Question

A nurse cares for a school-aged child diagnosed with acute glomerulonephritis. The child has peripheral edema and urine output of 35 mL/hr. Which diet does the nurse anticipate the provider will prescribe?

Answer 1

Correct Answers:

Low-sodium diet with fluid-restricted

Rationale :

✅Acute glomerulonephritis causes inflammation of the glomeruli, reducing the kidneys' ability to filter sodium and water effectively.

✅Retention of sodium and water leads to peripheral edema, hypertension, and increased circulating fluid volume.

✅ A low-sodium diet helps decrease sodium retention and prevents worsening edema and hypertension.

✅Fluid restriction may also be prescribed when the child has significant edema, hypertension, or decreased urine output.

✅The child's peripheral edema indicates that excess fluid is accumulating in the tissues and requires careful management.

✅The nurse should closely monitor daily weight, intake and output, blood pressure, edema, and urine output to evaluate fluid status.

✅Dietary restrictions are adjusted according to the child's kidney function, laboratory results, urine output, and severity of fluid retention.

❌Regular diet with no additional restrictions.

➡️ A regular unrestricted diet can worsen sodium and water retention in a child with acute glomerulonephritis and edema.

➡️ Sodium restriction is necessary to help control fluid accumulation and hypertension.

❌Low-protein diet with increased potassium intake.

Low-protein diet with increased potassium intake.

➡️ Protein restriction is not routinely necessary unless significant renal impairment or azotemia is present.

➡️ Increasing potassium intake can be dangerous because impaired kidney function may cause potassium retention and hyperkalemia.

❌Low-carbohydrate diet with reduced protein intake.

➡️ Carbohydrate restriction does not address the primary problem of sodium and fluid retention.

➡️Protein restriction may be prescribed only in selected clients with severe renal dysfunction, not routinely for every child with acute glomerulonephritis.

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Answer 2

Correct Answers:

Once my seizures stop, I can stop taking this medication.".

Rationale :

💊 Phenytoin is an anticonvulsant medication used to prevent and control seizures, and it should never be discontinued abruptly.

💊The absence of seizures usually indicates that the medication is effectively controlling the seizure disorder, not that the condition has been cured.

💊 Suddenly stopping phenytoin can cause rebound seizures or status epilepticus, which is a life-threatening emergency.

💊The client should continue taking phenytoin exactly as prescribed even when no seizures occur.

💊 If therapy needs to be discontinued, the healthcare provider will gradually reduce the dosage to minimize the risk of seizure recurrence.

💊The nurse should reinforce the importance of medication adherence and maintaining regular follow-up appointments.

💊 Serum phenytoin levels should be monitored because the medication has a narrow therapeutic range, generally 10 to 20 mcg/mL.

❌“I have scheduled a dental appointment for next week.”

🦷 Scheduling regular dental appointments demonstrates correct understanding because phenytoin can cause gingival hyperplasia.

🦷Clients should practice meticulous oral hygiene, massage the gums, floss regularly, and receive routine dental care.

❌“I will notify my healthcare provider before taking other medications.”

🦷Phenytoin has numerous clinically significant medication interactions because it affects hepatic drug metabolism.

🦷The client should consult the healthcare provider before taking prescription medications, over-the-counter drugs, or herbal supplements.

❌“I will take this medication with meals.”

🦷Taking phenytoin with or after meals can help decrease gastrointestinal irritation.

🦷The client should take the medication consistently at the same time each day and follow the prescribed administration instructions

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Answer 3

Correct Answers:

Intracranial bleeding causing cerebral swelling

Rationale :

🧠 Unequal pupil sizes (anisocoria) following a head injury are a significant neurological finding that can indicate increasing intracranial pressure (ICP).

🧠Intracranial bleeding can cause accumulation of blood within the skull, leading to cerebral edema and increased pressure on brain structures

🧠 As intracranial pressure rises, the expanding brain tissue can compress cranial nerve III (oculomotor nerve), which controls pupil constriction.

🧠Compression of this nerve can cause the pupil on the affected side to become dilated and sluggish or nonreactive to light.

🧠 The nurse should immediately assess the client's level of consciousness, pupil size and reactivity, motor responses, vital signs, and other neurological changes.

🧠A newly developed unequal pupil size after head trauma can indicate neurological deterioration and impending brain herniation.

