pain has been worsening for 2 days. They report constipation and nausea for 2 to 3 days and fever since this morning. The client states, "I knew when the fever started, I needed to come get checked out."Client reports pain as an 8 on a scale of 0 to 10. Client has past medical history of hypertension. Immediate intervention?
- temperature
- HR
- pain level
- hemoglobin & Stool results History and Physical1500:Client reports to ED and states, "My stomach is hurting."The client states abdominal pain has been worsening for 2 days. They report constipation and nausea for 2 to 3 days and fever since this morning. The client states, "I knew when the fever started, I needed to come get checked out."Client reports pain as an 8 on a scale of 0 to 10. Client has past medical history of hypertension. Appendicitis Diverticulitis Acute Pancreatitis Appendicitis
- pain scale
Pain level
- decrease BP
- decrease Nausea
- decrease Temp
- decrease WBC
- no change expected History and Physical1500:Client reports to ED and states, "My stomach is hurting."The client states abdominal pain has been worsening for 2 days. They report constipation and nausea for 2 to 3 days and fever since this morning. The client states, "I knew when the fever started, I needed to come get checked out."Client reports pain as an 8 on a scale of 0 to 10. Client has past medical history of hypertension. "You can get your next dose of morphine at 2015." "If you are discharged home on these oral antibiotics, you must avoid alcohol." "Loose or foul-smelling stools can indicate a secondary infection caused by your antibiotics." "I will monitor for the development of a rash as this can be a serious side effect of your prescriptions." History and Physical1500:Client reports to ED and states, "My stomach is hurting."The client states abdominal pain has been worsening for 2 days. They report constipation and nausea for 2 to 3 days and fever since this morning. The client states, "I knew when the fever started, I needed to come get checked out."Client reports pain as an 8 on a scale of 0 to 10. Client has past medical history of hypertension.
Drag one condition and one client finding to fill in each black in the folloiwng sentence. The nurse suspects that the client has developed ________ as evidenced by the client’s_________ The nurse suspects that the client has developed peritonitis as evidenced by the client’s abdominal exam A nurse is counseling a client who has been undergoing treatment for OCD. Which of the following statements should the nurse identify as an indication that the client's therapy has been effective? "I say 'stop' out loud whenever I have a compulsion to wash my hands." A nurse is teaching about approaches to care with the family of a client who has a diagnosis of dementia with confusion. Which of the following information should the nurse include in the teaching? Use pictures and gestures when giving instructions. A nurse is evaluating the plan of care for an adolescent who has ADHD. Which of the following statements made by the adolescent should indicate to the nurse an improvement in the adolescent's social interaction? "I work well in groups of two or three people." A nurse is providing discharge teaching for the guardian of a newborn who was recently circumcised. Which of the following statements should the nurse make? "Clean the penis with warm water until it is healed." A nurse is teaching a client who is preop for an abdominal hysterectomy with a bilateral salpingo-oophorectomy. Which of the following statements should the nurse make? "You might develop menopausal symptoms after this procedure." A nurse is providing dietary management to a client who is at 10 wks of gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make?
A nurse is reviewing the recent lab reports for a client who has anorexia nervosa with recurrent purging behavior. Which of the following lab values indicates a therapeutic response to the treatment plan? BUN 18 mg/dL A nurse is providing teaching to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse make? "You should be refitted for a new diaphragm if your weight changes by 20 percent or more." A nurse is assessing a client who has a BPD. Which of the following characteristics should the nurse expect? Impulsiveness A nurse in a providers office is reviewing the lab report of a client who takes lithium for Bipolar disorder. Which of the following lab results should the nurse report to the provider? Sodium 128 mEq/L A nurse is reviewing the medication hx of a client. The nurse should identify that which of the following findings indicates the client is at risk for a stroke? Takes a combination oral contraceptive A nurse is reviewing the lab report of a school-age child who has acute post-streptococcal glomerulonephritis. Which of the following lab values should the nurse expect? Increased specific gravity A nurse is assessing a client who has end-stage COPD. Which of the following images should the nurse identify as a late manifestation of this terminal illness? Clubbing A nurse is reviewing the lab findings of a client who has acute pancreatitis. which of the following findings should the nurse expect?
