Focus on Adult Health Exam questions & 100%
Correct Answers.
Terms in this set (100)
A nurse is monitoring a client Tall T waves
who is taking spironolactone Prolonged PR interval
for the treatment of
Hyperactive bowel sounds
hypertension. Which findings
denote adverse effects of the Rationale: Spironolactone is a potassium-sparing diuretic.
medication? Select all that Potassium-sparing diuretics can cause hyperkalemia.
apply. 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 Avoid drinking fluids before and during meals Select
instructions to a client with foods that are easy to chew and are not gas forming
chronic obstructive
Rationale: COPD is a progressive and irreversible condition
pulmonary disease (COPD)
characterized by diminished inspiratory and expiratory
who is experiencing a loss of
capacity of the lungs. Instruct the client who complains of
appetite and complains of
feeling too full to eat, to avoid drinking fluids before and
feeling "too full to eat." What
during the meal. Dry foods such as crackers stimulate
does the nurse encourage the
coughing; foods such as milk and chocolate may increase
client to do? Select all that
the thickness of saliva and secretions. Cheese is constipating
apply.
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.
Positive
Rationale: The tuberculin, or TST, test is a reliable determinant
A tuberculin skin test (TST) is
of tuberculosis (TB) infection. A reaction measuring 5 mm or
administered to a client with
more in diameter is considered positive in a client with HIV
a diagnosis of HIV infection.
infection. A reaction measuring 10 mm or more in diameter is
Forty-eight hours after
considered positive in a non-immunosuppressed client. In this
administration, the nurse
instance, the area of induration measures 9 mm, indicating a
checks the test site (see
positive reaction. A positive reaction does not mean that active
image).
disease is present, but it does indicate exposure to TB or the
presence of inactive (dormant) disease.
,A nurse is interpreting a 14 cm H2O
central venous pressure Rationale: CVP measurements are used to monitor blood
(CVP) reading from a client in
volume and the adequacy of venous return to the heart. The
whom right ventricular
failure has been diagnosed. CVP measures pressures from the right atrium or central
From this diagnosis, the veins. The normal CVP is 7 to 12 cm H2O. An increased CVP
nurse would expect that the reading may indicate right ventricular failure. A low CVP
most likely result is a
reading may indicate hypovolemia. A reading of 4 cm H2O is
pressure of
low. Readings of 8 and 11 cm H2O are normal. A reading of 14
cm
H2O is increased.
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
A nurse is caring for a client (resulting in hypocalcemia and tetany), damage to the
who has just undergone laryngeal nerves, and thyroid storm.
thyroidectomy. Which Hemorrhage is most likely during the 24 hours after surgery.
technique is the best way for If the client is bleeding after surgery, gravity will cause the
the nurse to assess the blood to seep down the sides of the dressing and drain onto
surgical site for bleeding? 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 Whole-milk shake and granola
major burn injury is Baked potato topped with cheese
beginning to take an oral diet Cheese and whole-wheat crackers
again. Which between-meal Rationale: To facilitate healing and meet continued high
menu selections meet the metabolic needs, the client with a major burn should eat a
diet high in calories, protein, and carbohydrates. This type
client's needs for wound
of diet also keeps the client in positive nitrogen balance.
healing and tissue repair? Foods such as milkshakes, granola, cheese, and whole-
Select all that apply. 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.
Calcium carbonate with vitamin D
Rationale: Hypoparathyroidism is an endocrine disorder in
which parathyroid function is decreased. The client with
A client is found to have
hypoparathyroidism is likely to have low calcium and high
hypoparathyroidism. Which
phosphate levels and should consume a diet high in calcium
nutritional supplement does
but low in phosphorus. Additionally, the generally used
the nurse, teaching the client
treatment is calcium supplementation (either as calcium
about measures to manage
carbonate or calcium citrate) coupled with vitamin D
the disorder, tell the client to
supplementation. Vitamin C supplementation is not a
take on a daily basis?
treatment measure for this disorder. Beta-carotene is
incorrect, because a client with hypoparathyroidism typically
has an increased phosphorus level
Correct Answers.