🧠 This finding requires immediate notification of the healthcare provider and rapid diagnostic evaluation and treatment.

❌ Decreased production of cerebrospinal fluid.

💧 Decreased cerebrospinal fluid production does not typically cause unequal pupils following a head injury.

💧It would not produce the acute cranial nerve compression associated with anisocoria.

❌ Visual impairment affecting ocular alignment.

💧 Visual impairment may affect visual acuity or eye alignment but does not adequately explain newly developed unequal pupils after head trauma.

💧 In this clinical setting, anisocoria should be treated as a potential sign of increased ICP and neurological deterioration.

❌Developmental disorder affecting cognition.

💧 Developmental disorders are chronic conditions and do not suddenly cause unequal pupils following an acute head injury.

💧They are unrelated to the client's new neurological assessment finding.

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Answer 4

Correct Answers:

“I need to catheterize the stoma several times each day."

Rationale :

🫁An ileal conduit is an incontinent urinary diversion in which urine drains continuously from the ureters through a segment of the ileum and exits through an abdominal stoma.

🫁Because urine flows continuously into an external collection pouch, routine catheterization of the stoma is not necessary.

🫁Catheterizing the stoma unnecessarily can cause trauma, bleeding, and introduce microorganisms that increase the risk of infection.

🫁The client should wear a properly fitted urinary pouch system to collect the continuous urine output.

🫁The nurse should teach the client to monitor the stoma, which should normally appear moist and pink to red, and report significant changes in color, size, or appearance.

🫁 The client should also maintain good peristomal skin care because continuous exposure to urine can cause irritation and skin breakdown.

🫁Catheterization is associated with continent urinary diversions, which require intermittent catheterization to empty an internal reservoir.

❌I will measure my stoma regularly and report major changes.”

📌 Monitoring the stoma's size and appearance is an appropriate part of ileal conduit care.

📌The stoma can change size, especially during the early postoperative period, and the pouch opening should fit properly to protect the surrounding skin.

❌ “I will wear a pouch system to collect urine from the stoma.”

📌 An ileal conduit continuously drains urine and requires an external pouching system for collection.

📌The pouch should fit securely around the stoma to prevent leakage and protect the peristomal skin.

❌ “I will clean the skin around the stoma with soap and water.”

📌 Gentle cleansing of the peristomal skin with mild soap and water is generally appropriate, followed by thorough rinsing and drying before applying the pouching system.

📌The client should avoid oily or heavily moisturizing soaps that can interfere with pouch adhesion.

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Answer 5

Correct Answers:

"Have you had a streptococcal infection recently?"

Rationale :

🦠 The client's flank pain, decreased urine output, periorbital edema, hematuria, proteinuria, and urinary casts are characteristic findings of acute glomerulonephritis.

🦠 Acute poststreptococcal glomerulonephritis can develop after an infection caused by certain strains of group A beta-hemolytic Streptococcus.

🦠The condition commonly occurs about 1 to 3 weeks after streptococcal pharyngitis or several weeks after a streptococcal skin infection.

🦠The immune response produces antigen-antibody complexes that become deposited in the glomeruli and trigger inflammation.

🦠Glomerular inflammation decreases the kidneys' filtration ability, resulting in decreased urine output, sodium and water retention, and edema.

🦠Damage to the glomerular filtration membrane allows red blood cells and protein to enter the urine, producing hematuria and proteinuria.

🦠 Asking about a recent streptococcal infection provides important information about the possible cause of the client's renal manifestations and supports the suspected diagnosis.

❌ “Have you had any recent unprotected sexual encounters?”

✅ Unprotected sexual activity increases the risk of sexually transmitted infections, some of which can cause urinary symptoms.

✅ However, STIs do not typically produce the combination of periorbital edema, oliguria, proteinuria, hematuria, and urinary casts seen in acute glomerulonephritis.

❌ “Have you noticed any recent changes in your vision?”

✅ Vision changes may occur with severe hypertension or other neurological and ophthalmic conditions. ✅Although hypertension can develop as a complication of glomerulonephritis, asking about vision changes does not identify the likely underlying cause of the client's renal manifestations.

❌ “Have you experienced any recent gastrointestinal illness?”

✅ Certain gastrointestinal infections can cause kidney complications, such as hemolytic uremic syndrome.

✅ However, the client's findings are most characteristic of acute glomerulonephritis, which commonly occurs following a streptococcal infection.

