FOCUS ON ADULT HEALTH EXAM WITH
CORRECT VERIFIED ANSWERS | ALL BUNDLED
TO BOOST AND EASE YOUR STUDY/ VERIFIED
BY EXPERTS / GUARANTEED PASS
A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension. Which
findings denote adverse effects of the medication? Select all that apply. - ANSWER Tall T waves
Prolonged PR interval
Hyperactive bowel sounds
Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing diuretics can cause
hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves, widened QRS
complexes, prolonged PR intervals, and flat P waves. Other cardiovascular manifestations include an
irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in
hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in hyperkalemia. Constipation,
hyporeflexia, and shallow respirations are signs of hypokalemia.
A nurse is providing dietary instructions to a client with chronic obstructive pulmonary disease (COPD)
who is experiencing a loss of appetite and complains of feeling "too full to eat." What does the nurse
encourage the client to do? Select all that apply. - ANSWER Avoid drinking fluids before and during meals
Select foods that are easy to chew and are not gas forming
Rationale: COPD is a progressive and irreversible condition characterized by diminished inspiratory and
expiratory capacity of the lungs. Instruct the client who complains of feeling too full to eat, to avoid
drinking fluids before and during the meal. Dry foods such as crackers stimulate coughing; foods such as
milk and chocolate may increase the thickness of saliva and secretions. Cheese is constipating and
should also be avoided by the client. The nurse should also teach the client about foods that are easy to
chew and do not encourage the formation of gas; for this reason, broccoli, which is a gas-forming food,
should be avoided.
A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection. Forty-eight hours
after administration, the nurse checks the test site (see image). - ANSWER Positive
,Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis (TB) infection. A reaction
measuring 5 mm or more in diameter is considered positive in a client with HIV infection. A reaction
measuring 10 mm or more in diameter is considered positive in a non-immunosuppressed client. In this
instance, the area of induration measures 9 mm, indicating a positive reaction. A positive reaction does
not mean that active disease is present, but it does indicate exposure to TB or the presence of inactive
(dormant) disease.
A nurse is interpreting a central venous pressure (CVP) reading from a client in whom right ventricular
failure has been diagnosed. From this diagnosis, the nurse would expect that the most likely result is a
pressure of - ANSWER 14 cm H2O
Rationale: CVP measurements are used to monitor blood volume and the adequacy of venous return to
the heart. The CVP measures pressures from the right atrium or central veins. The normal CVP is 7 to 12
cm H2O. An increased CVP reading may indicate right ventricular failure. A low CVP reading may indicate
hypovolemia. A reading of 4 cm H2O is low. Readings of 8 and 11 cm H2O are normal. A reading of 14 cm
H2O is increased.
A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way for
the nurse to assess the surgical site for bleeding? - ANSWER Checking for moisture on the back of the
dressing over the client's neck and shoulders
Rationale: Thyroid surgery may be complicated by hemorrhage, respiratory distress, parathyroid gland
injury (resulting in hypocalcemia and tetany), damage to the laryngeal nerves, and thyroid storm.
Hemorrhage is most likely during the 24 hours after surgery. If the client is bleeding after surgery, gravity
will cause the blood to seep down the sides of the dressing and drain onto the underlying bed linens
even as the top of the dressing remains clean and dry. Asking the client whether the dressing feels wet
and replacing the dry sterile dressing every 2 hours are not the best actions. Replacing the dressing
frequently when it is not warranted could also increase the risk of infection.
A client who sustained a major burn injury is beginning to take an oral diet again. Which between-meal
menu selections meet the client's needs for wound healing and tissue repair? Select all that apply. -
ANSWER Whole-milk shake and granola
Baked potato topped with cheese
Cheese and whole-wheat crackers
Rationale: To facilitate healing and meet continued high metabolic needs, the client with a major burn
should eat a diet high in calories, protein, and carbohydrates. This type of diet also keeps the client in
positive nitrogen balance. Foods such as milkshakes, granola, cheese, and whole-wheat products are
acceptable choices. Though fresh fruits and vegetables and skim milk are high in nutrients, higher-calorie
foods, including versions of dairy products prepared with whole milk, are preferable in this situation.
