Question

A nurse is caring for a client in a clinic.

Answer 1

Correct Answers

Abstain from foods containing dairy if symptoms increase [ indicated ]
Avoid consuming nuts and corn [ indicated ]
Practice stress-reducing activities [ indicated ]
Avoid smoking [ indicated ]
Expect medication to take effect within 3 days [ indicated ]
Avoid eating foods that are cold [ Not indicated ]
Increase intake of caffeinated beverages [ Not indicated ]
Replace water with carbonated beverages [ Not indicated ]

Rationale :

Abstain from foods containing dairy if symptoms increase.

💠 Lactose intolerance is common during active ulcerative colitis, and dairy can worsen diarrhea, bloating, and abdominal pain.

💠 Avoiding dairy during flares helps reduce intestinal irritation and supports symptom control.

💠 Dairy products can increase stool frequency when the inflamed colon cannot tolerate lactose well.

💠 Temporary elimination allows the bowel to rest and heal while inflammation is treated.

💠 Clients may later reintroduce dairy as tolerated when symptoms improve.

Practice stress-reducing activities.

💠 Psychological stress is a well-recognized trigger for ulcerative colitis exacerbations.

💠 Stress increases intestinal motility and can intensify abdominal pain and diarrhea.

💠 Relaxation techniques help stabilize the gut–brain axis, reducing symptom flares.

💠 Stress management supports long-term remission alongside medication therapy.

💠 Activities such as deep breathing or mindfulness improve overall disease control.

Avoid smoking.

💠 Smoking worsens gastrointestinal inflammation and interferes with healing.

💠 Tobacco use increases the risk of complications and medication resistance.

💠 Smoking can reduce the effectiveness of anti-inflammatory therapy like mesalamine.

💠 Avoidance supports mucosal healing and symptom reduction.

💠 Smoking cessation improves overall gastrointestinal health.

Expect medication to take effect within 3 days.

💠 Mesalamine works locally to reduce intestinal inflammation.

💠 Symptom improvement typically begins within a few days of therapy initiation.

💠 Early response indicates appropriate treatment for mild to moderate UC.

💠 Full therapeutic benefit may continue to increase over several weeks.

💠 Reinforcing expectations improves medication adherence.

Avoid consuming nuts and corn.

💠 High-fiber foods can irritate the inflamed intestinal lining during active disease.

💠 Nuts and corn may increase bowel frequency and abdominal discomfort.

💠 These foods are harder to digest when the mucosa is ulcerated.

💠 Limiting them helps reduce mechanical irritation.

💠 A low-residue approach supports symptom control during flares.

Avoid eating foods that are cold.

💠 Food temperature does not affect intestinal inflammation.

💠 There is no evidence linking cold foods to ulcerative colitis flares.

Increase intake of caffeinated beverages.

💠 Caffeine stimulates bowel motility, worsening diarrhea.

💠 It can increase abdominal cramping and urgency.

Replace water with carbonated beverages.

💠 Carbonation increases gas and bloating, aggravating discomfort.

💠 Adequate hydration with water is essential during chronic diarrhea.

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Answer 2

Correct Answers:

Withhold food and oral fluids from the client.

Rationale :

💠 Acute pancreatitis causes intense inflammation of the pancreas, and a paralytic ileus indicates that intestinal peristalsis has stopped, making oral intake unsafe and ineffective.

💠 Keeping the client NPO (nothing by mouth) helps reduce pancreatic stimulation, which decreases further enzyme secretion and limits worsening inflammation.

💠 Oral food or fluids in the presence of ileus can lead to abdominal distention, nausea, vomiting, and aspiration risk due to impaired bowel motility.

💠 Bowel rest allows time for the inflamed pancreas and intestines to recover, which is a core component of acute pancreatitis management.

💠 Nutrition and fluids are instead maintained through IV therapy until bowel sounds return and gastrointestinal function improves.

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Answer 3

Correct Answers:

Reports recurrent nightmares

Rationale :

💠 Posttraumatic stress disorder (PTSD) is characterized by re-experiencing symptoms, and recurrent nightmares are a classic manifestation related to traumatic combat memories.

💠 Nightmares reflect intrusive recollections that occur involuntarily and often disrupt sleep patterns in clients with PTSD.

💠 These dreams are typically vivid, distressing, and repetitive, directly linked to the traumatic event.

💠 Sleep disturbance from nightmares contributes to daytime anxiety, irritability, and hyperarousal.