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Answer 6

Correct Answers:

Obtain the client's vital signs.

Rationale :

👂Obtaining vital signs is a routine, noninvasive task that can be safely delegated to trained unlicensed assistive personnel (UAP).

👂 During the postictal phase, the client may experience confusion, drowsiness, fatigue, and decreased responsiveness, making continued monitoring important.

👂The UAP can measure the client's blood pressure, pulse, respiratory rate, temperature, and oxygen saturation and report abnormal findings to the nurse.

👂The nurse retains responsibility for interpreting these findings and determining whether further interventions are necessary.

👂According to delegation principles, tasks involving routine data collection with predictable outcomes can generally be assigned to UAP.

👂Medication administration, neurological assessment, and clinical evaluation require nursing knowledge and judgment and cannot be delegated to UAP.

👂The nurse should provide clear instructions about which findings require immediate reporting, such as respiratory distress, severe hypotension, or declining oxygen saturation.

❌ Administer a prescribed anticonvulsant medication.

💊 Medication administration requires specialized training, knowledge of medication effects, and evaluation of the client's response.

💊 A UAP cannot administer prescribed anticonvulsants. This responsibility must remain with the licensed nurse.

❌ Document the characteristics of the seizure.

💊 Accurate documentation of seizure characteristics requires nursing assessment and clinical judgment. 💊 The nurse who observed the seizure should document its onset, duration, movements, level of consciousness, and postictal findings.

❌Perform a neurological assessment.

💊 A neurological assessment requires specialized nursing knowledge, interpretation of findings, and clinical judgment.

💊 The nurse must evaluate the client's level of consciousness, pupil responses, motor function, and neurological status after the seizure.

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Answer 7

Correct Matches:

Uric Acid matches with Limit purine-rich foods and alcohol
Calcium Oxalate Stones matches with Limit foods high in oxalates
Cystine Stones matches with Increase fluid intake and alkalinize urine
Struvite Stones matches with Prevent and treat urinary tract infections

Rationale :

Renal Calculi TypeCorrect Dietary Recommendation

Uric Acid Stones

Limit purine-rich foods and alcohol

Calcium Oxalate Stones

Limit foods high in oxalates

Cystine Stones

Increase fluid intake and alkalinize urine

Struvite Stones

Prevent and treat urinary tract infections

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Answer 8

Correct Answers:

A segment of small intestine forms an internal reservoir that stores urine until catheterization.

Rationale :

🫁 An Indiana pouch is a continent urinary diversion that creates an internal reservoir for urine storage.

🫁 The reservoir is constructed from bowel tissue, classically using the right colon and a portion of the terminal ileum, and is connected to the ureters.

🫁 Unlike an ileal conduit, urine does not drain continuously into an external collection pouch.

🫁 The client empties the internal reservoir by inserting a catheter through a small abdominal stoma at scheduled intervals.

🫁 Because the pouch is continent, the client does not need to wear an external urine collection bag.

🫁The nurse should teach the client proper clean intermittent catheterization technique and the importance of emptying the reservoir regularly to prevent overdistention.

🫁Adequate fluid intake and pouch irrigation, when prescribed, help prevent mucus accumulation, urinary infection, and stone formation.

❌ The ureters drain into the intestine and urine exits with bowel movements.

🫁This description is consistent with a ureterosigmoidostomy, in which urine drains into the colon and is eliminated through the rectum.

🫁An Indiana pouch stores urine in an internal continent reservoir.

❌ A segment of large bowel forms a catheterized reservoir with a flank stoma.

🫁 The Indiana pouch does use the right colon to form much of the reservoir and requires intermittent catheterization.

🫁However, the catheterizable stoma is typically located on the abdomen, often near the umbilicus or right lower quadrant, rather than being defined as a flank stoma.

❌ A stoma drains urine continuously into an external collection pouch.

🫁 Continuous urinary drainage into an external pouch describes an ileal conduit, which is an incontinent urinary diversion.

🫁 An Indiana pouch stores urine internally and requires intermittent catheterization for emptying.

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Answer 9

Correct Answers:

Inability to regulate body temperature

Rationale :

✅The hypothalamus is the primary brain structure responsible for regulating body temperature and maintaining homeostasis.

✅Surgery near the hypothalamus can cause tissue injury, edema, or disruption of neural pathways that control thermoregulation.