, A client is found to have hypoparathyroidism. Which nutritional supplement does the nurse, teaching the
client about measures to manage the disorder, tell the client to take on a daily basis? - ANSWER Calcium
carbonate with vitamin D
Rationale: Hypoparathyroidism is an endocrine disorder in which parathyroid function is decreased. The
client with hypoparathyroidism is likely to have low calcium and high phosphate levels and should
consume a diet high in calcium but low in phosphorus. Additionally, the generally used treatment is
calcium supplementation (either as calcium carbonate or calcium citrate) coupled with vitamin D
supplementation. Vitamin C supplementation is not a treatment measure for this disorder. Beta-carotene
is incorrect, because a client with hypoparathyroidism typically has an increased phosphorus level
A nurse participating in a free health screening at the local mall obtains a random blood glucose level of
190 mg/dL (10.6 mmol/L) and a total cholesterol level of 210 mg/dL (5.4 mmol/L) in an otherwise
healthy client. What should the nurse tell the client to do next? - ANSWER Call his health care provider to
have these values rechecked as soon as possible
Rationale: Adult diabetes mellitus may be diagnosed on the basis of symptoms (e.g., polydipsia, polyuria,
polyphagia) or laboratory values. An abnormal glucose tolerance test, a random plasma glucose level
greater than 200 mg/dL (11.1 mmol/L), and a fasting plasma glucose level greater than 140 mg/dL (7.8
mmol/L) on two separate occasions are all diagnostic of diabetes mellitus. The total cholesterol should
be less than 200 mg/dL (5.2 mmol/L). Confirmation of this client's results is needed to ensure
appropriate diagnosis and therapy.
Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides information
to the client about the medication. Which occurrences does the nurse tell the client to report to the
health care provider? Select all that apply. - ANSWER Chest pain
Palpitations
Rapid heart rate
Rationale: The client taking levothyroxine sodium may have manifestations of hypothyroidism if the
dosage is inadequate or may experience manifestations of hyperthyroidism if the dosage is too high.
Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart, which may
result in angina and cardiac dysrhythmias. The client should be instructed to report chest pain,
palpitations, or a rapid heart rate immediately. Lethargy, constipation, and weight gain are symptoms of
hypothyroidism, which should improve with medication therapy (e.g., levothyroxine sodium).
A nurse is developing a plan of care for an older client with diabetic neuropathy of the lower extremities
resulting from type 2 diabetes mellitus. Which problem does the nurse recognize as the highest priority
for this client? - ANSWER Increased risk for injury
Rationale: The client with diabetic neuropathy of the lower extremities has a diminished sensation in the
legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system
CORRECT VERIFIED ANSWERS | ALL BUNDLED
TO BOOST AND EASE YOUR STUDY/ VERIFIED
BY EXPERTS / GUARANTEED PASS
A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension. Which
findings denote adverse effects of the medication? Select all that apply. - ANSWER Tall T waves
Prolonged PR interval
Hyperactive bowel sounds
Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing diuretics can cause
hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves, widened QRS
complexes, prolonged PR intervals, and flat P waves. Other cardiovascular manifestations include an
irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in
hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in hyperkalemia. Constipation,
hyporeflexia, and shallow respirations are signs of hypokalemia.
A nurse is providing dietary instructions to a client with chronic obstructive pulmonary disease (COPD)
who is experiencing a loss of appetite and complains of feeling "too full to eat." What does the nurse
encourage the client to do? Select all that apply. - ANSWER Avoid drinking fluids before and during meals
Select foods that are easy to chew and are not gas forming
Rationale: COPD is a progressive and irreversible condition characterized by diminished inspiratory and
expiratory capacity of the lungs. Instruct the client who complains of feeling too full to eat, to avoid
drinking fluids before and during the meal. Dry foods such as crackers stimulate coughing; foods such as
milk and chocolate may increase the thickness of saliva and secretions. Cheese is constipating and
should also be avoided by the client. The nurse should also teach the client about foods that are easy to
chew and do not encourage the formation of gas; for this reason, broccoli, which is a gas-forming food,
should be avoided.
A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection. Forty-eight hours
after administration, the nurse checks the test site (see image). - ANSWER Positive
,Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis (TB) infection. A reaction
measuring 5 mm or more in diameter is considered positive in a client with HIV infection. A reaction
measuring 10 mm or more in diameter is considered positive in a non-immunosuppressed client. In this
instance, the area of induration measures 9 mm, indicating a positive reaction. A positive reaction does
not mean that active disease is present, but it does indicate exposure to TB or the presence of inactive
(dormant) disease.