💠 Recognition of nightmares helps guide interventions focused on trauma-informed care and symptom management.

Exhibits diminished reflexes

💠 Diminished reflexes are associated with neurologic or peripheral nerve disorders, not PTSD.

💠 PTSD primarily affects emotional regulation and cognition, rather than motor reflex pathways.

Requests opportunity to discuss trauma

💠 Clients with PTSD often avoid reminders of the traumatic event rather than voluntarily discussing it.

💠 Avoidance is a core symptom cluster that limits engagement with trauma-related conversations.

Indicates working extra hours

💠 Working extra hours may represent coping or distraction, but it is not a defining clinical feature of PTSD.

💠 This behavior does not directly reflect re-experiencing, avoidance, or hyperarousal symptoms.

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Answer 4

Correct Answers:

Platelet count 98,000/mm3

Rationale :

💠 HELLP syndrome is defined by Hemolysis, Elevated Liver enzymes, and Low Platelet count, making thrombocytopenia a hallmark diagnostic finding.

💠 A platelet count below 100,000/mm³ reflects platelet consumption and destruction caused by widespread endothelial damage and microvascular injury.

💠 Low platelets significantly increase the risk for bleeding, disseminated intravascular coagulation (DIC), and postpartum hemorrhage.

💠 Monitoring platelet trends is critical to assess disease severity and progression.

💠 This finding supports the diagnosis and guides urgent maternal–fetal management decisions, including possible delivery.

Placenta previa

💠 Placenta previa is a placental implantation disorder, not a hematologic or hepatic complication.

💠 HELLP syndrome is related to systemic endothelial dysfunction, not placental location.

BUN 15 mg/dL

💠 A BUN of 15 mg/dL is within the normal reference range.

💠 HELLP syndrome more commonly shows elevated liver enzymes and low platelets, not isolated normal renal markers.

Polyhydramnios

💠 Polyhydramnios involves excess amniotic fluid and is associated with fetal anomalies or diabetes.

💠 HELLP syndrome is characterized by maternal systemic complications, not increased amniotic fluid volume.

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Answer 5

Correct Answers:

"Expect the provider to prescribe intramuscular penicillin to treat your infection."

Rationale :

💠 Intramuscular penicillin G is the first-line treatment for all stages of syphilis, making this statement accurate and essential teaching.

💠 Penicillin effectively eradicates Treponema pallidum, the bacterium responsible for syphilis.

💠 Early treatment prevents disease progression, long-term complications, and transmission to others.

💠 Penicillin therapy is especially critical to prevent neurosyphilis and congenital syphilis.

💠 Reinforcing the expected treatment improves adherence and follow-up compliance.

“You can engage in sexual activity during treatment if you use a condom.”

💠 Clients should avoid all sexual contact until treatment is completed and follow-up testing confirms cure.

💠 Condoms reduce risk but do not fully prevent transmission due to contact with lesions.

“The symptoms of syphilis occur within 24 hours after exposure to an infected partner.”

💠 Syphilis has an incubation period of approximately 3 weeks (range 10–90 days).

💠 Symptoms do not appear immediately after exposure.

“Men who are infected with syphilis typically have greenish-yellow discharge from the penis.”

💠 Greenish-yellow discharge is characteristic of gonorrhea, not syphilis.

💠 Syphilis typically presents with a painless chancre, not purulent discharge.

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Answer 6

Correct Answers:

Hypophonia

Rationale :

💠 Parkinson’s disease commonly affects the motor control of speech muscles, leading to hypophonia, which is an abnormally soft, weak, or monotonous voice.

💠 This occurs due to bradykinesia and rigidity of the laryngeal and respiratory muscles involved in speech production.

💠 Hypophonia often progresses gradually and may be one of the early communication-related manifestations of Parkinson’s disease.

💠 Reduced vocal volume can significantly impair communication and social interaction, affecting quality of life.

💠 Recognizing hypophonia allows timely referral for speech therapy, which can improve vocal strength and clarity.

Diarrhea

💠 Parkinson’s disease more commonly causes constipation due to slowed gastrointestinal motility.

💠 Diarrhea is not a characteristic autonomic manifestation of Parkinson’s disease.

Lordosis

💠 Parkinson’s disease is associated with stooped posture or kyphosis, not exaggerated inward spinal curvature.

💠 Lordosis is unrelated to the neuromuscular rigidity seen in Parkinson’s disease.