✅Damage to this area can result in hyperthermia, hypothermia, or fluctuating body temperatures.

✅The nurse should monitor the client's temperature frequently and assess for unexplained changes that could indicate hypothalamic dysfunction.

✅ The hypothalamus also regulates thirst, hunger, sleep-wake cycles, autonomic nervous system activity, and endocrine function through its connection with the pituitary gland.

✅ Therefore, injury near the hypothalamus can cause several serious disturbances in normal physiological regulation.

✅ Early recognition of abnormal temperature regulation allows prompt intervention to prevent complications associated with extreme body temperatures.

❌ Inability to perceive sound.

👂 Sound perception is primarily associated with the temporal lobe and auditory cortex.

👂 Damage near the hypothalamus does not typically cause loss of hearing.

❌ Visual disturbances.

👂 Visual disturbances are more directly associated with damage to the occipital lobe, optic pathways, or visual structures.

👂Although tumors near the hypothalamus can potentially affect nearby optic structures, temperature dysregulation is the complication most directly related to hypothalamic injury.

❌Persistent bradycardia.

👂 Persistent bradycardia can occur with increased intracranial pressure as part of Cushing's response.

👂It is not the most characteristic complication specifically associated with hypothalamic injury

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Answer 10

Correct Answers:

Generalized weakness
Polypharmacy
Previous military experience

Rationale :

Generalized weakness

💪 Generalized weakness increases the risk for falls, which are a leading cause of head injuries in older adults.

💪Age-related loss of muscle mass, reduced balance, and impaired mobility can make it difficult for older adults to recover from a loss of balance.

💪 Weakness can also interfere with the client's ability to use assistive devices safely.

💪Older adults may have slower protective reflexes and be unable to break a fall with their hands.

💪A fall can result in direct trauma to the head and serious intracranial injury. Nurses should assess mobility, gait, muscle strength, and the need for assistive devices.

Polypharmacy

💊Polypharmacy increases the risk for head injuries because older adults taking multiple medications are more likely to experience dizziness, sedation, hypotension, and impaired balance.

💊Medications such as antihypertensives, sedatives, opioids, and psychotropic drugs can increase fall risk. 💊Drug interactions and age-related changes in medication metabolism can further increase adverse effects. 💊Older adults taking anticoagulants or antiplatelet medications are also at increased risk for serious intracranial bleeding following head trauma.

💊 Medication reconciliation and regular medication review are important fall-prevention strategies.

💊The nurse should assess for medications associated with orthostatic hypotension, confusion, or impaired coordination.

💊Reducing unnecessary medications can decrease the risk of falls and subsequent head injuries.

Decreased visual acuity

👁️ Decreased visual acuity increases the risk of falls because older adults may have difficulty recognizing obstacles, stairs, changes in floor surfaces, and environmental hazards.

👁️ Age-related conditions such as cataracts, glaucoma, and macular degeneration can impair vision.

👁️Poor depth perception and reduced peripheral vision further increase the risk of losing balance or tripping. Inadequate lighting can make these visual impairments even more dangerous.

👁️Falls caused by impaired vision can result in serious head trauma.

👁️ Nurses should assess vision and encourage appropriate corrective lenses and regular eye examinations.

❌ Motor vehicle crashes

📌 Motor vehicle crashes can cause head injuries, but they are an external mechanism of injury rather than a common age-related factor that specifically increases an older adult's risk.

📌Falls are the major mechanism of traumatic brain injury among older adults.

❌Chronic hypertension

📌 Chronic hypertension increases the risk of stroke and other cardiovascular complications but is not a primary factor that commonly predisposes older adults to traumatic head injuries.

📌 It does not directly cause falls in the way weakness, medication effects, or impaired vision can.

❌ Previous military experience

📌 Previous military experience alone does not increase an older adult's current risk for head injury.

📌A history of previous traumatic brain injury could be clinically relevant, but military experience itself is not a recognized general risk factor.

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Summer 2026 VNSG 2510 Unit Exam 1

No.

1 : A nurse cares for a school-aged child diagnosed with acute glomerulonephritis. The child has peripheral edema and urine output of 35 mL/hr. Which diet does the nurse anticipate the provider will prescribe?

❌Regular diet with no additional restrictions.

❌Low-protein diet with increased potassium intake.

Low-protein diet with increased potassium intake.

❌Low-carbohydrate diet with reduced protein intake.