A nurse is interpreting a central venous pressure (CVP) reading from a client in whom right ventricular
failure has been diagnosed. From this diagnosis, the nurse would expect that the most likely result is a
pressure of - ANSWER 14 cm H2O
Rationale: CVP measurements are used to monitor blood volume and the adequacy of venous return to
the heart. The CVP measures pressures from the right atrium or central veins. The normal CVP is 7 to 12
cm H2O. An increased CVP reading may indicate right ventricular failure. A low CVP reading may indicate
hypovolemia. A reading of 4 cm H2O is low. Readings of 8 and 11 cm H2O are normal. A reading of 14 cm
H2O is increased.
A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way for
the nurse to assess the surgical site for bleeding? - ANSWER Checking for moisture on the back of the
dressing over the client's neck and shoulders
Rationale: Thyroid surgery may be complicated by hemorrhage, respiratory distress, parathyroid gland
injury (resulting in hypocalcemia and tetany), damage to the laryngeal nerves, and thyroid storm.
Hemorrhage is most likely during the 24 hours after surgery. If the client is bleeding after surgery, gravity
will cause the blood to seep down the sides of the dressing and drain onto the underlying bed linens
even as the top of the dressing remains clean and dry. Asking the client whether the dressing feels wet
and replacing the dry sterile dressing every 2 hours are not the best actions. Replacing the dressing
frequently when it is not warranted could also increase the risk of infection.
A client who sustained a major burn injury is beginning to take an oral diet again. Which between-meal
menu selections meet the client's needs for wound healing and tissue repair? Select all that apply. -
ANSWER Whole-milk shake and granola
Baked potato topped with cheese
Cheese and whole-wheat crackers
Rationale: To facilitate healing and meet continued high metabolic needs, the client with a major burn
should eat a diet high in calories, protein, and carbohydrates. This type of diet also keeps the client in
positive nitrogen balance. Foods such as milkshakes, granola, cheese, and whole-wheat products are
acceptable choices. Though fresh fruits and vegetables and skim milk are high in nutrients, higher-calorie
foods, including versions of dairy products prepared with whole milk, are preferable in this situation.
, A client is found to have hypoparathyroidism. Which nutritional supplement does the nurse, teaching the
client about measures to manage the disorder, tell the client to take on a daily basis? - ANSWER Calcium
carbonate with vitamin D
Rationale: Hypoparathyroidism is an endocrine disorder in which parathyroid function is decreased. The
client with hypoparathyroidism is likely to have low calcium and high phosphate levels and should
consume a diet high in calcium but low in phosphorus. Additionally, the generally used treatment is
calcium supplementation (either as calcium carbonate or calcium citrate) coupled with vitamin D
supplementation. Vitamin C supplementation is not a treatment measure for this disorder. Beta-carotene
is incorrect, because a client with hypoparathyroidism typically has an increased phosphorus level
A nurse participating in a free health screening at the local mall obtains a random blood glucose level of
190 mg/dL (10.6 mmol/L) and a total cholesterol level of 210 mg/dL (5.4 mmol/L) in an otherwise
healthy client. What should the nurse tell the client to do next? - ANSWER Call his health care provider to
have these values rechecked as soon as possible
Rationale: Adult diabetes mellitus may be diagnosed on the basis of symptoms (e.g., polydipsia, polyuria,
polyphagia) or laboratory values. An abnormal glucose tolerance test, a random plasma glucose level
greater than 200 mg/dL (11.1 mmol/L), and a fasting plasma glucose level greater than 140 mg/dL (7.8
mmol/L) on two separate occasions are all diagnostic of diabetes mellitus. The total cholesterol should
be less than 200 mg/dL (5.2 mmol/L). Confirmation of this client's results is needed to ensure
appropriate diagnosis and therapy.
Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides information
to the client about the medication. Which occurrences does the nurse tell the client to report to the
health care provider? Select all that apply. - ANSWER Chest pain
Palpitations
Rapid heart rate
Rationale: The client taking levothyroxine sodium may have manifestations of hypothyroidism if the
dosage is inadequate or may experience manifestations of hyperthyroidism if the dosage is too high.
Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart, which may
result in angina and cardiac dysrhythmias. The client should be instructed to report chest pain,
palpitations, or a rapid heart rate immediately. Lethargy, constipation, and weight gain are symptoms of
hypothyroidism, which should improve with medication therapy (e.g., levothyroxine sodium).
A nurse is developing a plan of care for an older client with diabetic neuropathy of the lower extremities
resulting from type 2 diabetes mellitus. Which problem does the nurse recognize as the highest priority
for this client? - ANSWER Increased risk for injury
Rationale: The client with diabetic neuropathy of the lower extremities has a diminished sensation in the
legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system