Amylase 300 units/L A nurse is assessing a client who is at 35 wk gestation and is experiencing a placental abruption. Which of the following findings should the nurse expect? Uterine hypertonicity A nurse is teaching a family member of a client who has Alzheimer's disease about minimizing a behavioral problem at home. Which of the following information should the nurse include in the teaching? Briefly leave the room when the client becomes agitated. A nurse is teaching a client who is scheduled for the placement of a pen ile implant for the treatment of ED. which of the following statements by the client indicates an understanding of the teaching? "This implant can be deflated by pushing a button in my scrotum." A nurse is teaching the guardian of a child who has juvenile idiopathic arthritis about joint pain management. Which of the following statements should the nurse make? Discourage your child from taking naps during the daytime." A nurse is teaching a client who has chronic pain about biofeedback. Which of the following information should the nurse include about this complementary therapy? Biofeedback provides audio and visual signals to induce a physiological change. A nurse is educating a group of staff nurses about the difference between non-hodgkins lymphoma NHL and Hodgkins lymphoma HL. The nurse should include which of the following statements in the teaching? "Non-Hodgkin's lymphoma progresses erratically through the lymphatic system." A nurse is teaching a client who has sickle cell anemia about preventing sick cell crisis. Which of the following information should the nurse include?
A nurse is assessing a client who has PTSD after a workplace explosion 3 months ago. Which of the following findings should the nurse expect? Hypervigilance A nurse is teaching about disease management with a client who has Parkinson's disease. Which of the following statements should the nurse include in the teaching? "Take medications at the same time each day." Graphic Record Temperature 37.5° C (99.5° F) rectallyHeart rate 110/min Respiratory rate 28/min A nurse is reviewing the MR of a 9-month-old infant. Which of the following findings should the nurse report to the provider? Gross motor skills A nurse is caring for a client who is at 13 wk of gestation and has a positive gonorrhea culture. Which of the following medications should the nurse plan to administer? Ceftriaxone A nurse is teaching about adalimumab with a client who has RA. Which of the following information should the nurse include in the teaching? Have a tuberculin skin test prior to administration of adalimumab. A nurse is assessing a client who has depression. Which of the following manifestations should indicate to the nurse that the client is experiencing low self-esteem? Hypersensitivity to criticism A nurse is assessing a client who has MS. Which of the following manifestations should the nurse expect? Decreased visual acuity
A hospice nurse is providing palliative care for a client who is near death and not responding to verbal stimuli. Which of the following actions should the nurse take? Apply a scopolamine transdermal patch for increased oral or respiratory secretions. A nurse is reviewing the MR for a client who is in active labor. Which of the following findings should the nurse identify as a risk factor for postpartum hemorrhage? Labor induced with oxytocin A nurse is caring for a client who is experiencing infertility. Which of the following medications should the nurse expect the provider to prescribe? Clomiphene A nurse is assessing a client who has a benign tumor resulting from a fibrocystic breast condition. Which of the following findings should the nurse expect? Breast pain A nurse in an ED is counseling a client who experienced sexual violence. After addressing the client's physical needs, which of the following statements is the priority for the nurse to make? "You are safe here." A nurse is assessing a newly admitted a newly admitted client who has a major depressive disorder. Which of the following manifestations should the nurse expect in this client? Experiences delusions of persecution A nurse is assessing a client following a stroke. The nurse should identify what which of the following findings is a manifestation of increased intracranial pressure? Vomiting A nurse is assessing a client who is a survivor of intimate partner violence. Which of the following findings indicates that the client is in the tension- building phase of battering?