Terms in this set (100)
A nurse is monitoring a client Tall T waves
who is taking spironolactone Prolonged PR interval
for the treatment of
Hyperactive bowel sounds
hypertension. Which findings
denote adverse effects of the Rationale: Spironolactone is a potassium-sparing diuretic.
medication? Select all that Potassium-sparing diuretics can cause hyperkalemia.
apply. 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 Avoid drinking fluids before and during meals Select
instructions to a client with foods that are easy to chew and are not gas forming
chronic obstructive
Rationale: COPD is a progressive and irreversible condition
pulmonary disease (COPD)
characterized by diminished inspiratory and expiratory
who is experiencing a loss of
capacity of the lungs. Instruct the client who complains of
appetite and complains of
feeling too full to eat, to avoid drinking fluids before and
feeling "too full to eat." What
during the meal. Dry foods such as crackers stimulate
does the nurse encourage the
coughing; foods such as milk and chocolate may increase
client to do? Select all that
the thickness of saliva and secretions. Cheese is constipating
apply.
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.
Positive
Rationale: The tuberculin, or TST, test is a reliable determinant
A tuberculin skin test (TST) is
of tuberculosis (TB) infection. A reaction measuring 5 mm or
administered to a client with
more in diameter is considered positive in a client with HIV
a diagnosis of HIV infection.
infection. A reaction measuring 10 mm or more in diameter is
Forty-eight hours after
considered positive in a non-immunosuppressed client. In this
administration, the nurse
instance, the area of induration measures 9 mm, indicating a
checks the test site (see
positive reaction. A positive reaction does not mean that active
image).
disease is present, but it does indicate exposure to TB or the
presence of inactive (dormant) disease.
,A nurse is interpreting a 14 cm H2O
central venous pressure Rationale: CVP measurements are used to monitor blood
(CVP) reading from a client in
volume and the adequacy of venous return to the heart. The
whom right ventricular
failure has been diagnosed. CVP measures pressures from the right atrium or central
From this diagnosis, the veins. The normal CVP is 7 to 12 cm H2O. An increased CVP
nurse would expect that the reading may indicate right ventricular failure. A low CVP
most likely result is a
reading may indicate hypovolemia. A reading of 4 cm H2O is
pressure of
low. Readings of 8 and 11 cm H2O are normal. A reading of 14
cm
H2O is increased.
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
A nurse is caring for a client (resulting in hypocalcemia and tetany), damage to the
who has just undergone laryngeal nerves, and thyroid storm.
thyroidectomy. Which Hemorrhage is most likely during the 24 hours after surgery.
technique is the best way for If the client is bleeding after surgery, gravity will cause the
the nurse to assess the blood to seep down the sides of the dressing and drain onto
surgical site for bleeding? 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 Whole-milk shake and granola
major burn injury is Baked potato topped with cheese
beginning to take an oral diet Cheese and whole-wheat crackers
again. Which between-meal Rationale: To facilitate healing and meet continued high
menu selections meet the metabolic needs, the client with a major burn should eat a
diet high in calories, protein, and carbohydrates. This type
client's needs for wound
of diet also keeps the client in positive nitrogen balance.
healing and tissue repair? Foods such as milkshakes, granola, cheese, and whole-
Select all that apply. 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.
Calcium carbonate with vitamin D
Rationale: Hypoparathyroidism is an endocrine disorder in
which parathyroid function is decreased. The client with
A client is found to have
hypoparathyroidism is likely to have low calcium and high
hypoparathyroidism. Which
phosphate levels and should consume a diet high in calcium
nutritional supplement does
but low in phosphorus. Additionally, the generally used
the nurse, teaching the client
treatment is calcium supplementation (either as calcium
about measures to manage
carbonate or calcium citrate) coupled with vitamin D
the disorder, tell the client to
supplementation. Vitamin C supplementation is not a
take on a daily basis?
treatment measure for this disorder. Beta-carotene is
incorrect, because a client with hypoparathyroidism typically
has an increased phosphorus level