Pallor

💠 Pallor is not a defining feature of Parkinson’s disease.

💠 Parkinson’s primarily affects movement, muscle tone, and autonomic function, not skin coloration.

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Answer 7

Correct Answers:

Epicanthal folds

Rationale :

💠 Down syndrome (trisomy 21) is commonly associated with characteristic facial features, including epicanthal folds, which are skin folds covering the inner corners of the eyes.

💠 These folds result from altered craniofacial development and are one of the most recognizable physical findings in infants with Down syndrome.

💠 Epicanthal folds are typically present at birth and persist through infancy and childhood.

💠 Their presence supports early clinical recognition and diagnosis, prompting appropriate genetic confirmation and care planning.

💠 Identifying these features allows nurses to anticipate associated conditions and provide family education and support.

Hypertonia

💠 Infants with Down syndrome characteristically have hypotonia, not increased muscle tone.

💠 Decreased muscle tone contributes to delayed motor development.

Absent red reflex

💠 An absent red reflex suggests congenital cataracts or retinoblastoma, not Down syndrome.

💠 Down syndrome may involve eye findings, but the red reflex is usually present.

Large ears

💠 Down syndrome is associated with small, low-set ears, not large ears.

💠 Ear size and placement are part of the syndrome’s distinct craniofacial pattern.

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Answer 8

Correct Answers:

Nonreactive pupils

Rationale :

💠 Nonreactive pupils are an acute neurologic warning sign indicating possible increased intracranial pressure (ICP), cerebral edema, or brain herniation following a craniotomy.

💠 Changes in pupillary response reflect brainstem compression, making this finding an immediate, life-threatening priority.

💠 Early identification allows for rapid intervention to prevent irreversible neurologic damage or death.

💠 Post-craniotomy clients are at high risk for intracranial bleeding or swelling, especially within the first 24 hours.

💠 Neurologic assessment findings always take priority over expected postoperative changes or stable laboratory values.

Periorbital ecchymosis

💠 Periorbital ecchymosis can occur due to surgical positioning or dependent bruising after cranial surgery.

💠 While it should be monitored, it is not immediately life-threatening.

15 mL of drainage in Hamock

💠 A small amount of drainage is expected postoperatively and does not indicate active hemorrhage.

💠 This finding is within an acceptable range and is not a priority concern.

Hgb 11 g/dL

💠 A hemoglobin level of 11 g/dL is slightly low but acceptable in the postoperative period.

💠 It does not explain acute neurologic compromise.

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Answer 9

Correct Answers:

A mole that is bleeding

Rationale :

💠 Bleeding from a mole is a warning sign of melanoma, indicating possible malignant skin changes and breakdown of normal tissue integrity.

💠 Melanoma lesions often show ulceration or spontaneous bleeding due to rapid, abnormal cell growth.

💠 Bleeding suggests the mole may no longer be confined to superficial skin layers, raising concern for invasive disease.

💠 This finding meets the ABCDE criteria for melanoma under E – Evolution, meaning a change in the lesion’s behavior.

💠 Any bleeding mole requires prompt evaluation and biopsy to rule out skin cancer.

A mole that is symmetrical

💠 Symmetry is characteristic of benign moles, not melanoma.

💠 Melanoma lesions are typically asymmetrical.

A mole with a well-defined border

💠 Smooth, regular borders suggest a noncancerous lesion.

💠 Melanoma usually presents with irregular or poorly defined edges.

A mole that is dark brown

💠 Uniform dark brown color can be normal for benign nevi.

💠 Melanoma more often shows multiple or uneven colors.

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Answer 10

Correct Answers:

BUN 30 mg/dL

Rationale :

💠 Elevated BUN indicates renal impairment, which is a serious complication of preeclampsia due to vasospasm and reduced renal perfusion.

💠 A BUN level of 30 mg/dL is above the normal range and suggests worsening kidney involvement, requiring prompt provider notification.

💠 Renal dysfunction in preeclampsia increases the risk for fluid imbalance, decreased urine output, and progression to severe disease.

💠 Monitoring renal labs is critical because declining kidney function can rapidly compromise maternal and fetal status.

💠 Early reporting supports timely interventions to prevent eclampsia, HELLP syndrome, or acute renal failure.

Platelet count 150,000/mm³

💠 This value is at the lower end of normal and does not indicate thrombocytopenia.

💠 Concerning platelet levels in preeclampsia are below 100,000/mm³.