➡️ Carbohydrate restriction does not address the primary problem of sodium and fluid retention.

➡️Protein restriction may be prescribed only in selected clients with severe renal dysfunction, not routinely for every child with acute glomerulonephritis.

2 : A nurse reinforces teaching for a client who has a new prescription for phenytoin (Dilantin). Which statement by the client indicates a need for further teaching?

❌“I have scheduled a dental appointment for next week.”

❌“I will notify my healthcare provider before taking other medications.”

❌“I will take this medication with meals.”

3 : A nurse assesses a client following a head injury and notes unequal pupil sizes. Which condition does the nurse suspect?

❌ Decreased production of cerebrospinal fluid.

❌ Visual impairment affecting ocular alignment.

💧 Visual impairment may affect visual acuity or eye alignment but does not adequately explain newly developed unequal pupils after head trauma.

❌Developmental disorder affecting cognition.

4 : . A nurse provides discharge teaching to a client who has an ileal conduit following bladder cancer surgery. Which statement by the client indicates a need for additional teaching?

❌I will measure my stoma regularly and report major changes.”

❌ “I will wear a pouch system to collect urine from the stoma.”

❌ “I will clean the skin around the stoma with soap and water.”

5 : . A 19-year old client reports flank pain, decreased urine output, and periorbital edema. Urinalysis results show white blood cells, red blood cells, protein, and casts. Which question provides the most important information for the nurse to collect?

❌ “Have you had any recent unprotected sexual encounters?”

❌ “Have you noticed any recent changes in your vision?”

❌ “Have you experienced any recent gastrointestinal illness?”

✅ Certain gastrointestinal infections can cause kidney complications, such as hemolytic uremic syndrome.

✅ However, the client's findings are most characteristic of acute glomerulonephritis, which commonly occurs following a streptococcal infection.

6 : A client experiences a seizure and is now in the postictal phase. Which task does the LVN/LPN delegate to the unlicensed assistive personnel (UAP)?

❌ Administer a prescribed anticonvulsant medication.

❌ Document the characteristics of the seizure.

❌Perform a neurological assessment.

Items to Match

Matching Options

8 : An LVN teaches a student nurse about urinary diversions. Which statement by the student demonstrates understanding of an Indiana pouch?

❌ The ureters drain into the intestine and urine exits with bowel movements.

❌ A segment of large bowel forms a catheterized reservoir with a flank stoma.

❌ A stoma drains urine continuously into an external collection pouch.

9 : A nurse collects data on a client following surgery to remove a brain tumor located near the hypothalamus. Which finding does the nurse monitor for as a potential complication?

❌ Inability to perceive sound.

❌ Visual disturbances.

👂Although tumors near the hypothalamus can potentially affect nearby optic structures, temperature dysregulation is the complication most directly related to hypothalamic injury.

10 : A nurse cares for an older adult client who sustained a head injury after a fall. Which factors commonly increase the risk for head injuries in older adults? Select all that apply.

❌ Motor vehicle crashes

1 :
A nurse cares for a school-aged child diagnosed with acute glomerulonephritis. The child has peripheral edema and urine output of 35 mL/hr. Which diet does the nurse anticipate the provider will prescribe?

2 :
A nurse reinforces teaching for a client who has a new prescription for phenytoin (Dilantin). Which statement by the client indicates a need for further teaching?

3 :
A nurse assesses a client following a head injury and notes unequal pupil sizes. Which condition does the nurse suspect?

4 :
. A nurse provides discharge teaching to a client who has an ileal conduit following bladder cancer surgery. Which statement by the client indicates a need for additional teaching?

5 :
. A 19-year old client reports flank pain, decreased urine output, and periorbital edema. Urinalysis results show white blood cells, red blood cells, protein, and casts. Which question provides the most important information for the nurse to collect?

6 :
A client experiences a seizure and is now in the postictal phase. Which task does the LVN/LPN delegate to the unlicensed assistive personnel (UAP)?

8 :
An LVN teaches a student nurse about urinary diversions. Which statement by the student demonstrates understanding of an Indiana pouch?

9 :
A nurse collects data on a client following surgery to remove a brain tumor located near the hypothalamus. Which finding does the nurse monitor for as a potential complication?

10 :
A nurse cares for an older adult client who sustained a head injury after a fall. Which factors commonly increase the risk for head injuries in older adults? Select all that apply.