Hemoglobin 16 g/dL

💠 Mildly elevated hemoglobin may reflect hemoconcentration, which can occur in pregnancy.

💠 This finding alone does not indicate acute deterioration.

Aspartate aminotransferase (AST) 18 units/L

💠 This value is within the normal range.

💠 Liver involvement in preeclampsia is marked by elevated AST/ALT, not normal levels.

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	indicated	Not indicated
Abstain from foods containing dairy if symptoms increase
Avoid consuming nuts and corn
Practice stress-reducing activities
Avoid smoking
Expect medication to take effect within 3 days
Avoid eating foods that are cold
Increase intake of caffeinated beverages
Replace water with carbonated beverages

RN Concept-Based Assessment Level 3 with NGN 2026

No.

1 :
A nurse is caring for a client in a clinic.

Correct Answers

2 :
A nurse is creating a plan of care for an older adult client who has acute pancreatitis and has developed a paralytic ileus. Which of the following interventions should the nurse include in the plan?

3 :
A nurse is assessing a client who has posttraumatic stress disorder following military combat. Which of the following findings should the nurse expect?

4 :
A nurse is reviewing the medical record of a client who has HELLP syndrome. Which of the following findings should the nurse expect?

5 :
A health department nurse is providing teaching to a client who has a new diagnosis of syphilis. Which of the following statements should the nurse make?

6 :
A nurse is assessing a client who has Parkinson's disease. Which of the following findings should the nurse expect?

7 :
A nurse is assessing a 6-month-old infant who has Down syndrome. Which of the following clinical manifestations should the nurse expect?

8 :
A nurse is assessing a client who is 4 hr postoperative following a craniotomy for the treatment of a benign brain tumor. Which of the following findings should the nurse identify as the priority?

9 :
A nurse is performing a skin assessment on a client. Which of the following moles should the nurse report to the provider as possible melanoma?

10 :
A nurse is reviewing the laboratory report of an antepartum client who is at 32 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

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RN Concept-Based Assessment Level 3 with NGN 2026

No.

1 : A nurse is caring for a client in a clinic.

Correct Answers

2 : A nurse is creating a plan of care for an older adult client who has acute pancreatitis and has developed a paralytic ileus. Which of the following interventions should the nurse include in the plan?

3 : A nurse is assessing a client who has posttraumatic stress disorder following military combat. Which of the following findings should the nurse expect?

4 : A nurse is reviewing the medical record of a client who has HELLP syndrome. Which of the following findings should the nurse expect?

5 : A health department nurse is providing teaching to a client who has a new diagnosis of syphilis. Which of the following statements should the nurse make?

6 : A nurse is assessing a client who has Parkinson's disease. Which of the following findings should the nurse expect?

7 : A nurse is assessing a 6-month-old infant who has Down syndrome. Which of the following clinical manifestations should the nurse expect?

8 : A nurse is assessing a client who is 4 hr postoperative following a craniotomy for the treatment of a benign brain tumor. Which of the following findings should the nurse identify as the priority?

9 : A nurse is performing a skin assessment on a client. Which of the following moles should the nurse report to the provider as possible melanoma?

10 : A nurse is reviewing the laboratory report of an antepartum client who is at 32 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

1 :
A nurse is caring for a client in a clinic.

2 :
A nurse is creating a plan of care for an older adult client who has acute pancreatitis and has developed a paralytic ileus. Which of the following interventions should the nurse include in the plan?

3 :
A nurse is assessing a client who has posttraumatic stress disorder following military combat. Which of the following findings should the nurse expect?

4 :
A nurse is reviewing the medical record of a client who has HELLP syndrome. Which of the following findings should the nurse expect?

5 :
A health department nurse is providing teaching to a client who has a new diagnosis of syphilis. Which of the following statements should the nurse make?

6 :
A nurse is assessing a client who has Parkinson's disease. Which of the following findings should the nurse expect?

7 :
A nurse is assessing a 6-month-old infant who has Down syndrome. Which of the following clinical manifestations should the nurse expect?

8 :
A nurse is assessing a client who is 4 hr postoperative following a craniotomy for the treatment of a benign brain tumor. Which of the following findings should the nurse identify as the priority?

9 :
A nurse is performing a skin assessment on a client. Which of the following moles should the nurse report to the provider as possible melanoma?

10 :
A nurse is reviewing the laboratory report of an antepartum client who is at 32 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?